Healthcare Analyst Systems & Regulations Flashcards

Under HIPAA's Minimum Necessary Standard, a covered entity must limit PHI disclosures to the:

Answer: Minimum amount reasonably needed to accomplish the intended purpose

The Minimum Necessary Standard requires covered entities to make reasonable efforts to limit PHI use, disclosure, and requests to the minimum needed to accomplish the intended purpose.

Which CMS program uses a 5-star quality rating system for Medicare Advantage and Part D plans?

Answer: Medicare Plan Finder Star Ratings

CMS's Medicare Plan Finder Star Ratings uses a 1-to-5-star system to rate Medicare Advantage and Part D plans on quality and performance measures.

In an EHR system, a Continuity of Care Document (CCD) is based on which standard?

Answer: HL7 CDA (Clinical Document Architecture)

The CCD is an implementation guide built on HL7's Clinical Document Architecture (CDA) standard for sharing patient summary information.

Which regulatory body enforces the False Claims Act in healthcare fraud cases?

Answer: Department of Justice (DOJ)

The Department of Justice (DOJ) enforces the False Claims Act, which imposes civil liability on those who submit fraudulent claims to federal healthcare programs.

A healthcare analyst notices a sudden spike in ED visits coded as 'chest pain unspecified.' Which data quality issue does this most likely indicate?

Answer: Lack of specificity or incomplete clinical documentation

A spike in unspecified codes typically signals incomplete clinical documentation rather than fraud, indicating physicians did not document enough detail for coders to assign specific codes.

In value-based care, a Hierarchical Condition Category (HCC) model is primarily used to:

Answer: Risk-adjust per-member-per-month capitation payments

HCC models risk-adjust capitation payments in Medicare Advantage and ACO programs so that plans caring for sicker patients receive higher payments.

Which provision of the 21st Century Cures Act specifically prohibits practices that unreasonably restrict access to electronic health information?

Answer: The Anti-Information Blocking Rule

The Anti-Information Blocking Rule, implemented under the 21st Century Cures Act, prohibits actors from engaging in practices that interfere with access, exchange, or use of electronic health information.