Regulatory and Compliance Standards Flashcards

A patient arrives at the emergency department unconscious and without identification. The hospital provides a medical screening exam and stabilizing treatment. Which federal act requires these actions, regardless of the patient's ability to pay?

Answer: Emergency Medical Treatment and Labor Act (EMTALA)

The Emergency Medical Treatment and Labor Act (EMTALA) requires Medicare-participating hospitals with emergency departments to screen and treat the emergency medical conditions of patients in a non-discriminatory manner, regardless of their ability to pay or insurance status.

A Patient Access Representative is registering a new patient and provides them with a document detailing their rights to make healthcare decisions, including the right to formulate advance directives. This action is mandated by which of the following?

Answer: The Patient Self-Determination Act (PSDA)

The Patient Self-Determination Act (PSDA) of 1990 requires healthcare institutions that receive Medicare and Medicaid funding to inform patients of their rights to make decisions concerning their medical care, including the right to accept or refuse treatment and the right to formulate advance directives.

During an internal audit, it is discovered that a billing employee has been consistently using a billing code for a more complex procedure than the one actually performed to increase reimbursement from Medicare. This practice is a violation of which regulation?

Answer: False Claims Act (FCA)

The False Claims Act (FCA) makes it illegal to knowingly submit a false or fraudulent claim for payment to the federal government. 'Upcoding,' or billing for a more expensive service than what was provided, is a primary example of a violation of the FCA.

Which of the following scenarios represents a potential violation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule by a Patient Access Representative?

Answer: Discussing a patient's diagnosis in a crowded waiting room.

The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other identifiable health information. Discussing a patient's diagnosis or other protected health information (PHI) in a public area where it can be overheard by others is a violation of the 'minimum necessary' standard and patient confidentiality.

A patient asks for a copy of their medical records in an electronic format. According to HIPAA, which of the following is the most appropriate response from the Patient Access Representative?

Answer: Tell the patient to submit a request in writing and that a fee for labor and supplies may be charged.

The HIPAA Privacy Rule gives individuals the right to access their protected health information (PHI) in the form and format they request, including electronically, if the information is readily producible in that format. Covered entities can require a written request and may charge a reasonable, cost-based fee for the copies.

Under the Emergency Medical Treatment and Labor Act (EMTALA), when is it appropriate for a hospital to transfer an unstable patient to another facility?

Answer: When a physician certifies that the medical benefits of the transfer outweigh the risks.

EMTALA strictly governs the transfer of unstable patients. An unstable patient may only be transferred if a physician certifies that the expected medical benefits of receiving treatment at another facility outweigh the risks of the transfer, or if the patient makes an informed request in writing. The receiving facility must also have the capacity and agree to accept the transfer.