CPHRM Exam Prep – Legal and Regulatory
Questions with Verified Correct Answers
Discuss The Joint Commission (TJC) as voluntary surveying body, including the
benefits of accreditation
TJC - independent, non-profit organization created in 1951 by merging the American College
of Surgeons' hospital standardization program with other programs from the American
College of Physicians, the American Hospital Association, the American Medical
Association, and the Canadian Medical Association.
Primary purpose - improve quality of healthcare by voluntary accreditation of healthcare
orgs.
TJC established a set of standards that are used objectively to evaluate safety and quality
patient care.
Surveys are unannounced and occur 18-36 months.
CMS has granted deeming authority to TJC to determine a facility meets Medicare and
Medicaid certification requirements.
Discuss the reporting of sentinel events to The Joint Commission (TJC)
Sentinel event policy encourages voluntary self-reporting of patient safety events in order to
reduce the risk of similar events occurring in the future. Including completion of a root cause
analysis (RCA) to examine the underlying contributors to an adverse event or condition after
it has occurred, along with a development of a corrective action plan.
Self-reporting may also be viewed favorably by the public that the organization is
cooperating with TJC to improve patient safety.
,Describe the Medicare Program, its history, purpose and coverage
Medicare - the largest US health insurance administered by the Center for Medicare &
Medicaid Services (CMS), a federal Health and Human Services (HHS) agency.
Signed up into law in 1965 as part of Title XVIII the Social Security Act to provide coverage
to people unable to afford necessary care.
In 1972, it was expanded to cover persons younger than 65 with specific long-term
disabilities.
Coverage:
Part A - inpatient/hospital services (including skill nurse, home health, etc.)
Part B - outpatient services (physician fees, medical equipment, diagnostics, etc.)
Part D - prescription drug coverage.
Medigap plan (aka Medicare supplements) was created to cover additional services not cover
under Part A and B.
Define DRG, prospective payment methods of Medicare reimbursement
In 1980s CMS adopted prospective payment system using standardized payment units called
Diagnosis Related Groups (DRG).
DRG classify healthcare cases into one or more groups based on the diagnosis, procedure,
and complication, in order to identify the care provided by the facility.
For example, appendectomy - product based on care typically provided with a patient with
appendicitis.
The prospective payment system was developed to encourage cost containment by
reimbursement an amount determined to be appropriate for the typical patient, rather than
whatever the facility determines are appropriate to bill Medicare.
,Define hospital-acquired conditions (HACs) and discuss Medicare reimbursement for
these conditions
Hospital-acquired conditions (HACs) are conditions that develop during a hospital stay,
which were not present upon a patient's admission
1. occur frequently, are costly, or both
2. change a primary assigned DRG to a higher payment due to a secondary diagnosis, and
3. are identifiable, preventable through evidence-based care, and serious in their
consequences.
Facilities won't receive payment for HACs unless it was present on admission.
CMS becomes aware of HACs from the facility because it is required to report them using
defined billing codes (ICD-10 codes).
Identify the categories of HACs for which Medicare won't reimburse the facility
Non-reimbursable HACs:
- unintentional retention of foreign objects
- air embolism
- blood incompatibility
- stage III and IV pressure ulcers
- conditions resulting from falls and other trauma
- evidence of poor glycemic control
- catheter-associated unitary track infections
- surgical site infections following specific procedures (coronary artery bypass, bariatric,
orthopedic surgeries, etc.)
- vascular catheter-associated infections
, - deep vein thrombosis/pulmonary embolism associated with orthopedic surgery
- latrogenic pneumothorax with venous catheterization
Discuss Emergency Medical Treatment & Labor Act (EMTALA) history, purpose and
legislation
EMTALA was enacted in 1986 under the Consolidated Omnibus Budget Reconciliation Act
(COBRA), commonly referred are the "antidumping statute."
EMTALA ensures that individuals receive a medical screening and stabilizing treatment for
emergency medical conditions, regardless of their ability to pay or insurance status. COBRA,
on the other hand, allows individuals who lose their job-based health insurance to temporarily
continue their coverage.
EMTALA requirements: any person who comes to the emergency department seeking
evaluation or treatment for a medical condition, regardless of their ability to pay, must be:
1. provided with a medical screening exam (MSE) to confirm if an emergency medical
condition exist.
2. if so, stabilize the emergency medical condition, and/or
3. transfer patient to a facility that provides higher level of care if necessary
Key EMTALA terms
Emergency Medical Condition - acute symptoms of sufficient severity, including severe pain,
resulting in placing patent's health in serious jeopardy (bodily function impairment, body
organ disfunction, etc.) - 42 USC 1395dd(e)(1).
Dedicated emergency department - specially equipped and staffed to treat patient with
Questions with Verified Correct Answers
Discuss The Joint Commission (TJC) as voluntary surveying body, including the
benefits of accreditation
TJC - independent, non-profit organization created in 1951 by merging the American College
of Surgeons' hospital standardization program with other programs from the American
College of Physicians, the American Hospital Association, the American Medical
Association, and the Canadian Medical Association.
Primary purpose - improve quality of healthcare by voluntary accreditation of healthcare
orgs.
TJC established a set of standards that are used objectively to evaluate safety and quality
patient care.
Surveys are unannounced and occur 18-36 months.
CMS has granted deeming authority to TJC to determine a facility meets Medicare and
Medicaid certification requirements.
Discuss the reporting of sentinel events to The Joint Commission (TJC)
Sentinel event policy encourages voluntary self-reporting of patient safety events in order to
reduce the risk of similar events occurring in the future. Including completion of a root cause
analysis (RCA) to examine the underlying contributors to an adverse event or condition after
it has occurred, along with a development of a corrective action plan.
Self-reporting may also be viewed favorably by the public that the organization is
cooperating with TJC to improve patient safety.
,Describe the Medicare Program, its history, purpose and coverage
Medicare - the largest US health insurance administered by the Center for Medicare &
Medicaid Services (CMS), a federal Health and Human Services (HHS) agency.
Signed up into law in 1965 as part of Title XVIII the Social Security Act to provide coverage
to people unable to afford necessary care.
In 1972, it was expanded to cover persons younger than 65 with specific long-term
disabilities.
Coverage:
Part A - inpatient/hospital services (including skill nurse, home health, etc.)
Part B - outpatient services (physician fees, medical equipment, diagnostics, etc.)
Part D - prescription drug coverage.
Medigap plan (aka Medicare supplements) was created to cover additional services not cover
under Part A and B.
Define DRG, prospective payment methods of Medicare reimbursement
In 1980s CMS adopted prospective payment system using standardized payment units called
Diagnosis Related Groups (DRG).
DRG classify healthcare cases into one or more groups based on the diagnosis, procedure,
and complication, in order to identify the care provided by the facility.
For example, appendectomy - product based on care typically provided with a patient with
appendicitis.
The prospective payment system was developed to encourage cost containment by
reimbursement an amount determined to be appropriate for the typical patient, rather than
whatever the facility determines are appropriate to bill Medicare.
,Define hospital-acquired conditions (HACs) and discuss Medicare reimbursement for
these conditions
Hospital-acquired conditions (HACs) are conditions that develop during a hospital stay,
which were not present upon a patient's admission
1. occur frequently, are costly, or both
2. change a primary assigned DRG to a higher payment due to a secondary diagnosis, and
3. are identifiable, preventable through evidence-based care, and serious in their
consequences.
Facilities won't receive payment for HACs unless it was present on admission.
CMS becomes aware of HACs from the facility because it is required to report them using
defined billing codes (ICD-10 codes).
Identify the categories of HACs for which Medicare won't reimburse the facility
Non-reimbursable HACs:
- unintentional retention of foreign objects
- air embolism
- blood incompatibility
- stage III and IV pressure ulcers
- conditions resulting from falls and other trauma
- evidence of poor glycemic control
- catheter-associated unitary track infections
- surgical site infections following specific procedures (coronary artery bypass, bariatric,
orthopedic surgeries, etc.)
- vascular catheter-associated infections
, - deep vein thrombosis/pulmonary embolism associated with orthopedic surgery
- latrogenic pneumothorax with venous catheterization
Discuss Emergency Medical Treatment & Labor Act (EMTALA) history, purpose and
legislation
EMTALA was enacted in 1986 under the Consolidated Omnibus Budget Reconciliation Act
(COBRA), commonly referred are the "antidumping statute."
EMTALA ensures that individuals receive a medical screening and stabilizing treatment for
emergency medical conditions, regardless of their ability to pay or insurance status. COBRA,
on the other hand, allows individuals who lose their job-based health insurance to temporarily
continue their coverage.
EMTALA requirements: any person who comes to the emergency department seeking
evaluation or treatment for a medical condition, regardless of their ability to pay, must be:
1. provided with a medical screening exam (MSE) to confirm if an emergency medical
condition exist.
2. if so, stabilize the emergency medical condition, and/or
3. transfer patient to a facility that provides higher level of care if necessary
Key EMTALA terms
Emergency Medical Condition - acute symptoms of sufficient severity, including severe pain,
resulting in placing patent's health in serious jeopardy (bodily function impairment, body
organ disfunction, etc.) - 42 USC 1395dd(e)(1).
Dedicated emergency department - specially equipped and staffed to treat patient with
