AAHAM Certification Exam Questions With Correct Answers

What are the Federal Agencies that are part of the U.S. Department of Health and Human Services (HHS)? - Answer Centers of Medicare & Medicaid Services (CMS) Office of Inspector General (OIG) What are the HHS Operating Divisions? - Answer National Institutes of Health (NIH) Food and Drug Administration (FDA) Centers of Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) Indian Health Service (HIS) Health Resources and Services Administration (SAMHSA) Agency for Healthcare Research and Quality (AHRQ) Centers for Medicare and Medicaid Services (CMS) Administration for Children and Families (ACF) Administration for Community Living (ACL) What is the role of the CMS? - Answer CMS is responsible for developing rules and regulations that govern Medicare and Medicaid. They also administer the Quality Improvement Organization (QIO) to monitor and improve quality of care for Medicare beneficiaries. Medicare = Title XVIII 18 Medicaid = Title XIX 19 What is the role of OIG? - Answer Protect the integrity of HHS programs and the health and welfare of the beneficiaries of those programs. They have a major role in investigating fraud and abuse Name major federal regulations and describe their impact in the following areas: - Answer Patient Rights Administrative simplification Data storage and recovery Affordable care Consumer Marketplace Anti-fraud and abuse Telephone consumer protection Credit and Collections Patient anti-dumping Performance Improvement Describe Patient's Bill of Rights? - Answer Developed by the American Hospital Association (AHA) to state expectations that patients and their families can have about how they want to be treated in healthcare situations. It is also known as the plain language brochure called the Patient Care partnership. What are the criteria in the plain language brochure? - Answer High quality hospital care A clean and safe environment Involvement in your care Protection of your privacy Help when leaving the hospital Help with your billing claims What is HIPAA? - Answer The Health Insurance Portability and Accountability Act creates national standards for the safe and accurate exchange of patient information. What is PHI? - Answer Protected Health Information under HIPAA including any data that couple be used individually or in combination to match patient's medical information. How can PHI be shared? - Answer · Can be shared without explicit consent for treatment, payment, or healthcare operations · Cannot be shared for marketing purposed without explicit consent · Cannot be shared with law enforcement agencies without consent or proper notification to the patient, except under court order · Vendors who handle PHI on behalf of providers much sign an agreement that obligates them to treat it on the same basis as covered entities Who does the confidentiality of patient information apply to? - Answer Every employee, not just those dealing with medical records due to the volume of data and the multiple people who might have access to it What is the Patient Self Determination Act (PSDA)? - Answer Ensures that patients understand their right to participate in decisions about their own healthcare and to provide a means to ensure it Define advance directives and describe each type: - Answer Advance directives are written statements of a patient's wishes regarding medical treatment in the event that he or she becomes unable to make certain decisions. · Living Will - a document that specifies what treatments a patient does and does not wish to receive. Patients can make known the circumstances under which they will die. This is made while they are alert. · Healthcare Power of Attorney or Durable Power of Attorney - a document that designates someone else's to make decisions on behalf of the patient if he or she is unable to do so · Do Not Resuscitate Order (DNR) - a document that states a patient does not wish to have CPR or similar interventions performed in the event of a medical emergency What are hospitals and other healthcare providers whom receive federal funds required to do under the PSDA? - Answer · Inform the adult patient in writing of his or her right to accept or refuse medical treatments and to formulate advance directives · Provide each patient with written information describing the facilities policies regarding their rights · Inquire and then document in the patient's medical record whether or not the patient has executed an advance directive · Provide staff and community education on advance directives · Refrain from discriminating against the patient on whether or not the patient has executed an advance directive What is the Patient Protection and Affordable Care Act (PPACA)? - Answer It decreases the number of uninsured Americans which reduces the overall cost of healthcare Define consumer marketplace and describe the various options available for healthcare: - Answer · Agents and brokers - compensated by health insurance companies and may only sell plans from specific health insurance companies. These services are free to all consumers. · Navigators - Determine which programs consumers qualify for and help them get enrolled into coverage and refer them to the appropriate state agencies (Medicaid/Children's Health Insurance Program). They are funded through state and federal grant programs. · Non-Navigators - they only exist in a state-based Marketplace. They are funded through separate grants or contracts administered by the state. These services are free for all consumers. · Certified application counselors - Provide free info about insurance programs and assist them in apply for coverage. They do not receive federal grant money. They are funded by federal funding through Medicaid. · Call centers - can assist consumers with the Marketplace application process. · Consumer assistance programs - help address consumers problems or questions about health coverage What is the difference between Fraud and Abuse? - Answer · Fraud - is the intentional or illegal deception or misrepresentation that an individual knows or suspects to be false and knows that it could results in some type of benefit to themselves, someone else, or the organization. Abuse - describes incidents or practices where providers, physicians, or suppliers are inconsistent with accepted sound medical, business, or fiscal practices, which results in unnecessary costs or improper reimbursement of services that fail to meet professionally recognized standards of care or that are deemed medically unnecessary What is the Anti-Kickback Statue and False Claims Act? - Answer Prohibits offering free or discounted services to a physician associated with, or refers patients to, another healthcare facility What are administrative sanctions? - Answer Can be taken to address an issue of inappropriate/fraudulent behavior on the part of a provider · Denial or revocation of the provider number application - CMS can deny or revoke an application for a Medicare provider number is there is evidence of impropriety or if the provider doesn't meet state or federal licensure/certification requirements. · Suspension of provider payments - CMS has the authority to suspend provider payments if the provider is suspected of fraud or if an overpayment exists. o Payment suspensions may last up to 180 days and an additional 180-day suspension payment may be placed. It can also be indefinite. o There are no appeal rights o It can be lifted once funds are recovered or if there is sufficient information in the provider's rebuttal statement to demonstrate that payment suspension is not necessary. · Application of Civil Monetary Penalties (CMPs) - can be imposed when Medicare has determined that an individual or entity has violated the Medicare rules and regulations. What are exclusions by the OIG when it comes to providers and suppliers participating in any federal healthcare programs? - Answer There are Mandatory and Permissive Exclusions · Mandatory - involved providers and suppliers who are convicted of: o Medicare fraud o Patient neglect o Patient abuse o Felonies o Healthcare related fraud o Healthcare related theft o Financial Misconduct o Prescription fraud o Unlawfully manufacturing, distributing, or dispensing of controlled substances · Permissive - involve misdemeanor convictions which are related to: o Controlled substances o Healthcare fraud o License revocation o Suspension of licensure o Obstruction of any type of healthcare investigation What is Telephone Consumer Protection Act (TCPA)? - Answer Restricts telephone solicitations and the use of automated telephone equipment. · The patient must make prior consent for any call, auto-mated or manual, made to a wireless phone · The provider can only make calls related to the original consent What is the Truth in Lending Act (Regulation Z)? - Answer Promotes the informed use of consumer credit by requiring disclosures about its terms and cost. A creditor is given 30 days to respond to a written notice of a dispute or billing error. What is the Fair Credit Billing Act? - Answer Provides settlement procedures for disputes about "billing errors". · A patient must notify the hospital of any error within 60 days after a statement is mailed · The hospital must respond to the complaint within 30 days of receiving it · The error must be corrected, or the accuracy of the statement explained to the customer within two billing cycles or a maximum of 90 days · If any of the above time frames are not met, a patient's rights are violated, and collection of the account may be forfeited. What is the Fair Debt Collection Practices Act (FDCPA)? - Answer Requires that debt collectors follow specific practices when collecting debt without being abusive, deceptive, and unfair. · Prohibits harassment or abuse or use of false or misleading information in the collection process · Defines unfair collection process · Defines permissible actions regarding multiple debts · Provide procedures to validate debts What is the Equal Credit Opportunity Act (ECOA)? - Answer Prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because someone receives public assistance. They can ask for most of the information but cannot use it when deciding whether to give a person credit or when setting the terms of credit. What is patient anti-dumping/Emergency Medical Treatment and Active Labor Act (EMTALA)? - Answer Registration staff are allowed to gather basic demographic information from a patient seeking treatment but questions on how they intend to pay are prohibited until the patient has received a medical screening exam. What are the major provisions of EMTALA patient screen and transfer regulations? - Answer · The patient must receive a medical screening examination to determine whether any emergency medical condition exists · The patient must be stable prior to being transferred · The physician must certify that the transfer is appropriate · A patient can request transfer, but not as the suggestion of the hospital · The transferring hospital must send medical records with the patient What are the two major areas of performance healthcare improvement? - Answer Laboratory Certification and Quality Payment Who does EMTALA apply to? - Answer It applies to any location on a hospital's campus and to all patients in the facility, not just ED patients What is Clinical Laboratory Improvement Amendments (CLIA)? - Answer Ensures quality laboratory testing through how tests are performed, the level of testing performed, and who can perform tests. The CLIA number must be reported on the claim form when the provider is a Medicare participating provider. What are the 5 types of CLIA certificates? - Answer · Certificate of Waiver · Certificate for Provider-Performed Microscopy Procedures · Certificate of Registration · Certificate of Compliance · Certificate of Accreditation What are the two states exempt from CLIA certification? - Answer Washington and New York What is the Physician Quality Payment Program? - Answer Encourages individual eligible professionals and group practices to assess the quality of care provided to Medicare beneficiaries and to report that information to Medicare. This is an incentive program and physicians can participate in two ways: · The Merit-based Incentive Payment Systems (MIPS) - physicians are subjected to performance-based reviews · Advanced Alternative Payment Models (APMs) - Earn a Medicare incentive payment for sufficiently participating in an innovative payment model What is the Joint Commission (TJC)? - Answer Is a private agency that seeks to protect and improve the quality and safety of care. TJC will conduct an audit of a hospital every 39 months and of a laboratory every two years. They can be audited at any time What does the TJC survey include? - Answer · Distribution and discussion about advanced directives · Patient rights and responsibilities · Organizational ethics · Continuum of care · Management of environment of care · Confidentiality · Privacy · Security · Communication How does TJC require hospitals to outline disaster plans? - Answer Contingency plans should outline the actions to take before, during, and after a disaster or major disruption. Emergencies can include disasters and bomb threats. What is the primary duty of Front Office personnel? - Answer To act as a liaison between the physician and the patient. · Scheduling · Preadmission and preregistration · Precertification and preauthorization · Registration and admission · Insurance verification · Financial counseling · Collection · Compliance What are the trends in the patient access process? - Answer · Placing the focus on customer service to improve the initial patient impression · Training staff to improve point of service collections and protect the patient's financial health · Ensuring that the admitting staff is well educated and can answer questions correctly · Identifying ways to decrease wait times · Preregistering patients whenever possible · Making the process a positive experience for the patient/guarantor/family What are the benefits of preadmission? - Answer · Wait times are reduced on the day of service · The patient can report directly to the area of service · More time to verify benefit information · Policy requirements and limitations can be placed · Identify needs for financial assistance · Identify copays and deductibles · Precertification can take place · Clinical work can be arranged · Special needs can be arranged How are mental health and substance abuse treatments handled during the preauthorization process? - Answer They are handled by a behavioral health company and are separate from the main insurance. The requirements are often different and should be carefully determined.