Chaa Ch. 2 Regulatory Compliance

The correct answer is PPACA (The Patient Protection and Affordable Care Act of 2010). This program is commonly referred to as Obamacare because it was signed into law by President Barack Obama in 2010. It aimed to provide affordable healthcare options for all Americans and implemented various reforms in the healthcare system.

The Veterans Choice program is designed to address the issue of delayed or unavailable healthcare services at a veteran's local VA healthcare center. It allows veterans to seek care from the community, giving them the option to access timely and necessary medical services. This program aims to ensure that veterans receive the care they need in a timely manner, even if it means seeking care outside of the VA healthcare system.

The method used to determine financial eligibility for Medicaid, CHIP, and Marketplace cost sharing is called MAGI (Modified Adjusted Gross Income). MAGI takes into account various factors such as income, deductions, and exemptions to calculate an individual or family's eligibility for these programs. It is a standardized method used to ensure consistency and fairness in determining financial eligibility across different states and programs.

EMTALA, also known as the Emergency Medical Treatment and Labor Act, is a statute created to ensure that all individuals have access to emergency medical treatment, regardless of their ability to pay. This law requires hospitals to provide an appropriate medical screening examination to anyone who seeks emergency care and to stabilize any emergency medical condition found, regardless of the individual's insurance status or ability to pay for the treatment. EMTALA plays a crucial role in protecting the rights and well-being of individuals in need of emergency medical care.

EMTALA, also known as the Emergency Medical Treatment and Active Labor Act, is a regulation that ensures patients are not denied emergency medical treatment due to their inability to pay. It requires hospitals to provide appropriate medical screening and stabilization services to all patients, regardless of their financial situation. This regulation aims to protect patients from being turned away or delayed in receiving necessary emergency care solely based on their inability to afford it.

CHAMPVA is the correct answer because it is a government healthcare program specifically designed to provide medical coverage for the surviving spouses of veterans who were killed in the line of duty. Tricare is a separate healthcare program for active duty military personnel and their families, while Veterans Choice is a program that allows veterans to receive care from non-VA providers.

not-available-via-ai

The correct answer is "Financial assistance brochure" because PHI stands for Protected Health Information, which refers to any information that can be used to identify an individual and is related to their health condition, healthcare services, or payment for healthcare. Patient names and computer IP addresses can potentially be linked to specific individuals and their health information, thus qualifying as PHI. However, a financial assistance brochure does not typically contain personal health information and is not directly related to an individual's health condition or healthcare services.

Unknowingly billing for services at a higher complexity is not considered an example of fraud and abuse because it implies that the billing was done without knowledge or intention to deceive. Fraud and abuse typically involve intentional actions to deceive or manipulate billing processes for personal gain. In this case, the billing error may be due to a mistake or lack of understanding, rather than an intentional act of fraud or abuse.

The Important Message from Medicare (IMM) provides information to the patient about their rights as hospital patients and instructions on what to do if they feel they are being discharged too soon. However, it does not inform the patient that if their inpatient stay is deemed experimental, they will be responsible for any costs.

Presumptive eligibility is the name given when a provider screens a patient for temporary Medicaid coverage. This means that the patient is given temporary coverage based on their self-attestation of their eligibility, without the need for a complete application or verification process. It allows individuals to receive immediate healthcare services while their full eligibility is being determined.

The correct answer is the Medicare Two-midnight rule. This rule states that an inpatient stay must cross two midnights in order to be eligible for payment under Medicare Part A. This rule was implemented to ensure that only patients with more serious conditions requiring a longer hospital stay are classified as inpatients and receive the associated benefits and coverage. It helps to distinguish between inpatient and outpatient care, ensuring appropriate reimbursement for hospitals and proper utilization of Medicare resources.

An effective compliance level must have a minimum of 7 levels. This suggests that there are multiple layers or stages in the compliance process that need to be followed in order to ensure adherence to regulations and standards. Having a sufficient number of levels allows for thorough oversight and control, ensuring that all necessary steps are taken to achieve compliance.

The Meaningful Use program is designed to encourage healthcare providers to adopt qualified electronic health records (EHRs). By doing so, it aims to improve the quality, safety, and efficiency of healthcare delivery. This is achieved by promoting the use of EHRs to capture and share patient health information, which can lead to better coordination of care, reduced medical errors, and improved patient outcomes. The program does not focus on increasing the adoption of paper documentation or reducing the cost of care to patients.

The correct answer is MOON (Medicare Outpatient Observation Notice). This document is given to Medicare beneficiaries who are admitted as outpatients receiving observation status. It informs them that they may have to pay a co-payment and co-insurance for their observation services.

The Advanced Beneficiary Notice (ABN) is the form given to Medicare beneficiaries to inform them of potential non-coverage of out-patient services. This form is used when a healthcare provider believes that Medicare may not cover a particular service or procedure, and it allows the beneficiary to make an informed decision about whether to proceed with the service and accept financial responsibility if Medicare does not cover it. The ABN ensures that beneficiaries are aware of their rights and responsibilities regarding Medicare coverage and helps them make informed decisions about their healthcare.

Tricare is a healthcare program that provides coverage to various groups, including uniformed service members and their families, survivors, and Medal of Honor recipients. However, it does not provide healthcare to civilians working in a military treatment facility. This means that while Tricare covers a wide range of individuals associated with the military, it does not extend its coverage to civilians in these specific roles.

Medicare is considered the primary payer in most scenarios, but not when a Medicare patient has ESRD (End-Stage Renal Disease) and is in their 60th month of dialysis. In this specific case, Medicare becomes the secondary payer and the patient's ESRD coordination period ends, allowing them to enroll in Medicare Advantage or other private insurance plans. This exception is due to the unique circumstances of ESRD patients who have been receiving dialysis for a prolonged period.

The MSP (Medicare Secondary Payor) requires that we ask pertinent questions to determine if there are other sources of payment primary to Medicare. This means that before Medicare can be billed for services, we need to determine if there are any other insurance plans or programs that should be billed first. This helps ensure that Medicare is not unnecessarily billed and that other primary payers are identified and billed correctly.

Organizations seek Joint Commission accreditation because it enhances community confidence in the quality and safety of care. This accreditation demonstrates that the organization has met rigorous standards and has undergone a thorough evaluation process. By achieving this accreditation, organizations can assure the community that they are committed to providing high-quality care and maintaining a safe environment. This can help build trust and credibility among patients, families, and the community as a whole.

When a Medicare patient is under the age of 65 and is covered by their spouse's BCBS plan through the Federal Government, BCBS becomes the primary payer. This means that BCBS will be responsible for covering the majority of the patient's healthcare costs, while Medicare will serve as the secondary payer and cover any remaining costs that BCBS does not cover.

Condition Code 44 is the correct answer because it is a specific tracking code used for patients who are admitted as inpatients to the hospital but do not meet the criteria for an inpatient stay. This code allows hospitals to track and report these cases separately from regular inpatient admissions.

An effective compliance program includes performing internal audits to ensure that all rules and regulations are being followed. It also involves establishing standards, procedures, and policies to guide employees in their compliance efforts. However, creating standards of privacy is not typically considered a part of a compliance program. Privacy standards are usually addressed separately through privacy policies and practices, which may be a part of an organization's overall compliance program but are not directly related to compliance with laws and regulations.

The 30-month coordination period is the time period when a Medicare patient on ESRD's group health plan is the primary payer. During this period, the group health plan pays first for the patient's healthcare services, and Medicare becomes the secondary payer. This coordination period allows the patient to continue receiving coverage from their group health plan while transitioning to Medicare as their primary insurance.

The Office of the Inspector General (OIG) is responsible for protecting the integrity of the Hospital and Human Services (HHS) program by detecting and preventing fraud. The OIG is an independent agency that conducts audits, investigations, and evaluations to ensure that HHS programs are operating efficiently and effectively. They have the authority to take legal action against individuals or organizations found to be engaged in fraudulent activities.