Regulatory and Compliance Standards Flashcards

What is the primary purpose of the False Claims Act (FCA) in healthcare?

Answer: To penalize the submission of fraudulent claims to federal healthcare programs

The False Claims Act imposes liability on individuals and organizations that submit false or fraudulent claims for payment to federal programs such as Medicare and Medicaid.

An Advance Beneficiary Notice (ABN) must be given to a Medicare patient when:

Answer: Medicare is likely to deny payment for a service due to medical necessity

An ABN is required when a provider believes Medicare will likely deny payment so the patient can decide whether to receive the service and accept financial responsibility.

Which organization accredits hospitals and publishes quality performance data that patient access staff must be aware of for compliance purposes?

Answer: The Joint Commission (TJC)

The Joint Commission accredits and certifies healthcare organizations and programs, and its standards are widely used as a benchmark for quality and compliance.

Under HIPAA's Minimum Necessary standard, when a staff member accesses PHI they should:

Answer: Access only the information needed to accomplish the intended purpose

The Minimum Necessary standard requires that PHI disclosures and internal uses be limited to the least amount of information needed to accomplish the task.

The OIG Exclusion List is important to patient access because:

Answer: Providers and employees on the list cannot participate in federal healthcare programs

Hiring or contracting with individuals or entities on the OIG Exclusion List can result in significant civil monetary penalties for the healthcare organization.

Which of the following best describes the purpose of a hospital compliance program?

Answer: To prevent, detect, and correct violations of laws, regulations, and internal policies

A compliance program is designed to establish a culture of integrity and provide systematic processes to prevent, detect, and correct non-compliance with legal and regulatory requirements.

A patient who is a minor presents to the ED without a parent or guardian. Under EMTALA, the hospital should:

Answer: Provide a medical screening examination and stabilizing treatment as necessary

EMTALA requires a medical screening exam and stabilizing treatment for all individuals presenting to the ED, including unaccompanied minors, due to the emergency exception to consent.