HIPAA Flash Cards CHC
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
1.
Compliance Program
Following rules and regulations
2.
Integrity Program
Values doing the right thing
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
3.
Current Compliance activities
in many organizations
Equal Employment Opportunity Commission (EEOC)
Employee Retirement Income Security Act (ERISA)
Wage and Hour Rule
Occupational Safety and health Administration (OSHA)
Nuclear Regulatory Commission
Joint Commission on Accreditation of Healthcare Organization (JCAHO)
Research compliance
4.
What is a Compliance Program?
Prevention, Detection, Collaboration, and Enforcement
System of policies and procedures developed to assure
compliance with and conformity to all applicable federal and state laws governing organization
Ongoing process, part of fabric of organization, commitment to ethical way of conducting business
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
5.
Who needs compliance? Why?
Physicians practices
Medicare
Ambulance Services
3rd Party Billing
Pharmaceutical Manufacturing
Hospitals
Laboratories
DME
Home Health
Memory aid: APRN & 3 MD work In HHHC
6.
HHS Office of Inspector General
(OIG) in conjunction with Justice
Department is responsible for
enforcing the rules and
regulations under
HHS Office of Inspector General (OIG) in conjunction with Justice Department is responsible for enforcing the rules and regulations under Medicare/Medicaid laws outlined as part of the Social Security
Act and administered by CMS
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
7.
Government estimates on fraud
10% of total US health care expenditures, about $100 billion annually
8.
Justice Department (priorities)
Violent Crime - 1st Priority
Health care fraud - 2nd Priority
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
9.
Benefits of Compliance Program
Safeguards organization legal responsibility to abide by applicable laws and regulations
Demonstrate to employee and community the organization's commitment to good corporate conduct
Identify and prevent criminal and unethical conduct
Improve the quality of patient care
Create a centralized source of info on health care regs
Develop a methodology that encourages employees to report potential problems
Develop procedures that allow the prompt, thorough investigation of alleged misconduct
Initiate immediate and appropriate corrective action
Reduce the organization remedies, such as program exclusion
10.
Why Compliance Programs are
Essential
Payback to fiscal intermediaries or carriers may result in audited services
Probation and court imposed programs
Government designed programs
Exclusion from government program
Reduced threat of qui tam (whistle-blower) lawsuit
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
11.
OIG Top 10 Reasons to
Implement a Compliance
Program (1-5)
Adopting a compliance program concretely demonstrates to the community at large that a provider has a strong commitment to honesty and responsible corporate citizenship.
Compliance programs reinforce employee's innate sense of right and wrong.
An effective compliance program helps a provider fulfill its legal duty to government and private payers.
Compliance programs are cost effective.
A compliance program provides a more accurate view of employee and contractor behavior relating to fraud and abuse.
12.
OIG Top 10 Reasons to
Implement a Compliance
Program (6-10)
The quality of care provided to patients is enhanced by
an effective compliance program.
A compliance program provides procedures to promptly correct misconduct.
An effective compliance program may mitigate any sanction imposed by the government.
Voluntarily implementing a compliance program is preferable to waiting for the OIG to impose a Corporate Integrity Agreement (CIA).
Effective corporate compliance programs may protect corporate directors from personal liability.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
13.
Corporate Integrity
Agreement(CIA)
If provider does not have one in place, the OIG will develop one that is enforceable through a corporate integrity agreement. CIA has detailed
policy, training, audit, and reporting requirements that are typically in force for 5 years and involve substantial oversight.
14.
HIPAA of 1996
Makes it a criminal offense to submit claims based on incorrect codes or medically unnecessary services and the government has the power to exclude the organization from Medicare, Medicaid, and a long list of other government programs.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
15.
Balance Budget Act of 1997
Has three strike rule - 3 strikes and you're out clause, requiring permanent expulsion for healthcare organization found guilty of fraud a third time.
16.
False Claim Act (FCA)
Empowers government to investigate and bring civil action in fraud case. Implemented during Civil War to curb war time price gouging
Also allow private citizen to bring civil actions against an organization in the name of United States. This action provided significant incentive for the private citizen to come forward. This action is better known as
Qui Tam, whistle blower.
Sometimes called Lincoln’s Law as it was implemented during
the Civil War to protect against price gouging to
the military.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
17.
Corporate Integrity Agreement
(CIA)
Organization does not admit fault or liability but does submit itself to government corrective action plan. Government imposed CIA has been onerous in the past and is expected to become more onerous in the future. CIAs are usually 3-5 years but can last as long as 8 years.
18.
February 27, 1997
Date of OIG open letter to all providers - encourages health care organization to implement compliance programs in order to protect themselves from fraud and abuse. With that letter, Model compliance
plan for Clinical Laboratory was offered as guidance. Since that time, a Model compliance plan has been implemented in
many areas.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
19.
1984 Sentencing Reform Act
Designed to correct inequities in deferral sentences. Includes the Federal Sentencing Guidelines that include guidance for assessing fines and detailed method for calculation of a "culpability score."
20.
2004 - Federal Sentencing
Commission released "Ch 8 Part
B - Remedying Harm from
Criminal Conduct, and Effective
Compliance and Ethics Program"
These revisions focused on effective compliance and ethics programs. Page 10
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
21.
4 Aggravating Factors to a
culpability score
If an upper level employee has "participated in, condoned, or was willfully ignorant of the offense"
If the violation is a repeat offense
If the government was hindered during its investigation and
If awareness of and tolerance of the violation were pervasive
22.
4 Mitigating Factors to a
culpability score
If the organization had an effective compliance program, even though there was a violation
If the organization reported the violation promptly
If the organization cooperated with the government investigators
If the organization accepted responsibility for the violation
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
23.
Federal Sentencing Commission
has stated
"Compliance and ethics programs shall be designed, implemented, and enforced so that the program is generally effective in preventing and detecting criminal conduct. The failure to prevent or detect the instant offense does not necessarily mean that the program is not generally effective in preventing and detecting criminal conduct."
24.
7 Elements in OIG CPG Guidance
for Hospital
Written standards of conduct
Designating a chief compliance officer and other appropriate bodies
Effective education and training
Audit and evaluation techniques to monitor compliance
Reporting process and procedures for complaints
Appropriate disciplinary mechanism
Investigation and remediation of systemic problem
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
25.
Obstacles to Effective Compliance
Implementation (1-5)
Commitment and buy-in
Lack of funding
Too many roles for compliance professional
Interpreting laws and regulations
Lack of resources and staff
26.
Obstacles to Effective Compliance
Implementation (6-10)
Lack of education and training
Resistance to change
Lack of or poor communication
Fear of retaliation/retribution
No internal enforcement
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
27.
In all OIG program guidance
The first prescribed elements calls for the development and distribution of written standards of conduct, as well as written policies and procedures that promote a commitment to compliance.
28.
Code of Conduct: Content
Checklist
Demonstrate system wide emphasis on compliance with all applicable laws and regulations
Written plainly and concisely so all employees can understand the standards
Includes internal and external regulations
Mentions organizational policies without completely restating them
Is consistent with company policies and procedures
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
29.
Code of Conduct and Employees
All employees must receive, read, and understand the standards
A supervisor should explain the standards and answer any questions
Employee should attest in writing that they have received, read, and understood the standards
Employee compliance with standards must be enforced through appropriate discipline when necessary
Discipline for non-compliance should be stated in the standards
30.
Code of Conduct Purpose
To present specific guidelines for employees to follow
To confirm that all employees comprehend what is required of them
To provide a process for proper decision making
To confirm that employees put standards into everyday practice
To elevate corporate performance in basic business relationship
To confirm that the organization upholds and supports proper compliance conduct
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
31.
Compliance policies and
procedures should be integrated
into existing policies
Only thing worse than not having a
policy is having a policy and not following it. Develop policies carefully and review them regularly. Make sure they are realistic and measurable.
32.
Development of policies and
procedures begin with areas of
risk
Targeting areas on OIG Work Plan that apply to your organization and adequately address them in your policies and procedures.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
33.
Every organization needs
policies and procedures for:
Internal assessment
Record Retention (where, how long)
Self-disclosure
Medicare sanction checks (LEIE)
Billing policies
Unbundling
Credit Balance
No charge visit
Incomplete/Unsuccessful procedure
Documentation requirement
34.
Upcoding
Using a billing code that provides a higher reimbursement rate than the billing code that actually reflects the service furnished.
Major focus of OIG enforcement efforts and HIPAA added additional civil monetary
penalty to OIG sanctions.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
35.
DRG Creep
Using a Diagnosis Related Group (DRG) code that provides a higher payment rate than the DRG code that accurately reflects the service furnished to the patient.
36.
Teaching physician Rule
Special documentation requirement for services provided by residents and teaching physicians.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
37.
Project Bad Bundled
OIG Effort to identify laboratory tests processed in groups but reported individually at a higher rate of reimbursement; also unbundling.
38.
Lincoln’s Law
Refers to the False Claims Act given that the FCA was introduced during the Civil War.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
39.
72 hour rule
Stipulates that diagnostic tests provided on an outpatient basis within 72 hours of an admission must be billed as part of the admission DRG.
40.
Anti-kickback statute
Prohibits any knowing and willful conduct involving solicitation, receipt, offer, or payment of any kind of remuneration in return for referring an individual or for recommending or arranging the purchase, lease, or ordering of an item or services that may be wholly or partially paid for under a federal health care program.
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
41.
Compliance Program
Responsibilities according
to OIG
Oversight and implementation of Compliance Program (CP).
Reporting on a regular basis to governing body, CEO, and compliance committee
Revising compliance program as needed
Developing, coordinating, and participating in training and education
Ensuring contractors and agents are aware of CP requirements
Ensuring background checks are done to eliminate sanctioned individuals and contractors
Assisting with internal compliance review and monitoring activities
Independently investigating and acting on matters related to compliance
42.
HCCA prepared and published
Code of Ethic for Health Care
Compliance Professional
addressing 3 principles
Principle 1 - Obligation to public
Principle 2 - Obligation to employing organization - should serve organization with highest sense of integrity, unprejudiced, and unbiased judgment
Principle 3 - Obligation to profession - uphold integrity and dignity of profession, to advance effectiveness of compliance program and to promote professionalism in health care compliance
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
43.
Compliance Committee
"to advise the compliance officer and assist in the implementation of the compliance program."
44.
Function of Compliance
Committee:
Analyzing legal requirement and specific risk areas
Regularly reviewing and assessing policies and procedures
Assisting with the development of standards of conduct and policies and procedures
Monitoring internal systems related to standards, policies, and procedures
Determining the appropriate strategy to promote compliance
Developing a system to solicit, evaluate, and respond to complaints and problems
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
45.
OIG suggest training be
separated into two sessions:
The first a general session on compliance for all employees and
The second covering more specific information for appropriate personnel
46.
OIG Work Plan
Identifies high risk & key areas of focus for auditing
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
47.
Code of Conduct
Must be distributed within 90 days
of hire
48.
OIG can impose mandatory
exclusion for a minimum of
5 years
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
49.
Federal Sentencing Guidelines
(FSG)
Very clear on the expected board commitment
50.
A teaching hospital may want
their support for a compliance
program
To come from the Dean
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HIPAA Flash Cards, Set 1-52 from Frank Ruelas; Updated by Carl Russell 11/5/2018.
51.
Caremark International
Derivative Litigation
Makes the board responsible for implementation of a system to gather information on the company's efforts to prevent and detect fraud and abuse
52.
FSG suggests offering
Incentives to those who follow the
compliance and ethics program
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