Regulatory and Payer Requirements Flashcards
7 cards from real CDIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Regulatory and Payer Requirements flashcards as text
Under HIPAA, what is the minimum necessary standard as it relates to protected health information (PHI) in the context of CDI?
Answer: Access to PHI should be limited to the minimum needed to accomplish the intended purpose
The HIPAA minimum necessary standard requires that disclosures and uses of PHI be limited to the least amount needed to accomplish the intended purpose.
Which CMS program penalizes hospitals with excess readmissions for specific conditions such as heart failure, pneumonia, and hip/knee replacement?
Answer: Hospital Readmissions Reduction Program (HRRP)
The HRRP reduces Medicare payments to hospitals with higher-than-expected 30-day readmission rates for specified conditions.
A query sent to a physician to clarify a diagnosis for CDI purposes must conform to which key compliance principle?
Answer: Queries must be compliant, non-leading, and clinically supported by health record documentation
AHIMA and ACDIS guidelines require that physician queries be non-leading, clinically supported, and compliant to avoid fraudulent documentation.
Medicaid is jointly funded by which two entities?
Answer: Federal government and state governments
Medicaid is a joint federal-state program where both the federal government and individual state governments share funding and administration.
The Hospital-Acquired Condition Reduction Program (HACRP) penalizes hospitals that rank in which quartile for HAC rates?
Answer: Top 25% (highest HAC rates — worst performers)
HACRP reduces Medicare payments by 1% for hospitals in the worst-performing quartile (top 25% highest HAC rates).
Under Medicare's Inpatient Rehabilitation Facility (IRF) coverage criteria, what percentage of a facility's patient population must require intensive rehabilitation for at least one of the qualifying conditions?
Answer: 60%
The '60% Rule' requires that at least 60% of IRF patients have one of the qualifying conditions to maintain IRF designation and payment rates.
Which federal law governs the anti-kickback provisions that prohibit offering remuneration to induce Medicare or Medicaid referrals?
Answer: Anti-Kickback Statute (AKS)
The Anti-Kickback Statute (42 U.S.C. § 1320a-7b) prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce or reward federal healthcare program referrals.