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CRCS Chapter 2
AAHAM CRCS Certification Chapter 2
| Question | Answer |
|---|---|
| What are the major areas of federal regulations that relate to the medical revenue cycle? | Patient rights, Administrative simplification, Affordable care, Anti-Fraud and abuse, Telephone consumer protection, Credit and collections, Patient anti-dumping, Performance improvement. |
| Who developed the original "Patient's Bill of Rights" and when was it adopted? | American Hospital Association (AHA) in 1970s. |
| What has the "Patient's Bill of Rights" been replaced by? | Brochure called "Patient Care Partnership" |
| In general what is does the "Patient Care Partnership" brochure talk about? | It states the expectations that patients and their families can have about how they will be treated in healthcare situations. |
| What are the topics that the "Patient Care Partnership" brochure state patients should expect during a hospital stay? | High quality hospital care, a clean and safe environment, Involvement in your care, Protection of your privacy, Help when leaving the hospital, and help with your billing claims. |
| What does HIPAA stand for? | Health Insurance Portability and Accountability Act |
| What did HIPAA create? | Creates federal standards for insurers, health maintenance organizations (HMOs), and employer plans including those who are self-insured. |
| What are the national standards of the HIPAA Privacy Rule? | Gives pt's control of their info. Sets boundaries of what can be released. Sets standards to protect health info., Holds violators accountable. Strikes balance to support public disclosure of some data. |
| What does the HIPAA Privacy Rule mean for patients? | Enables pt's to know how info being used, limits release of pt info, gives pt's right to exam medical records and request corrections. Empowers individuals to control certain uses and disclosures of their health information. |
| What does PHI stand for? | Protected Health Information |
| What is PHI? | Individually identifiable patient information. Any data that could be used, individually or in combination, to match patients with medical information. |
| What are examples of PHI? | name, date of birth, address, phone number, email address, Social Security Number, medical record number, employer's name/address, relative's name/address, certificate number (such as pacemaker serial number, photographs, fingerprints, etc |
| When can PHI be shared WITHOUT explicit consent? | For treatment, payment, or healthcare operations. This is also known as TPO. |
| When can't PHI be shared without explicit consent? | For marketing purposes. |
| When can PHI be shared with law enforcement? | With consent, proper notification, or under a court order. |
| What do vendors who handle PHI need to do? | They must have a signed business associate agreement that obligates them to treat PHI on the same basis as covered entities. |
| Who's responsibility is it to keep patient information confidential? | EVERYONE'S |
| Has Administrative Simplification allowed for cast savings? | No; they have not materialized for several reasons. |
| What does PSDA stand for? | Patient Self-Determination Act |
| What is the PSDA do? | Ensures that patients understood their right to participate in decisions about their own healthcare and to provide a means to ensure it. |
| What tools do the PSDA use to help patients participate in their healthcare? | Living Will, Healthcare Power of Attorney or Durable Power of Attorney for Healthcare, Do Not Resuscitate Order |
| What is a Living Will? | a document that specifies what treatments a patient does and does not wish to receive if they become incapacitated and can't make decisions regarding their medical treatment. |
| What is a Healthcare Power of Attorney or Durable Power of Attorney for Healthcare? | A document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient's behalf if he or she is unable to do so. |
| What does DNR stand for? | Do Not Resuscitate order |
| What does a DNR order do? | It is a document that states that the patient does not wish to have CPR or similar interventions performed in the events of a medical emergency. |
| What does PPACA stand for? | Patient Protection and Affordable Care Act |
| What is other name is the PPACA know as? | Affordable Care Act |
| What does the PPACA do? | It is aimed at decreasing the number of uninsured Americans and reduce the overall costs of healthcare. |
| What methods are used in the PPACA to reduce uninsured Americans and reduce costs of healthcare? | Mandates, subsidies, and tax credits to employers and individuals. |
| Does the PPACA require ins companies to cover all applicants and offer the same rates regardless of pre-existing conditions or gender? | YES |
| What is fraud? (not examples) | Intentional or illegal deception or misrepresentation made for the purpose of personal gain, or to harm or manipulate another person or organization. |
| What are somethings that would be fraudulent? Examples | Incorrect reporting of diagnoses and procedure codes to max pmts, billing for services not furnished, altering claims to receive pmt, accepting kickbacks, the routine waiver of deductible and coinsurance amts, etc. |
| What is abuse? ( not examples) | Incidents or practices of healthcare workers that, although not usually considered fraudulent, are inconsistent with accepted sound practices. |
| What are some examples of things that would be considered abuse? | Excessive or unwarranted use of technology, pharmaceuticals, and services; abuse of authority; abuse of privacy, confidentiality, or duty of care. This includes improper billing practices (like billing Medicare instead of primary insurer) |
| What is the False Claims Act | It prohibits making a false record or statement to get false/fraudulent claim paid by the government, submission of false/fraudulent claims, and conspiring to have false/fraudulent claims claims paid by the government. |
| What tool is used if CMS determines the existence of inappropriate/fraudulent behavior on the part of a provider? | CMS will use Administrative Sanctions |
| What are the Administrative Sanctions that CMS uses if they so need? | Denial or revocation of the provider number application; Suspension of provider payments; Application of Civil Monetary Penalties (CMP) |
| What does TCPA stand for? | Telephone Consumer Protection Act |
| What does the Telephone Consumer Protection Act restrict? | The use of automated telephone equipment to contact a debtor on a cell phone without express consent and limits the use of artifical or prerecorded voice, text messages and fax machines. |
| If a provider offers "credit" and payment plans must they comply with applicable laws governing credit and collections? | YES |
| What are the 5 federal laws governing credit and collections? | Truth in Lending Act (Regulation Z); Fair Credit Billing Act; Fair Credit Reporting Act; Fair Debt Collection Practices Act; Equal Credit Opportunity Act; |
| What other name does the Truth and Lending Act go by? | Regulation Z |
| What is the Truth in Lending Act (Regulation Z) | Deals with the disclosure of information before credit is extended. It requires that annual % and finance charges are clearly identified. Requires that written disclosures must be provided to the consumer. |
| What does the Fair Credit Billing Act do? | It protects consumers from inaccurate or unfair practices by issuers of open-ended credit. The act requires creditors to inform debtors of their rights and of the responsibilities of the creditor. |
| What does the Fair Credit Reporting Act do? | Defines what info from "consumer reports" cand be used, by whom, and when. It provides the max protection of a consumer's right to privacy and confidentiality of credit reports. |
| What does FDCPA stand for? | Fair Debt Collection Practices Act |
| Why did the Fair Debt Collection Practice Act enacted? | As a result of evidence that debt collectors were using abusive, deceptive, and unfair collection practices. |
| What does the FDCPA impose strict limitations on? | 1. Acquisition of information regarding the location of the debtor. 2. Communication with the debtor or others in collection of a debt. |
| What does the FDCPA act prohibit? | Harassment or abuse in the collection process; use of false or misleading info in the collection process, calling at unusual times or places, contacting consumer at or place of employment; contacting debtor if have legal rep. |
| What is considered an "unusual" time to call a debtor? | Before 8am or after 9pm in the debtor's time zone |
| What does ECOA stand for? | Equal Credit Opportunity Act |
| What is does the ECOA prohibit? | Credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because someone receives public assistance. |
| What are the only three marital terms a creditor may ask? | Married, unmarried, separated |
| Can a creditor consider a person's immigration status and whether the person has the right to stay in the country long enough to repay the debt? | Yes |
| If applying for a separate, unsecured account can a creditor ask about the applicant's marital status? | No |
| When are creditor's allowed to ask for information about a spouse? | If the spouse is applying with the person, spouse allowed to use the account, if person is relying on spouses' income, alimony or child support to pay debt, if person lives in community property state. |
| What does EMTALA stand for? | Emergency Medical Treatment and Active Labor Act |
| What is another name that the EMTALA is known as? | Federal Anti-Dumping Statue |
| Why was the EMTALA enacted? | In response to concerns that hospitals were refusing to treat patients without insurance and even transferring them to other facilities and leaving them there. Sometimes without notifying the receiving facility. |
| What 3 general requirements does EMTALA cover? | Medical screening examination, Necessary stabilizing treatment, restricting transfer until stabilization. |
| Can registration staff ask questions about how the patient intends to pay before the patient receives a medical screening exam? | No, but they may gather basic demographic information. |
| Does EMTALA only apply to Emergency Departments? | NO, it applies to any location on a hospital's campus, and to all patients in the facility, not just ED patients. |
| What does CLIA stand for? | Clinical Laboratory Improvement Amendment |
| What does CLIA require | It requires that all clinical laboratory services furnished to Medicare beneficiaries must be performed by a provider who has a CLIA certificate. |
| Do all qualifying providers of laboratory need to report their CLIA number on a claim? | Yes |
| How can a state become exempt from CLIA status? | If the state has legal requirements that are equal to or more stringent than CLIA's statutory and regulatory requirements. |
| What are the only states currently exempt from CLIA status? | New York and Washington |
| What does TJC stand for? | The Joint Commission |
| What is the TJC? | Private agency that seeks to protect and improve the quality and safety of care that accredits hospitals. |
| Are all hospitals accredited by the TJC? | No, some are accredited by their states or other agnencies. |
| How often will TJC conduct an audit of a hospital? | Every 39 months |
| How often will the TJC conduct an audit of a laboratory? | Every 2 years |
| When can the TJC conduct an audit without advance notice after the initial audit? | Has early as 9-30 months after its initial audit. |
| What areas can Patient Access expect surveys in? | Distribution and discussion about advanced directives, patient rights and responsibilities, organizational ethics, continuum of care, management of environment of care, confidentiality, privacy, security, communication. |
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