Certified Revenue Cycle Representative
Section 1 Cont.
What is HIPAA? - ANSThe Health Insurance Portability and Accountability Act
When was HIPAA passed? - ANS1996
What are some of the HIPAA requirements that specifically address compliance? -
ANSCoordinating 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 is PHI? - ANSPatient Health Information
Why were NPI's created? - ANSto eliminate the myriad of provider identifiers previously used
within the healthcare industry.
What is the goal of HIPAA? - ANSExpand 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 required in order to allow external entities access to patient specific records or PHI. -
ANSBusiness Associate Agreements (BAA)
What is an NPI? - ANSNational Provider Identifier
What is the OIG? - ANSOffice of Inspector General
Why was the OIG created? - ANSto 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 are the OIG Responsibilities? - ANSIdentifying opportunities to improve program
economy, efficiency, and effectiveness.
Holding accountable those who do not meet program requirements or who violate federal laws.
, Who is the "Self-Police"? - ANSOffice of Inspector General (OIG)
Who follows the OIG? - ANSHome 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 happens when a providers violate CMS regulations? - ANSProviders are subject to
Corporate Integrity Agreements.
What are some key risk area's that can lead to potential fraud and abuse? - ANS"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
When did corporate compliance programs in healthcare begin to rise? - ANS1980's
What is the FERA? - ANSFraud Enforcement and Recovery Act
What is the FCA? - ANSFalse Claims Act
What does the FCA do? - ANSThe 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.
Section 1 Cont.
What is HIPAA? - ANSThe Health Insurance Portability and Accountability Act
When was HIPAA passed? - ANS1996
What are some of the HIPAA requirements that specifically address compliance? -
ANSCoordinating 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 is PHI? - ANSPatient Health Information
Why were NPI's created? - ANSto eliminate the myriad of provider identifiers previously used
within the healthcare industry.
What is the goal of HIPAA? - ANSExpand 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 required in order to allow external entities access to patient specific records or PHI. -
ANSBusiness Associate Agreements (BAA)
What is an NPI? - ANSNational Provider Identifier
What is the OIG? - ANSOffice of Inspector General
Why was the OIG created? - ANSto 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 are the OIG Responsibilities? - ANSIdentifying opportunities to improve program
economy, efficiency, and effectiveness.
Holding accountable those who do not meet program requirements or who violate federal laws.
, Who is the "Self-Police"? - ANSOffice of Inspector General (OIG)
Who follows the OIG? - ANSHome 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 happens when a providers violate CMS regulations? - ANSProviders are subject to
Corporate Integrity Agreements.
What are some key risk area's that can lead to potential fraud and abuse? - ANS"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
When did corporate compliance programs in healthcare begin to rise? - ANS1980's
What is the FERA? - ANSFraud Enforcement and Recovery Act
What is the FCA? - ANSFalse Claims Act
What does the FCA do? - ANSThe 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.
