Cbcs Study Guide 2.1 Chapter 1- Regulatory Compliance Q&a

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WHAT DOCUMENTATION IS USUALLY INCLUDED?

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DATES OF CLINICAL ENCOUNTERS. AUTHOR OF THE DOCUMENT. PATIENT’S MEDICAL HISTORY AND PERTINENT FAMILY HISTORY. MEDICATIONS THE PATIENT IS CURRENTLY TAKING. REPORT OF THE PATIENT’S INITIAL PHYSICAL EXAMINATION. ANY ALLERGIES, INCLUDING FOOD AND MEDICATION. PHYSICIAN’S DIAGNOSTIC AND THERAPEUTIC ORDERS. REPORTS AND RESULTS OF EVERY DIAGNOSTIC AND THERAPEUTIC PROCEDURE PERFORMED.

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WHAT ARE SOME EXAMPLES OF DIAGNOSTIC AND THERAPEUTIC PROCEDURES THAT CAN BE PERFORMED?

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LABORATORY TESTS PERFORMED ON BLOOD, URINE, TISSUE AND OTHER SAMPLES FROM THE PATIENT. PATHOLOGICAL EXAMPLES OF TISSUE SAMPLES AND TISSUE OR ORGANS REMOVED DURING SURGICAL PROCEDURE. RESULTS OF IMAGING PROCEDURES, SUCH AS ULTRASOUND OR MRI

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WHAT IS THE DIFFERENCE BETWEEN INFORMED CONSENT AND IMPLIED CONSENT?

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INFORMED CONSENT REFERS TO THE PROCESS OF EXPLAINING ANY MEDICAL OR DIAGNOSTIC PROCEDURES, AS WELL AS SURGICAL INTERVENTIONS TO PATIENTS AND GIVING THEN THE OPPORTUNITY TO ASK QUESTIONS BEFORE ANY WORK IS DONE. DOCUMENTS VERIFYING THAT THIS HAS TAKEN PLACE MUST BE SIGNED. IF A PATIENT VOLUNTARILY UNDERGOES TREATMENT, THE CONSENT IS ASSUMED. THIS IS CALLED IMPLIED CONSENT, AND SIGNATURES ARE NOT REQUIRED

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IN WHAT YEAR DID THE AMERICAN RECOVERY AND REINVESTMENT ACT (AARA) SIGN THE HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND CLINICAL HEALTH ACT (HITECH)?

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2009

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WHAT DOES TYPES OF INFORMATION COULD BE CONSIDERED INDIVIDUALLY IDENTIFIABLE?

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INFORMATION THAT INCLUDES PAST, PRESENT, OR FUTURE PHYSICAL OR MENTAL CONDITIONS. INFORMATION THAT INCLUDE PROVISIONS OF HEALTHCARE INFORMATION THAT INCLUDES PAYMENT FOR THE PROVISION OR HEALTH CARE

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WHAT ELEMENTS MUST BE INCLUDED IN AN AUTHORIZATION?

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A SPECIFIC MEANINGFUL DESCRIPTION OF THE INFORMATION TO BE USED OR DISCLOSED. THE NAME OR OTHER SPECIFIC IDENTIFICATION OF THE PERSON OR PERSONS OR CLASS OF PERSONS AUTHORIZED TO MAKE THE REQUESTED USE OR DISCLOSURE. THE NAME OR OTHER SPECIFIC IDENTIFICATION OF THE PERSON OR PERSONS TO WHOM THE COVERED ENTITY MAY MAKE THE REQUESTED USE OR DISCLOSURE. AN EXPIRATION DATE OR EVENT THAT RELATES TO THE INDIVIDUAL OR THE PURPOSE OF THE USE OR DISCLOSURE. A STATEMENT OF THE INDIVIDUAL'S RIGHT TO REVOKE THE AUTHORIZATION IN WRITING AND THE EXCEPTION TO THE RIGHT TO REVOKE, WITH A DESCRIPTION OF HOW THE INDIVIDUAL MAY REVOKE. A STATEMENT THAT INFORMATION USED OR DISCLOSED PURSUANT TO THE AUTHORIZATION MAY BE SUBJECT TO RE-DISCLOSURE BY THE RECIPIENT AND NO LONGER PROTECTED BY THIS RULE. SIGNATURE OF THE INDIVIDUAL AND THE DATE. WHEN THE AUTHORIZATION IS SIGNED BY A PERSONAL REPRESENTATIVE OF THE INDIVIDUAL, A DESCRIPTION OF THE REPRESENTATIVE’S AUTHORITY TO ACT FOR THE INDIVIDUAL

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WHAT IS THE KEY PART OF CLAIMS?

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CODE SETS

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WHAT ARE THE ADOPTED FOR PROCEDURES, DIAGNOSES, AND DRUGS?

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CPT – CURRENT PROCEDURAL TERMINOLOGY, ICD-10-CM – INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION, CLINICAL MODIFICATION, ICD-10-PCS – INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION, PROCEDURE CODING SYSTEM, ICD-9-CM – INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH REVISION, CLINICAL MODIFICATION, HCPCS - HEALTHCARE COMMON PROCEDURE CODING SYSTEM, AND NDC – NATIONAL DRUG CODES

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WHAT ARE THE SPECIFIC EXAMPLES OF FRAUD?

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KNOWINGLY BILLING FOR SERVICES OR SUPPLIES NOT PROVIDED, INCLUDING BILLING MEDICARE FOR APPOINTMENTS THAT THE PATIENT FAILED TO KEEP. KNOWINGLY ALTERING CLAIM FORMS TO RECEIVE HIGHER PAYMENT, UPCODING.

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WHAT ARE EXAMPLES OF ABUSE?

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ANY PRACTICE THAT IS NOT CONSISTENT WITH THE GOALS OF PROVIDING PATIENTS WITH SERVICES THAT ARE MEDICALLY NECESSARY, MEET PROFESSIONALLY RECOGNIZED STANDARDS, AND FAIRLY PRICED. CHARGING EXCESSIVELY FOR SERVICES OR SUPPLIES. BILLING FOR SERVICES THAT WERE NOT MEDICALLY NECESSARY. MISSING CODES ON A CLAIM.

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WHY ARE AUDITS CONDUCTED?

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IT IS A WAY TO PREVENT SUBMITTING CLAIMS THAT ARE EITHER FRAUDULENT OR REFLECT ABUSE.

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WHAT IS THE DIFFERENCE BETWEEN FRAUD AND ABUSE?

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THE INDIVIDUAL’S INTENT

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WHAT LAWS ARE IN PLACE TO MINIMIZE OCCURRENCES OF FRAUD AND ABUSE?

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HIPPA, THE STARK LAW, THE FAIR DEBIT COLLECTION PRACTICE ACT, AND THE FALSE CLAIMS ACT

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WHAT IS HIPPA?

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A LEGISLATION DESIGNED TO PROTECT THE PRIVACY AND SECURITY OF PATIENT INFORMATION

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WHERE IS THE INFORMATION ABOUT FRAUD AND ABUSE COMPLIED?

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HEALTHCARE INTEGRITY PROTECTION DATA BANK (HIPDB)

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WHY IS THE HEALTHCARE INTEGRITY PROTECTION DATA BANK TRANSITIONING?

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DUE TO THE OVERLAPPING DATA IN THE HEALTHCARE INTEGRITY PROTECTION DATA BANK

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WHAT IS THE HEALTHCARE INTEGRITY PROTECTION DATA BANK TRANSITIONING TO?

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NATIONAL PRACTITIONER DATA BANK

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WHAT TYPE OF INFORMATION IS REPORTED TO THE NATIONAL PRACTITIONER DATA BANK?

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FEDERAL OR STATE LICENSING AND CERTIFICATION ACTIONS, INCLUDING REVOCATION, REPRIMANDS, CENSURES, PROBATIONS, SUSPENSIONS, AND ANY OTHER LOSS OF LICENSE, OR THE RIGHT TO APPLY FOR OR RENEW A LICENSE, WHETHER BY VOLUNTARY SURRENDER, NON-RENEWABILITY, OR OTHERWISE. EXCLUSION FROM PARTICIPATION IN FEDERAL OR STATE HEALTHCARE PROGRAMS. ANY OTHER ACTION OR DECISIONS DEFINED IN THE NATIONAL PRACTITIONER DATA BANK REGULATIONS

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WHEN WAS THE FINAL RULE ISSUED?

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JANUARY 2013

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WHO ISSUED THE FINAL RULE?

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THE OFFICE OF CIVIL RIGHTS (OCR) PART OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

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WHO HAS THE OVERSIGHT RESPONSIBILITIES FOR THIS LAW?

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THE CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS)

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WHAT SERVICES CANNOT BE REFERRED UNDER THE STARK LAW?

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CLINICAL LABORATORY, PHYSICAL; OCCUPATIONAL THERAPY; SPEECH AND LANGUAGE THERAPY; RADIATION AND IMAGING; RADIATION THERAPY AND SUPPLIES; DURABLE MEDICAL EQUIPMENT; PARENTERAL AND ENTERAL NUTRIENTS, EQUIPMENT, AND SUPPLIES; PROSTHETICS, ORTHOTICS, PROSTHETIC DEVICES AND SUPPLIES; HOME HEALTH; OUTPATIENT PRESCRIPTION DRUGS; AND INPATIENT AND OUTPATIENT HOSPITAL SERVICES

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WHAT ARE THE PENALTIES FOR VIOLATING THE FALSE CLAIMS ACT?

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FINES AND DAMAGES UP TO THREE TIMES THE AMOUNT SUSTAINED BY THE GOVERNMENT, ARE ASSOCIATED WITH ANY PHYSICIAN WHO KNOWINGLY SUBMITS A FALSE OR FRAUDULENT CLAIM

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WHAT DOES IT MEAN BY “KNOWING”?

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INCLUDES DOING THIS IN “DELIBERATE IGNORANCE” OR WITH “RECKLESS DISREGARD OF THE TRUTH RELATED TO THE CLAIM”

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WHAT IS THE ROLE OF THE OFFICE OF THE INSPECTOR GENERAL (OIG)?

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TO PROTECT MEDICARE AND OTHER HHS PROGRAMS FROM FRAUD AND ABUSE BY CONDUCTING AUDITS, INVESTIGATIONS, AND INSPECTIONS TO ANSWER FORMAL COMPLAINTS

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WHAT WAS THE PROGRAM HIPPA ESTABLISHED TO COMBAT FRAUD?

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THE HEALTH CARE FRAUD AND ABUSE CONTROL (HCFAC)

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WHERE IS THE HEALTH CARE AND FRAUD AND ABUSE CONTROL AND WHO IS IT RUN BY?

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IT IS HOUSED IN THE OFFICE OF THE GENERAL AND IS JOINTLY RUN BY THE DEPARTMENT OF JUSTICE (DOJ) AND THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS).

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WHAT DOES THE OIG HAVE THE AUTHORITY TO DO?

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TO EXCLUDE INDIVIDUALS AND ENTITIES WHO HAVE ENGAGED IN FRAUD AND ABUSE FROM PARTICIPATING IN MEDICARE, MEDICAID AND OTHER FEDERAL HEALTH CARE PROGRAMS. THEY CAN ALSO IMPOSE PENALTIES ON OFFENDERS

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WHAT LIST DOES THE OIG KEEP IN THE OFFICE?

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THE LIST OF EXCLUDED INDIVIDUALS/ENTITIES

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IN WHAT YEAR DID THE DEPARTMENT OF JUSTICE AND HHS ESTABLISH THE HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM (HEAT)?

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2009

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WHAT IS THE PURPOSE OF HEAT?

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TO STRENGTHEN EFFORTS TO FIGHT FRAUD AND INVEST IN NEW TECHNOLOGIES TO PREVENT FRAUD AND ABUSE.

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WHAT IS THE MAIN JOB OF THE OFFICE OF THE INSPECTOR GENERAL?

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THE OFFICE OF THE INSPECTOR GENERAL PROTECTS MEDICARE AND OTHER HHS PROGRAMS FROM FRAUD AND ABUSE BY CONDUCTING AUDITS, INVESTIGATIONS, AND INSPECTIONS