Healthcare Analyst Risk Assessment & Compliance Flashcards

A healthcare analyst reviewing contracts notices a vendor is paid per patient referral. Which law is most likely being violated?

Answer: Anti-Kickback Statute

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b) prohibits offering, paying, soliciting, or receiving remuneration to induce or reward referrals of federally reimbursable items or services.

What is the significance of the OIG Exclusion List (LEIE) in healthcare compliance?

Answer: It lists individuals and entities excluded from participation in federal healthcare programs

The OIG's List of Excluded Individuals/Entities (LEIE) identifies those barred from participating in Medicare, Medicaid, and other federal healthcare programs; employing an excluded party can result in significant penalties.

In healthcare analytics, a 'near miss' event is best defined as:

Answer: An event that could have caused harm but was caught before affecting a patient

A near miss is an unplanned event that did not reach the patient and therefore caused no harm, but had the potential to do so under slightly different circumstances.

Which accrediting body uses the Tracer Methodology to evaluate healthcare organizations' compliance with patient care standards?

Answer: The Joint Commission (TJC)

The Joint Commission uses Tracer Methodology during surveys, following an individual patient's care experience across departments to evaluate system-wide compliance with standards.

A healthcare analyst is reviewing a Corrective Action Plan (CAP). What is the primary goal of a CAP in a compliance context?

Answer: To outline specific steps to remediate identified compliance deficiencies

A Corrective Action Plan outlines targeted, time-bound steps an organization will take to address identified compliance deficiencies and prevent their recurrence.

Under HIPAA, a 'minimum necessary' standard applies to:

Answer: Limiting PHI use and disclosure to the least amount necessary to accomplish the intended purpose

The HIPAA minimum necessary standard requires covered entities to make reasonable efforts to limit PHI use, disclosure, and requests to the minimum needed for the intended purpose.

Which statistical method is most commonly used by healthcare analysts to detect anomalous billing patterns that may indicate fraud?

Answer: Cluster analysis and outlier detection

Cluster analysis and outlier detection techniques allow analysts to compare a provider's billing patterns against peers and flag statistical anomalies that may warrant further investigation.