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A comprehensive overview of healthcare regulations and procedures, covering key areas such as patient rights, billing practices, and consent procedures. It includes definitions of important acronyms and terms, as well as explanations of key regulations like hipaa, emtala, and psda. The document also outlines essential aspects of patient access, including scheduling, pre-admission testing, and collection processes. It further explores the role of case management and utilization review in ensuring quality healthcare delivery.
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HHS ✔✔Health and Human Services
CMS ✔✔Centers for Medicare and Medicaid Services
HHS ✔✔U.S. Department of Health and Human Services
NIH ✔✔National Institutes of Health
FDA ✔✔Food and Drug Administration
ACL ✔✔Administration for Community Living; one of the HHS Operating Divisions.
QIO ✔✔Quality Improvement Organization
OIG ✔✔Office of Inspector General
ACF ✔✔Administration for Children and Families
Title XVIII ✔✔Medicare
Title XIX ✔✔Medicaid
AHA ✔✔American Hospital Association
Patient's Bill of Rights ✔✔Patient Care Partnership
HIPAA ✔✔Health Insurance Portability and Accountability Act
PHI ✔✔Protected Health Information
TPO ✔✔Treatment, Payment & Operations
ERA ✔✔Electronic Remittance Advice
ABN ✔✔Advance Beneficiary Notice of Noncoverage
HINN ✔✔Hospital Issued Notice of Non coverage
ALOS ✔✔average length of stay
MOON ✔✔Medicare Outpatient Observation Notice
Patient Care Partnership ✔✔Replaces the Patient's Bill of Rights, was adopted by the AHA, and is a plain-language brochure
PHI ✔✔Can be shared without explicit consent, cannot be shared for marketing purposes w/o explicit consent, cannot be shared with law enforcement without consent or notification to the patient, except under court order
Advance Directive ✔✔Living will, Healthcare Power of Attorney, DNR Order
Administrative Sanction for Inappropriate Behavior on the part of a provider ✔✔Denial or revocation of the provider number application, suspension of provider payments, application of CMP's
True of TJC ✔✔TJC will conduct an audit of a hospital every 39 months
PSDA ✔✔Deals with advance directives
ECOA ✔✔Prohibits credit discrimination, allowing creditors to request info but not use it to grant credit or set terms
EMTALA ✔✔Prohibits questions about payment until an ED patient has been medically screened
PPACA ✔✔Has primary aim to decrease number of uninsured Americans and reduce healthcare costs
Regulation Z ✔✔Requires clear identification of APR's and finance charges
Balance in scheduling ✔✔1. Patient satisfaction
Collection process gathers ✔✔1. Patient demographics
Pre-admission/service testing ✔✔Diagnostic medical testing of patients in advance of surgical or invasive procedures to determine hospitalization/surgical situability
Collection Points- Institutional Setting ✔✔1. Pre-admission
Collection Points- Professional Setting ✔✔1. Pre-service
Advantages of a deposit collection program ✔✔Increased Hospital Cash Collections
Reduced Amount Due at Discharge
Reduced Overall Accounts Receivable
Reduced Financial Risk and Bad Debt
NOTICE ✔✔Notice of Observation Treatment and Implication for Care Eligibility Act requires that hospitals must inform patients who are hospitalized for more than 24 hours if they are in observation status
MOON ✔✔Standardized notice developed to inform beneficiaries when they are an outpatient receiving observation services and are not inpatient of hospital or critical access hospital
Don't Require an ABN or HINN ✔✔Screening mammogram
Prostate Screening Antigen
Routine Physical
Routine Foot Care
Cosmetic Surgery
Dental Care and Dentures
Non-Emergent Services
Chiropractic Care
Ambulance Service that is considered a technical denial
Services listed in the beneficiary Medicare manual
Self-Administered Drugs
Typical Goal for Reengineering Patient Access ✔✔1. Place the focus on customer service to improve the initial patient impression
Diagnostic medical testing before surgical or invasive procedures to determine hospitalization/surgical suitability ✔✔Preadmission testing
Precertification/Preauthorization ✔✔Getting auth for medical necessity, auth to treat, auth for average LOS/number of services for the patient condition
Failure to preauthorize can result in total denial of claims
Suggested practice before seeing a patient in the office ✔✔Gathering information
Pulling charts and preparing fee tickets
Obtaining referrals for visits
Needed to calculate the patient's estimated responsibility for a hospital stay ✔✔a. ALOS for the diagnosis
b. Average cost/day by type of service
c. Admitting physician's estimated LOS
d. The hospital's flat rate procedures/DRG/Contractual Payer Allowance
e. The daily room charge by type
Levels of patient care ✔✔INSTITUTION
Inpatient- Admitted to a bed
Observation- Occupy a bed, but are outpatient
ER- Outpatient
Recurring or Series- Repetitive types of treatment
Long Term Care- Chronically ill, might be in nursing home
Office- care provided in a practitioner's place of business
Outpatient- Outpatient clinics
Skilled Nursing Facility- separate wing of hospital, nursing home, or a freestanding facility- medicare requires that a person have been inpatient at least 3 consecutive days
Hospice- Coordinated, palliative care provided to terminally ill patients and their families by nonprofit organizations
Respite- short-term, temporary custodial care that allows family members to get relief from caring for a physically frail or dependent person at home
Home Health- Limited part time or intermittend skilled nursing care and home health aide services, pt, ot, ect...
General Consent Form ✔✔routine lab testing, diagnostic imaging, medical treatment
Special Consent Form ✔✔HIV Positive Testing
Major/Minor Surgery
Anesthesia
Nonsurgical procedures
Cobalt or radiation therapy
Electroshock Treatment
Experimental Procedures
Treatment for drug/alcohol disorders
Blood Transfusions
actual or expressed consent ✔✔written or oral agreement by the patient to the treatment outlined.
implied consent- in fact ✔✔consent by silence; the patient implies consent to the treatment by not objecting.
EHR ✔✔electronic health record
Verbal telephone orders can be given by ✔✔a physician extender
a RN
Verbal telephone orders must contain ✔✔-the date and time the order was received
-the name of the ordering physician
-the name of the patient and his or her status
-the exact order, transcribed verbatim
-the full name and designation of the staff member documenting the order
NCD ✔✔National Coverage Determination - medical review policies issued by CMS which identify specific medical items, services, treatment procedures, or technologies that can be covered and paid for by the Medicare program
LCD ✔✔Local Coverage Determination - policies developed by MAC's that specify criteria for services and show under what clinical circumstances an item or service is considered to be reasonable, necessary, and appropriate
definitive diagnosis ✔✔The LCD and NCD discusses and lists specific diagnosis codes, ICD procedure codes, and possibly signs and symptoms to support the need for the item or service being given
non-definitive LCD/NCD ✔✔A policy that provides potential coverage circumstances, but most likely does not provide specific diagnoses, signs, symptoms or ICD-9-CM codes that will be covered or non-covered; when the Medicare contractor considers or utilizes factors and information other than that in the LCD/NCD when making a coverage determination.
Until 1980 ________ was the primary payer for nearly all Medicare-covered services ✔✔Medicare
MSP ✔✔Medicare Secondary Payer / all info must be retained for 10 years
Medicare is the secondary payer ✔✔The working aged
Under the age of 65 who are disabled and covered by a group plan
Individuals with ESRD (end stage renal disease)
midnight census ✔✔the number of patients in the hospital at midnight census; determined from the census count for the previous midnight, minus any discharges, plus any admissions, plus/minus any status changes.
ADC ✔✔average daily census; the average number of inpatients maintained in the hospital each day for a specific period of time.
Average Daily Census (ADC) ✔✔Total number of Patient Days / Number of Days
percentage of occupancy ✔✔The patient census divided by the number of beds on the unit
number of patients seen per day ✔✔total number of patient encounters / number of days
The patient is terminally ill and is receiving palliative care ✔✔hospice care
SNF ✔✔skilled nursing facility - continuous care to regain strength and function
home health care ✔✔care that takes place in a person's home
A patient is seen at a providers place of business ✔✔office
To qualify for SNF coverage... ✔✔Medicare requires that a person to be hospital inpatient for at least three consecutive days
Assignment of Benefits ✔✔written authorization to have insurance benefits paid directly to the provider
Beneficiary obligation for days 1-60 of a hospital stay - Medicare Part A ✔✔$1,408 per spell of illness
Beneficiary obligation for days 61-90 of a hospital stay- Medicare Part A ✔✔$352 per day
Beneficiary obligation for days 91-150 of a hospital stay-Medicare Part A ✔✔$704 per day
SNF (skilled nursing facility) ✔✔Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies. (Patients need three midnights as an inpatient to qualify for Medicare coverage in a SNF.)
