lesson 3

Tax Equity and Fiscal Responsibility Act (1982)

- Its purpose was to control the rising cost of providing healthcare services to Medicare beneficiaries. -Prior to TEFRA, Medicare beneficiaries' healthcare services were reimbursed on a retrospective (fee-based) payment system. The legislation required the gradual implementation of a Prospective Payment System (PPS) for Medicare reimbursement to healthcare providers.

The Joint Commission

Founded in 1952, the Joint Commission (TJC) has continually evolved to meet the changing needs of healthcare organizations and has grown into the largest standards-setting body in the world -With a Mission "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest qualify and value."

Which of the following federal legislations was responsible for the creation of the Healthcare Integrity and Protection Data Bank (HPDB)?

HIPAA

ORYX Initiative

Hospitals and Critical Access Hospitals report on a minimum of six sets of specific ORYX® core measures which are process and /or outcome measures of performance. The JC posts a list of ORYX® vendors for facilities to select from

Which of the following professional organizations is NOT one of the Cooperating Parties?

It is the American Medical Association (AMA) that is NOT part of the organization. The Cooperating Parties are the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS).

The Health Insurance Portability and Accountability Act (HIPAA) has a provision for standard medical code sets that include ICD-10-CM, ICD-10-PCS, and CPT coding systems.

It is true that the Health Insurance Portability and Accountability Act has a provision for medical code sets that include ICD-10-CM, ICD-10-PCS, and CPT code sets.

National Patient Safety Goals

Joint Commission Website. Listed here are a few of the 2016 hospital National Patient Safety Goals: Indentify patients correctly, Improve staff communication, Use medicines safely, Use alarms safely, Prevent mistakes in surgery.

Which governmental agencies share responsibility for overseeing all changes and modifications to the ICD-10-CM and ICD-10-PCS?

National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS)

AHIMA

Organization for managers of health record services and healthcare information

_______ was the federal legislation responsible for the origin of utilization review by establishing professional standards review organizations (PSROs).

Public Law 92-603

ACHE

Society for healthcare leadership and management

Which of the following is NOT an activity of the American Medical Association (AMA)?

The AMA does not license physicians.

This association was founded in 1928 under the name of the Association of Record Librarians of North America.

The American Health Information Management Association (AHIMA) was founded in 1928 under the name of the Association of Record Librarians of North America.

Which of the following is NOT a government organization?

The Institute of Medicine (IOM)

Which healthcare agency is part of the Centers for Disease Control and Prevention (CDC)?

The NCHS is one of the organizational components of the Centers for Disease Control.

American College of Healthcare Executives (ACHE)

-40,000-member international professional society that seeks to improve the health of society by advancing healthcare leadership and management -known for its prestigious credentialing and educational programs -Access to Affordable Healthcare and Organ/Tissue/Blood/Blood Stem Cell Donation

Associations Influencing Healthcare and Medicine

-American College of Healthcare Executives (ACHE) -American Health Information Management Association (AHIMA) -American Hospital Association (AHA) -American Medical Association (AMA) -American Nurses Association (ANA) -Blue Cross and Blue Shield Association (BCBSA) -The Institute of Medicine (IOM) -The National Committee for Quality Assurance (NCQA)

Social Security Act (1935)

-By 1931, nine states had created old age pension programs -On June 8, 1934, he announced a committee that would study the issue and report to Congress in January 1935. The committee consisted of four members of the cabinet and the federal relief administrator and was headed by the secretary of labor, Frances Perkins -The Committee on Economic Security was in favor of health insurance as part of Social Security -In the end, the Social Security bill included only one reference to health insurance as a subject that the new Social Security Board might study and the Social Security Act was passed in 1935

Public Law 89-97 (1965)

-Medicare is a federal program providing healthcare benefits for people 65 years old and older who are covered by Social Security (SSA 2014). The program was inaugurated on July 1, 1966. Since then, amendments have extended coverage to individuals not covered by Social Security but who are willing to pay a premium for coverage, to the disabled, and to those suffering from chronic kidney disease -Medicaid is a federally mandated program providing healthcare benefits to low-income people and their children. Beginning in January 1967, Medicaid provided federal funds to states on a cost-sharing basis to guarantee welfare recipients' medical services. Coverage of four types of care was required: inpatient and outpatient services, other laboratory and X-ray services, physician services, and nursing facility care for persons over the age of twenty-one

American Recovery and Reinvestment Act of 2009

-The American Recovery and Reinvestment Act (ARRA) is one of the single largest health information technology laws in recent history and was signed by President Barack Obama in February of 2009. ARRA provided stimulus funds to the US economy. -Title XIII of the Act, which is entitled the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act allocated funding for the implementation of a nationwide health information exchange as well as implementation of electronic health records (EHRs) -The four major components of this bill include: =Meaningful use (requiring that providers use certified EHRs to improve patient outcomes) =EHR standards and certifications =Regional Extension Centers (used to assist providers with the selection and implementation of EHRs) =Breach notification guidance

NIH Agencies

-The NIH is one of eight health agencies of the Public Health Services which, in turn, is part of the US Department of Health and Human Services -Specifically of interest to coding professionals, diagnosis and procedure codes submitted by healthcare facilities in bills and vital statistic reports play a big role in data gathering, statistic compilation and pattern trending reports maintained by the NIH.

Omnibus Budget Reconciliation Act (1989)

-The Omnibus Budget Reconciliation Act of 1989 instituted the Agency for Health Care Policy and Research (AHCPR), which is a Public Health Service agency in the Department of Health and Human Services (HHS). The agency was reorganized in 1999 as the Agency for Healthcare Research and Quality (AHRQ). -Its "sister" agencies include:The National Institutes of Health, The Centers for Disease Control and Prevention, The Food and Drug Administration, The Centers for Medicare and Medicaid Services, The Health Resources and Services Administration

Public Law 98-21 (1983)

-The Prospective Payment System (PPS) for acute hospital care (inpatient) services was implemented on October 1, 1983, according to Public Law 98-21. -inpatient PPS, reimbursement for hospital care provided to Medicare patients is based on diagnosis-related groups (DRGs) -Implementation of the Ambulatory Payment Classification (APC) system for hospital outpatient services began in the year 2000

National Center for Health Statistics (NCHS)

-The agency provides data that can be used to monitor the nation's health and since its inception has received several legislative mandates and authorities works with CDC -NCHS data systems include "data on vital events as well as information on health status, lifestyle and exposure to unhealthy influences, the onset and diagnosis of illness and disability, and the use of healthcare" -NCHS is responsible for the modifications to ICD-10-CM and CMS is responsible for the modifications to ICD-10-PCS. NCHS serves as the World Health Organization (WHO)

Health Care Quality Improvement Act (1986)

-established the National Practitioner Data Bank (NPDB). The purpose of the NPDB is to provide a clearinghouse for information about medical practitioners who have a history of malpractice suits and other quality problems -Hospitals are required to consult the NPDB before granting medical staff privileges to healthcare practitioners.

American Nurses Association (ANA)

-founded in 1897. It is headquartered in Washington, DC -The ANA's purpose is to advance the nursing profession by "fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the general public."

Which of the following is a professional association with a stated vision of "leading the advancement and ethical use of quality health information to promote health and wellness worldwide"?

A stated vision of American Health Information Management Association (AHIMA) is "quality healthcare through quality information."

Which of the following periodicals is the only official publication for ICD-10-CM and ICD-10-PCS coding advice for these code sets?

Coding Clinic for ICD-10-CM and ICD-10-PCS is the only official publication for coding advice for these code sets.

NCQA

Develops quality standards and performance measures for healthcare entities

The federal legislation responsible for the establishment of Accountable Care Organizations (ACOs) is

The Patient Protection and Affordable Care Act is responsible for the establishment of ACOs.

national patient safety goals

These are specific Joint Commission goals established each year for patient safety for various care settings

TJC

This organization performs accreditation surveys on acute care hospitals.

The Joint Commission accredits

acute care hospitals, ambulatory care facilities, long-term care facilities, behavioral health facilities, healthcare networks, and managed care organizations.

Which aspect of the Tax Equity and Fiscal Responsibility Act of 1982 still has a profound influence on healthcare reimbursement today?

for the gradual implementation of a prospective payment system.

Utilization Review Act (1977)

in 1977, the Utilization Review Act required that hospitals conduct continued stay reviews for Medicare and Medicaid patients. Continued stay reviews determine whether it is medically necessary for a patient to remain in the hospital. Fraud and abuse regulations were also included in this legislation.

Consolidated Omnibus Budget Reconciliation Act (1985)

made it possible for the Health Care Financing Administration (HCFA) to deny reimbursement for substandard healthcare services provided to Medicare and Medicaid beneficiaries. HCFA's name was changed to the Centers for Medicare and Medicaid Services (CMS) in June 2001

CARF accredits

medical rehabilitation facilities.

ORXY

this is an initiative that incorporates the ongoing collection of quality and performance data into the accreditation process.

What is the primary function of the National Institutes of Health?

to uncover knowledge leading to better public health.

CARF is a not government-sponsored organization.

true

Commission on Accreditation of Rehabilitation Facilities

was founded in 1966 and is an independent and nonprofit accreditor of human service providers in aging services, behavioral health, child and youth services, vision rehabilitation, DMEPOS, employment and community services, medical rehabilitation, and opioid treatment programs.

The purpose of the Agency for Healthcare Research and Quality is to evaluate how the healthcare system is _______.

working

National Institutes of Health (NIH)

The NIH mission is "to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability" - Goals are 1. To foster fundamental creative discoveries, innovative research strategies, and their applications as a basis for ultimately protecting and improving health 2.To develop, maintain, and renew scientific human and physical resources that will ensure the Nation's capability to prevent disease, foster fundamental creative discoveries, innovative research strategies, and their applications as a basis for ultimately protecting and improving health 3. To expand the knowledge base in medical and associated sciences in order to enhance the Nation's economic well-being and ensure a continued high return on the public investment in research 4. To exemplify and promote the highest level of scientific integrity, public accountability, and social responsibility in the conduct of science.

Biologics Control Act (1902)

-Direct federal sponsorship of medical research began when early researchers were seeking methods for controlling epidemics and outbreaks of infectious disease. The first research of this type was performed by the Marine Hospital Service where, in 1887, a young doctor named Joseph Kinyoun set up a bacteriological laboratory in the Marine Hospital at Staten Island, New York -In 1902, it received authority to test and improve biological products when Congress passed the Biologics Control Act; in that same year, the Hygienic Laboratory began doing research in chemistry, pharmacology, and zoology -regulated the vaccines and serums sold via interstate commerce. -n 1912, the US Public Health Service was authorized to study chronic diseases in addition to the infectious ones it already studied . In 1930, the Hygienic Laboratory was reorganized under the Randsdell Act and became the National Institutes of Health (NIH). Later, in the decade, in 1938, it moved to a large, privately donated estate in Bethesda, Maryland

American Medical Association (AMA)

-Founded in 1847 -acts as an accreditation body for medical schools and residency programs. It also maintains and publishes the Current Procedural Terminology (CPT) coding system. -Journal of the American Medical Association, a Code of Medical Ethics -Mission To promote the art and science of medicine and the betterment of public health.

Blue Cross and Blue Shield Association (BCBSA)

-The forerunner of the Blue Cross and Blue Shield Association (BCBS) was a commission instituted by the AHA in 1939. In 1960, the commission was replaced by the Blue Cross Association and ties to the AHA were broken. In 1982, the Blue Cross Association merged with the National Association of Blue Shield Plans to become the Blue Cross and Blue Shield Association. -consists of 36 independently operated Blue Cross and Blue Shield member companies, a Federal Employee Program and an Association -The Association owns and manages the Blue Cross and Blue Shield trademarks and names in more than 170 countries and territories around the world. The Association grants licenses to independent companies to use the trademarks and names in exclusive geographic areas. The association is headquartered in Chicago. -Today, enrollment in Blue Cross and Blue Shield health insurance plans represents one third of all Americans covered by some form of health insurance. -The Blue Cross and Blue Shield companies are often contractors for federal healthcare programs. These contractors, Medicare Administrative Contractors (MACs), process healthcare claims for beneficiaries and provide payments to healthcare providers. Coding professionals must keep abreast of reporting guidelines and reimbursement policies, as so often they will interact with these contractors.

Patient Protection and Affordable Care Act (2010)

-This law also requires the establishment of Accountable Care Organizations (ACOs). ACOs follow a healthcare model that develops a partnership between hospitals and physicians to coordinate and deliver quality care to Medicare patients. -Its major provisions include: Health insurance market reforms, including: =Subsidized premiums for people with pre-existing conditions =Elimination of lifetime limits on benefits The option of covering children on parents' insurance until the age of 26 =Development of state-based and state-administered health insurance exchanges =Consumer Operated and Oriented Plan program =Expansion of Medicaid to individuals under 65 with incomes up to 133 percent of federal poverty level =Individual mandate to have minimum acceptable coverage or pay a tax penalty =Employers with 50 or more employees must provide health coverage =Premium subsidies to individuals =Small employer tax credits

Health Insurance Portability and Accountability Act (1996)

-Title I of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects health insurance coverage when workers change or lose their jobs (State of California 2014). Workers' families are also protected. -Title II, the Administrative Simplification provisions, requires the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. -The data bank's mission is to inform federal and state agencies about final adverse actions regarding clinicians' quality problems as well as suppliers and other providers of healthcare services -The regulations published as a result of HIPAA have profoundly affected healthcare transactions through the creation of standardized code sets for electronic data interchange.

AHA Mission

-Today, the mission of the AHA is to advance the health of individuals and communities. The association has a current membership of approximately 5,000 hospitals, healthcare systems, networks, other providers of care, and 37,000 individual executives active in the healthcare field. The association's headquarters are located in Chicago. -Coding Guidance The AHA houses the Central Office on ICD-10-CM and ICD-10-PCS Coding. -AHA is one of the four Cooperating Parties for the development and maintenance of ICD-10. This organization also publishes Coding Clinic for ICD-10-CM and ICD-10-PCS

Public Law 92-603 (1972)

-Utilization review can be traced to professional standards review organizations (PSROs) that were established by the federal government in 1972 by Public Law 92-603, an amendment to the Social Security Act. The purpose of PSROs was to curtail Medicare and Medicaid spending by providing a mechanism for ongoing evaluation by local peer review organizations of care rendered to Medicare (Title XVIII) and Medicaid (Title XIX) patients. -PSROs performed professional review and evaluated patient care services for necessity, quality, and cost-effectiveness. PSROs were eventually replaced by Peer Review Organizations (PROs) in 1982. In 2002, PROs became Quality Improvement Organizations (QIOs) as the role of these organizations was to improve quality of care across the care continuum.

Mental Health Parity Act of 1996

-a federal law that applies to two different types of coverage: 1. Large group self-funded group health plans 2. Large group fully insured group health plans -The second discussion exists in an environment where effective new treatment strategies have transformed the practice of behavioral healthcare, and health insurance plans are using a new generation of tools to promote optimal care

American Hospital Association (AHA)

-founded in 1899 -Its first meeting consisted of eight hospital superintendents who gathered in Cleveland, Ohio, to exchange ideas, compare methods of hospital management, discuss economics, and explore common interests and new trends. The original group was called the Association of Hospital Superintendents. -Its mission was "to facilitate the interchange of ideas, comparing and contrasting methods of management, the discussion of hospital economics, the inspection of hospitals, suggestions of better plans for operating them, and such other matters as may affect the general interest of the membership," which has developed into its present mission, "to advance the health of individuals and communities. The AHA leads, represents and serves hospitals, health systems and other related organizations that are accountable to the community and committed to health improvement" (American Hospital Association 2016). The association adopted a new constitution in 1906 and a new name, the American Hospital Association. At that time, it had 234 members. Its major concerns were developing hospital standards and building the management skills of it members.

The Agency for Healthcare Research and Quality (AHRQ)

-is the federal agency responsible for research on the healthcare system -It began in 1989 as the Agency for Health Care Policy and Research (AHCPR) and is a Public Health Service agency in the Department of Health and Human Services (HHS). The agency reorganized in 1999 as the Agency for Healthcare Research and Quality. Its "sister" agencies include the National Institutes of Health, the Centers for Disease Control and Prevention, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, and the Health Resources and Services Administration.

The National Committee for Quality Assurance (NCQA)

-provides "Report Cards" and accreditation to healthcare plans -"NCQA Accreditation is used by most of the nation's Fortune 500 employers, federal and state governments, and consumers like you to help select among competing health plans. Only NCQA's Health Plan Report Card is based on a rigorous evaluation of clinical quality, member satisfaction and a comprehensive assessment of key systems and processes." -developing quality standards and performance measures for a broad range of health care entities

The Institute of Medicine (IOM)

-provides a vital service by working outside the framework of government to ensure scientifically informed analysis and independent guidance -mission is to serve as adviser to the nation to improve health. The Institute provides unbiased, evidence-based, and authoritative information and advice concerning health and science policy to policy-makers, professionals, leaders in every sector of society, and the public at large -committee reports or studies on a wide range of health-related subjects, from quality of medical care to the national smallpox vaccination program; from centers of excellence at the National Institutes of Health (NIH) to protecting the nation's food supply

Peer Review Improvement Act (1982)

-redesigned the PSRO program and renamed the agencies Peer Review Organizations (PROs). Today, PROs are known as Quality Improvement Organizations (QIOs). This name change officially took place on January 10, 2002. -The mission of the QIOs is to ensure the quality, efficiency, and cost-effectiveness of the healthcare services provided to Medicare beneficiaries in its locale

American Health Information Management Association (AHIMA)

-the professional membership organization for managers of health record services and healthcare information -founded in 1928 under the name of the Association of Record Librarians of North America, it adopted a constitution and bylaws in 1929. The name of the association was changed to the American Medical Record Association in 1970 and then to the American Health Information Management Association in 1991. -The association's vision is "leading the advancement and ethical use of quality health information to promote health and wellness worldwide." AHIMA's mission is to "lead the health informatics and information management community to advance professional practice and standards." These commitments are achieved through the five strategic pillars of information, leadership, information governance, innovation, and public good. -one of the four Cooperating Parties for the ongoing development and maintenance of ICD-10.

BCBSA

A contractor for federal and private healthcare programs