Certified Revenue Cycle Representative Section 1 Cont.
1. The Health Insurance Portability and Accountability Act: What is HIPAA?
2. 1996: When was HIPAA passed?
3. 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 are some of the HIPAA requirements that specifically
address compliance?
4. Patient Health Information: What is PHI?
5. to eliminate the myriad of provider identifiers previously used within the
healthcare industry.: Why were NPI's created?
6. 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 finan-
cial and administrative transactions carried out by health plans, healthcare
clearinghouses, and healthcare providers.: What is the goal of HIPAA?
7. Business Associate Agreements (BAA): What is required in order to allow
external entities access to patient specific records or PHI.
8. National Provider Identifier: What is an NPI?
9. Office of Inspector General: What is the OIG?
10. to protect the integrity of the Health and Human Services (HHS) Depart-
ment programs and operations and the well-being of beneficiaries by detect-
ing and preventing fraud, waste, and abuse.: Why was the OIG created?
11. Identifying opportunities to improve program economy, efficiency, and
effectiveness.
Holding accountable those who do not meet program requirements or who
violate federal laws.: What are the OIG Responsibilities?
12. Office of Inspector General (OIG): Who is the "Self-Police"?
13. 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
, Certified Revenue Cycle Representative Section 1 Cont.
Nursing facilities
Pharmaceutical companies
Ambulance providers: Who follows the OIG?
14. Providers are subject to Corporate Integrity Agreements.: What happens
when a providers violate CMS regulations?
15. "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 are some key risk area's that can lead to poten-
tial fraud and abuse?
16. 1980's: When did corporate compliance programs in healthcare begin to rise?
17. Fraud Enforcement and Recovery Act: What is the FERA?
18. False Claims Act: What is the FCA?
19. 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 govern-
ment 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 does the FCA do?
20. A comprehensive plan will also insulate the hospital from violations of
False Claims (Fraud and Abuse) regulations ($11,665 - 23,331 per claim, ad-
justed for inflation and triple damages) and may lessen the monetary effect of
inadvertent violations in the future.: What is a comprehensive compliance plan?
21. 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.: How did the Federal Justice Department recover
$2.6 billion in 2017?
1. The Health Insurance Portability and Accountability Act: What is HIPAA?
2. 1996: When was HIPAA passed?
3. 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 are some of the HIPAA requirements that specifically
address compliance?
4. Patient Health Information: What is PHI?
5. to eliminate the myriad of provider identifiers previously used within the
healthcare industry.: Why were NPI's created?
6. 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 finan-
cial and administrative transactions carried out by health plans, healthcare
clearinghouses, and healthcare providers.: What is the goal of HIPAA?
7. Business Associate Agreements (BAA): What is required in order to allow
external entities access to patient specific records or PHI.
8. National Provider Identifier: What is an NPI?
9. Office of Inspector General: What is the OIG?
10. to protect the integrity of the Health and Human Services (HHS) Depart-
ment programs and operations and the well-being of beneficiaries by detect-
ing and preventing fraud, waste, and abuse.: Why was the OIG created?
11. Identifying opportunities to improve program economy, efficiency, and
effectiveness.
Holding accountable those who do not meet program requirements or who
violate federal laws.: What are the OIG Responsibilities?
12. Office of Inspector General (OIG): Who is the "Self-Police"?
13. 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
, Certified Revenue Cycle Representative Section 1 Cont.
Nursing facilities
Pharmaceutical companies
Ambulance providers: Who follows the OIG?
14. Providers are subject to Corporate Integrity Agreements.: What happens
when a providers violate CMS regulations?
15. "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 are some key risk area's that can lead to poten-
tial fraud and abuse?
16. 1980's: When did corporate compliance programs in healthcare begin to rise?
17. Fraud Enforcement and Recovery Act: What is the FERA?
18. False Claims Act: What is the FCA?
19. 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 govern-
ment 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 does the FCA do?
20. A comprehensive plan will also insulate the hospital from violations of
False Claims (Fraud and Abuse) regulations ($11,665 - 23,331 per claim, ad-
justed for inflation and triple damages) and may lessen the monetary effect of
inadvertent violations in the future.: What is a comprehensive compliance plan?
21. 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.: How did the Federal Justice Department recover
$2.6 billion in 2017?
