Certified Revenue Cycle Representative Section 1 Cont.
What are some of the HIPAA requirements that specifically address compliance?
Coordinating a fraud and abuse control program. Establishing a fraud and abuse control account. Increasing the civil money penalties. Permitting the exclusion of individuals with ownership or control interest in a sanctioned entity.
What does CCI stand for?
Correct Coding Initiative
What is the 6th Element of the Corporate Compliance Program
Development and implementation of a regular, comprehensive training and education program for affected personnel, including physicians.
Who does CCO report to
Directly to the board of directors/trustees as well as the chief executive officer
What is the 13th Element of the Corporate Compliance Program
Discretionary authority vested in persons unlikely to engage in criminal conduct.
What is EPHI?
Electronic Protection health information.
What is the taxpayer identifier number?
Employer ID Number (EIN)
What is the 10th Element of the Corporate Compliance Program
Established compliance standards and procedures.
What are essential elements of a effective compliance program?
Established compliance standards and procedures. Oversight of personnel by high-level personnel. Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines.
How is the ACA reforming the healthcare delivery system?
Establishing regulations for the development and financing of Accountable Care Organizations (ACOs). Developing new approaches to payment and delivery systems through the Center for Medicare and Medicaid Innovation.
What is the 8th Element of the Corporate Compliance Program
Exercise in due diligence with regard to employment of sanctioned individuals or individuals who may otherwise be excluded from participation in the federal healthcare program.
What is the goal of HIPAA?
Expand health coverage by improving the portability and continuity of health insurance coverage in group and individual markets. Give patients access to their health files and the right to request amendments or make corrections. Facilitate the electronic exchange of medical information with respect to financial and administrative transactions carried out by health plans, healthcare clearinghouses, and healthcare providers.
What is the FCA?
False Claims Act
When was The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act?
February 17, 2009
What type of HIPAA transaction is an 148?
First report of injury, illness or incident
What is the FERA?
Fraud Enforcement and Recovery Act
What is the 3rd Element of the Corporate Compliance Program
Full support of the highest level of personnel within the organization, including the designation of an appropriate senior management member as compliance officer.
What type of HIPAA transaction is an 997?
Functional Acknowledgment - used to confirm file received
What type of HIPAA transaction is an 835?
Health Care Claim Payment/Advice
What type of HIPAA transaction is an 276/277?
Health Care Claim Status Request & Response
What type of HIPAA transaction is an 837I?
Health Care Claim: Instutional
What type of HIPAA transaction is an 837P?
Health Care Claim: Physician
What type of HIPAA transaction is an 270/271?
Health Care Eligibility Benefit Injury & Response
What type of HIPAA transaction is an 278?
Health Care Services Review-Request for Review & Response
What is HITECH stand for?
Health Information Technology for Economic and Clinical Health
Who follows the OIG?
Home health agencies Third-party medical billing companies Medicare Advantage organizations Hospice Durable medical equipment (DME) Prosthetics Orthotics Individual physicians and small group practices Supply industry Nursing facilities Pharmaceutical companies Ambulance providers
What is an HINN?
Hospital Part A notification of noncoverage because the care is not medically necessary, not delivered in the most appropriate setting or custodial in nature.
What are the OIG Responsibilities?
Identifying opportunities to improve program economy, efficiency, and effectiveness. Holding accountable those who do not meet program requirements or who violate federal laws.
When should an ABN be given?
If an ordered service does not meet medical necessity based on the test and diagnostic information provided, the provider is required to issue the appropriate Advance Beneficiary Notice of Noncoverage (ABN).
What type of HIPAA transaction is an 999?
Implementation Acknowledgement - Used to confirm file received
What is the 16th Element of the Corporate Compliance Program
Implementation of an audit plan with the following elements: Clearly defined goals that identify the specific company practices to be audited Personnel who will conduct the audit Individuals to be interviewed Documents to be reviewed Steps to be taken to ensure protection by the attorney-client privilege
What provisions does the ACA include?
Improve the quality of care. Reform the healthcare delivery system. Encourage pricing transparency and modernized financing systems. Address the issues of waste, fraud, and abuse.
What does condition code 51 mean?
Indicates that the OP charge is unrelated to the admission.
What does IPPS stand for?
Inpatient Prospective Payment System
What is the purpose of CCI?
Is to ensure that the most comprehensive groups of codes, rather than the component parts, are billed.
When was the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act signed into law?
June 25th 2010
What is the 7th Element of the Corporate Compliance Program
Maintenance of a "hotline" or other mechanism to receive anonymous communications regarding potential compliance issues.
What is the 14th Element of the Corporate Compliance Program
Mechanisms for monitoring compliance, including independent evaluations.
What does MAC Stand for?
Medicare Administrative Contractor
What does MSP Mean?
Medicare Secondary Payer
If the patient has Disability Medicare & a LGHP with less then 100 employees who would be primary?
Medicare.
What is an NPI?
National Provider Identifier
What is an NEMB
Notice of Exclusion for Medicare Benefits
What is the OCR?
Office of Civil Rights
What is the OIG?
Office of Inspector General
Who is the "Self-Police"?
Office of Inspector General (OIG)
Liability Coverage is primary to Medicare unless it occues?
On the patients own property.
What is the CCO Role?
Oversees Code of Conduct
What is the 4th Element of the Corporate Compliance Program
Oversight of personnel by high-level personnel.
What is PHI?
Patient Health Information
What do business/organizational ethics represent?
Principles and standards by which organizations operate
What happens when a providers violate CMS regulations?
Providers are subject to Corporate Integrity Agreements.
What is the 9th Element of the Corporate Compliance Program
Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines.
How is the ACA reforming quality of care?
Reducing hospital readmissions. Reducing hospital acquired conditions. Comprehensive Joint Replacement and Cardiac Services Improving physician quality reporting.
What is the 1st Element of the Corporate Compliance Program
Self-reporting of adverse administrative events and recommendations regarding corrective action may preempt or mitigate the need for sanctions
What is the definition of a compliance program?
Systematic procedures instituted by an organization to ensure that the provisions of the regulations imposed by a government agency are being met.
In order to promote the use of correct coding methods on a national basis and prevent payment errors due to improper coding, CMS developed what?
The Correct Coding Initiative (CCI)
What is HIPAA?
The Health Insurance Portability and Accountability Act
What is a Level 2 Modifier?
The Level II Modifiers apply whether Medicare is the primary or secondary payer. They may be appended to CPT codes. Level II anatomical modifiers are required to add specificity to the reporting of procedures performed on eyelids, fingers, toes, and arteries. Provide additional detail about an anatomical location or about a procedure or service. Apply to HCPCS codes. Consist of either: Two letters, or A letter and a number
Why do you use Modifiers?
The appropriate use of modifiers reduces the need for separate procedure listings on a bill by describing the modifying circumstance.
What does the FCA do?
The closure of loopholes, and to enhance the ability of the government, whistleblowers, and reporting individuals to identify and successfully pursue entities and individuals who improperly receive government funds. Before FERA, whistleblowers could assert a claim under the False Claims Act only if the provider had wrongfully obtained government funds to which the provider was not entitled. If the provider received excessive funds as a result of an error by the government or innocent mistake by the provider, the harsh penalties under the FCA did not apply. Pursuant to the new legislation, whistleblowers can now bring a FCA action against providers who knowingly and improperly keep government funds that are paid to them in error.
What is the Code of Conduct for Compliance?
The code of conduct, if implemented effectively and enhanced as needed, can reduce weaknesses by helping employees and agents understand their roles and responsibilities while fostering an environment where concerns and questions are raised without fear of retaliation or retribution.The code of conduct is a living, breathing embodiment of the organization's compliance program, and with it, the organization's culture.
Why did Medicare implement BNI?
This initiative details the 9 different types of financial liability notices required under both the traditional Medicare and Medicare Advantage programs.
What is the propose of Corporate Compliance Program Elements?
Transparent, Clearly articulated, and Emphasized to all employees at every level as a seriously held personal and organizational responsibility, one that relies on full communication inside and outside the organization. There are a total of 16 Corporate Compliance elements, the first 9 elements will be discussed on this page and the remainder will be discussed on the next page.
What is a Level 1 Modifier?
Used for OPPS: Usually provide information about performance of a procedure, although there are exceptions. Apply to CPT codes. Consist of two numbers.
What is a Violation of the DRG Window?
When the required bundling of services is not done and individual claims are submitted to the Medicare Administrative Contractor
What is the 11th Element of the Corporate Compliance Program
Written communication standards and procedures.
What is the 5th Element of the Corporate Compliance Program
Written procedures, including an employee code of ethics and written policies and procedures that promote the organizations' commitment to compliance.
What type of HIPAA transaction is an 275?
claims attachments
What does the CCI program consist of?
edits that are implemented within providers' claim processing systems. The CCI edits are incorporated within the outpatient code editor. The edits also check for mutually exclusive code pairs.The unit-of-service edits determine the maximum allowed number of services for each Healthcare Common Procedure Coding System (HCPCS) code. Other coding initiatives include: Modifiers, Exception, and Modifiers Used for Outpatient Prospective Payment System (OPPS)
What is an ACO?
is a delivery system of physicians, hospitals, and other healthcare providers, who work collaboratively to manage and coordinate the care of a patient population.
What is the point of the ACO collaboration?
is to ensure: Appropriateness of care Elimination of duplicate services Prevention of medical errors for a population of patients
What is RAC?
recovery audit contractors
What does the HITECH Act address?
the privacy and security concerns associated with the electronic transmission of health information, in part through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules.
Why were NPI's created?
to eliminate the myriad of provider identifiers previously used within the healthcare industry.
Why was When was The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act?
to promote the adoption and meaningful use of health information technology.
Why was the OIG created?
to protect the integrity of the Health and Human Services (HHS) Department programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse.
What was the ACA designed to do?
to reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services.
What is the Two Midnight Rule?
"Two-Midnight Rule" policy whereby the agency will generally consider hospital admissions spanning two midnights as appropriate for payment under the IPPS rule. In contrast, hospital stays of less than two midnights will generally be considered outpatient cases, regardless of clinical severity.
What are some key risk area's that can lead to potential fraud and abuse?
"Upcoding" of MS-DRG assignments Inaccurate or incorrect coding Bundling/unbundling of services Duplicate billing Billing for medically unnecessary services Waiving of deductibles to entice business Insufficient documentation
What information is needed when cancelling a claim to a liability carrier and billing Medicare?
05 occurrence code with date of injury
A IPPS Medicare provider can cancel the liability claim and bill Medicare after how many days?
120
When did corporate compliance programs in healthcare begin to rise?
1980's
When was HIPAA passed?
1996
When was the ACA passed and signed into law?
2010
What is a comprehensive compliance plan?
A comprehensive plan will also insulate the hospital from violations of False Claims (Fraud and Abuse) regulations ($11,665 - 23,331 per claim, adjusted for inflation and triple damages) and may lessen the monetary effect of inadvertent violations in the future.
What is the 2nd Element of the Corporate Compliance Program
A corporate culture that encourages the constructive identification of potential or actual violations of federal and state statutes and regulations, and therefore takes immediate action with all appropriate parties to remedy the situation.
Annually, the OIG publishes a work plan of compliance issues and objectives that will be focused on throughout the following year. What are the work plan tasks?
A. Payments to Physicians for Co-Surgery Procedures B. Denials and Appeals in Medicare Part D C. Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies
What does ACO stand for?
Accountable Care Organization
What is an ABN?
Advanced Beneficiary Notice of Noncoverage
What is an SNFABN
Advanced Beneficiary Notice of Noncoverage for SNF Services
What is the ACA?
Affordable Care Act
How did the Federal Justice Department recover $2.6 billion in 2017?
Allegedly provided unnecessary or inadequate care. Paid kickbacks to healthcare providers to induce the use of certain goods and services. Overcharged for goods and services paid for by Medicare, Medicaid and other federal healthcare programs.
What is the 12th Element of the Corporate Compliance Program
An effective plan to communicate the above written standards and procedures internally to employees and agents.
What is the Medicare DRG Three-Day Payment Window?
Any Outpatient Services Treated as Inpatient if DOS is 3 days prior to IP Stay
What is the 15th Element of the Corporate Compliance Program
Appropriate and consistent disciplinary measures and mechanisms for employees violating procedures/ethics.
What is a BNI?
Beneficiary Notices Initiative
What type of HIPAA transaction is an 834?
Benefit Enrollment & Maintence
What is required in order to allow external entities access to patient specific records or PHI.
Business Associate Agreements (BAA)
What does CCO stand for?
Chief Compliance Officer