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CRCP Chapters 1-2
AAHAM CRCP Chapters 1-2
| Question | Answer |
|---|---|
| What does MACRA stand for? | Medicare Access and CHIP Reauthorization Act of 2015 |
| What does SGR stand for? | Sustainable Growth Rate |
| What did MACRA do? | it ended the Sustainable Growth Rate formula, which would have significantly cut payment rates for participating Medicare clinicians. |
| MACRA required us to implement what program? | Quality Payment Program |
| What are the two ways clinicians can choose to participate in the Quality Payment Program? | 1. The Merit-based Incentive Payment System (MIPS) – If you’re a MIPS eligible clinician, you’ll be subject to a performance-based payment adjustment through MIPS. 2. Advance Alternative Payment Models (APMs) – If you decide to take part of an Advanced APM, you may earn a Medicare incentive payment for sufficiently participating in an innovative payment model. |
| What does MIPS stand for? | Merit-based Incentive Payment System |
| What does APMs stand for? | Alternative Payment Models |
| What are hospitals and other healthcare providers who receive federal funds are required to do under the PSDA? | 1. Inform each adult pt in writing of their right to accept or refuse medical treatment and of their right to formulate advance directives. 2. Provide each adult pt with written info describing the fac policies re: the implement of these pt rights 3. Inquire and then doc in the pt’s med record whether or not the pt has executed an advance directives. 4. Provide staff and community ed on advance directives 5. Refrain from discriminating against pt, whether or not the pt has exec an advance directive |
| What does PPACA stand for? | Patient Protection and Affordable Care Act |
| The PPACA is commonly known as what? | Affordable Care Act |
| What is the PPACA is primarily aimed at? | Decreasing the number of uninsured Americans and reducing the overall cost of healthcare. |
| What mechanisms does the PPACA provide to employers and individuals in order to increase coverage rate? | 1. Mandates 2. Subsidies 3. Tax Credits |
| What are the various ways consumers can learn about the options available for healthcare? | 1. Agents and brokers 2. Navigators 3. Non-navigators 4. Certified application counselors 5. Call Centers 6. Consumer assistance programs |
| What do agents and brokers do? | help individuals and small businesses find insurances and enroll for insurance through the Marketplace. This service is Free. |
| What do Non-Navigators do? | The perform the same functions as Navigators but they only exist in a state-based marketplace. The services they provide are free to everyone. |
| What do Certified application counselors do? | they can be staff members or volunteers who fill the same roles as navigators and non-navigators. They are funded by federal funding through grant programs or Medicaid. |
| What are call centers? | They are centers that are available for consumers to ask questions about health coverage options and to obtain assistance with the Marketplace application process. |
| What are consumer assistance programs? | They help to address consumers’ problems or questions about health coverage. |
| What is the definition of Fraud? | The term describes the intentional or illegal deception or misrepresentation that an individual knows or suspects to be false and knows that the deception could result in some type of benefit to themselves, some other person, or organization. |
| What is the definition of Abuse? | The term describes incidents or practices of providers, physicians, or suppliers of services that, although not usually considered fraudulent, are inconsistent with accepted sound medical, business, or fiscal practices, directly or indirectly resulting in unnecessary costs to the insurer and improper reimbursement for services that fail to meet professionally recognized standards of care or that are medically unnecessary. |
| What is the Anti-Kickback Statute and False Claims Act? | They prohibit offering “free or discounted services to a physician associated with , or who refers patients to, another healthcare facility.” |
| What are the three administrative sanctions CMS can appose on a provider? | Denial or revocation of the provider number application, suspension of provider payments, and/or Application of civil monetary penalties. |
| What does the administrative sanction of denial or revocation of the provider number application entail? | CMS has the authority to deny or revoke an application for a Medicare provider number if there is evidence of impropriety or if the provider does not meet state or federal licensure/certification requirements. |
| What does the administrative sanction of suspension of provider payments entail? | CMS has the authority to suspend payments to a provider if fraud is suspected or if an overpayment exists. |
| What does the administrative sanction of application of civil monetary penalties entail? | CMPSs can be imposed when Medicare has determined that an individual or entity has violated Medicare rules and regulations. |
| What are the two types of exclusions by the OIG? | Mandatory exclusions and Permissive exclusions. |
| "What are the mandatory exclusions reason? | Providers or suppliers who are convicted of: 1. Medicare Fraud 2. Patient neglect 3. Patient abuse 4. Felonies 5. Healthcare related fraud 6. Healthcare related theft 7. Financial misconduct 8. Prescription fraud 9. Unlawfully manufacturing, distributing, or dispensing of controlled substances |
| What are the permissive exclusions reasons? | 1. Controlled substances 2. Healthcare fraud 3. License revocation 4. Suspension of licensure 5. Obstruction of any type of healthcare investigation |
| What does CMPs stand for? | Civil Monetary Penalties |
| What does TCPA stand for? | Telephone Consumer Protection Act |
| What does the TCPA do? | restricts telephone solicitations and the use of automated telephone equipment. |
| What is the Truth in Lending Act (Regulation Z)? | it requires disclosures about and credits terms and cost. |
| Under Regulation Z how many days is a creditor given to respond to a written notice of a dispute or billing error? | 30 days |
| What does the Fair Credit Billing Act provide? | It provides settlement procedures for disputes about “billing errors.” It addresses both sides of the issue: what consumers must do to take advantage of the protections offered and what creditors must do to promptly correct billing errors. |
| How many does dos the patient have to notify the hospital/provider of a error after receiving a statement? | 60 days |
| How many days the hospital/provider have to respond to the complaint after receiving the dispute? | 30 days |
| How soon must the error be corrected, or the accuracy of the statement explained to the customer? | with in two billing cycles or a max of 90 days. |
| What happens if any of the time frames for billing dispute is not met? | The patient’s rights are violated and collection of the account may be forfeited. |
| What is the Fair Credit Reporting Act? | It defines what information from “consumer reports” can be used, by whom, and when. The act provides the maximum protection of a consumer’s right to privacy and confidentiality of credit reports. |
| What does FDCPA stand for? | Fair Debt Collection Practices Act |
| "What does the FDCPA do? | 1. Prohibits harassment or abuse or use of false or misleading information in the collection process. 2. Defines unfair collection practices 3. Defines permissible actions regarding multiple debts 4. Provides procedures to validate debts |
| Who is a debt collector? | Someone who regularly collects debts owed to others. |
| Are providers who collect debts using their own name considered debt collectors? | NO |
| What are the 5 things debt collectors must do when speaking with a consumer about a debt? | 1. Must identify themselves 2. Give the name and address of the original creditor 3. Notify the consumer of the right to dispute the debt 4. Provide verification of the debt 5. Notify the debtor that the communication is an attempt to collect a debt |
| What are the hours during the day that a debt collector may contact consumer? | Between 8am and 9pm |
| What does ECOA stand for? | Equal Credit Opportunity Act |
| What does the ECOA do? | Prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because someone receives public assistance. |
| What does EMTALA stand for? | Emergency Medical Treatment and Active Labor Act |
| What other name is the EMTALA known as? | Federal Anti-Dumping Statute |
| What are the major provisions of the EMTALA? | 1. The patient must receive a medical screening examination to determine whether an emergency medical condition (EMC) exists. 2. The patient must be stable prior to transfer. 3. The physician must certify that the transfer is appropriate. 4. A patient can request transfer, but not at the suggestion of the hospital. 5. The transferring hospital must send medical records with the patient. |
| Does the EMTALA apply only to the Emergency Department? | No, it applies to all patients in any location on the hospital’s campus. |
| What does EMC stand for? | emergency medical condition |
| What does CLIA stand for? | clinical laboratory Improvement Amendments |
| What does CLIA insure? | The quality of laboratory testing |
| What are the 5 types of CLIA certificates? | 1. Certificate of Waiver 2. Certificate for Provider-Performed Microscopy Procedures 3. Certificate of Registration 4. Certificate of Compliance 5. Certificate of Accreditation |
| What two states are exempt from CLIA certification? | Washington and New York |
| What does MPFS stand for? | Medicare Part B Physician Fee Schedule |
| What does TJC stand for? | The Joint Commission |
| What is the TJC? | a private agency that seeks to protect and improve the quality and safety of care. |
| Does the TJC accredit hospitals? | Yes |
| How often will the TJC audit a hospital? | Every 39 months |
| How often will the TJC audit a laboratory | Every two years |
| How soon can the TJC audit a healthcare facility without advance notes after their initial audit? | 9-30 months after initial audit. |
| What areas of Patient Access does the TJC survey? | 1. Distribution and discussion about advance directives 2. Patient rights and responsibilities 3. Organizational ethics 4. Continuum of care 5. Management of environment of care 6. Confidentiality 7. Privacy 8. Security 9. Communication |
| Does the TJC require hospitals to have a facility-wide emergency (or disaster) plans? | YES |
| What must the contingency plans outline? | The actions to take before, during, and after a disaster or major disruption. |
| What are different type of emergencies? | 1. Fires 2. Floods 3. Storms 4. Earthquakes 5. Civil disorders 6. Power failures 7. Injuries 8. Explosions 9. Bomb threats |
| What does ACF stand for? | Administration for Children and Families. |
| What does PHI stand for? | Private Health Information. |
| What is PHI? | Data that could be used individually or in combo, to match patients with medical information. |
| What are Advance directives? | Written statements of a patient's wishes regarding medical treatment in the event that he/she becomes unable to make certain decisions. |
| What is a Living Will? | a document that specifies what treatments a patient does and does not wish to receive. |
| What are several types of advance directives? | Living Will, DNR, Durable Power or Power of Attorney for Healthcare. |
| What is a Healthcare Power of Attorney or Durable Power of Attorney for Healthcare? | A document that designates someone else to make decisions on the patient's behalf if they are unable to do so. |
| What does DNR stand for? | Do Not Resuscitate. |
| What is a DNR order? | a document that states that the patient does not wish to have CPR or similar interventions performed in the event of a medical emergency. |
| What does NIH stand for? | National Institutes of Health |
| What does HHS stand for? | U.S Department of Health & Humand Services |
| What does QIO stand for? | Quality Improvement Organization |
| What are two agencies that are apart of the HHS? | Centers for Medicare & Medicaid Services and the Office of Inspector General. |
| What does IHS stand for? | Indian Health Sevices |
| CMS stands for ____? | Centers for Medicare & Medicaid Services |
| OIG stands for? | Office of Inspector General. |
| ____ stands for Food & Drug Administration. | FDA |
| ____- stands for Substance Abuse & Mental Health Services Administration. | SAM-HSA |
| The ____ is a plain-language brochure that describes what a patient can expect during a hospital stay. | Patient Care Partnership Brochure |
| ____ stands for the American Hospital Association. | AHA |
| The five ____ that the Patient Care Partnership Brochure tell patient's what they can expect during a hospital stay are high-quality hospital care, a clean & safe environment, involvement in your care, protection of privacy, help when leaving the hospital, and help with billing their claims. | areas |
| The new plain language of "____ Bill of Rights" is called the Patient Care Partnership. | Patient |
| The American Hospital Association (____) adopted the "Patient Bill of Rights". | AHA |
| The 11 operating divisions of the ____ are NIH, FDA, CDC, ATSDR, IHS, HRSA, SAM-HSA, AHRQ, CMS, ACF, and the ACL. | HHS |
| The ____ program monitors and improves utilization and quality of care for Medicare beneficiaries. | QIO |
| ____ is responsible for developing rules and regulations that govern Medicare and Medicaid. | CMS |
| ____ also contracts with entities who administer Medicare benefits in various regions of the country. | CMS |
| The principal agency for protecting the health of all Americans is the ____. | HHS |
| ATSDR stands for Agency for Toxic Substance and ____. | Disease Registry |
| TPO stands for treatment, payment, or ____. | healthcare operations |
| ____ stands for Health Insurance Portability and Accountability Act. | HIPAA |
| The Patient Self-Determination Act ensures that ____ understand their right to participate in decisions about their own healthcare & to provide a means to ensure it. | patients |
| PSAD stands for the ____. | Patient Self-Determination Act |
| The QIO Program is administered by ____. | CMS |
| CMS, ____, QIO are agencies that impact Revenue Cycle Managers on a daily basis. | OIG |
| The mission of the OIG is to protect the integrity of ____ programs & the health & welfare of beneficiaries of those programs. | HHS |
| ACL stands for ____. | Administration for Community Living |
| ____ stands for Health Resources and Services Administration. | HRSA |
| ____ stands for the Agency of Healthcare Research and Quality. | AHRQ |
| The office of the Secretary and it's 11 operating divisions conduct the work of the ____. | HHS |
| What does CDC stand for? | Centers for Disease Control & Prevention |
| What does ACF stand for? | Administration for Children & Families |
| What does PHI stand for? | Private Health Information |
| What data is considered "PHI" | Data that could be used, individually or in combo, to match patients with medical information. |
| What are some examples of PHI? | Name, DOB, Address, Phone #, email address, SS#, Employers name/address, relatives name/address, certificate #, photos, fingerprints, and so forth. |
| What are advance directives? | Written statements of a patient's wishes regarding medical treatment in the event that he/she becomes unable to make certain decisions. |
| What is a Living Will? | A document that specifies what treatments a patient does and does not wish to receive. |
| What are several types of advance directives? | Living Will, DNR, Durable Power or Power of Attorney for Healthcare |
| What is a Healthcare Power of Attorney or Durable Power of Attorney for Healthcare? | A document that designates someone else to make decisions on the patient's behalf if they are unable to do so. |
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