The Patient Protection and Affordable Care Act implemented what?
implemented new requirements for insurance, Medicaid, and more.
The Drug Enforcement Administration and the Food and Drug Administration
regulate what?
regulate the creation and distribution of medication.
The Department of Health and Human Services and the Office of the Inspector
General help protect against what?.
Fraud
True or False. Medicare and Medicaid regulations occur at both state and federal
levels.
True
Occupational Safety and Health Administration and the Equal Employment
Opportunity Commission oversee What?? regulations.
Workplace regulations
Mike Armstrong
Advocate for patient safety after having a blood test mis-read that showed he had
leukemia. Donated over 15 million dollars to John Hopkins to develop programs
for patient safety and diagnostic excellence.
Common reason for data breaches of PHI
criminal attacks (cyber attacks)
HIPAA security rule covers what
PHI (electronic format) of medical records
When considering the regulatory requirements for healthcare, which agencies
primarily oversee the use of medication<\/p>\n\n\n\n
FDA and DEA
Medicare and Medicaid focus on specific groups of people. Individuals over the
age of 65 and disabled individuals are the current focus of what?
Medicare
Medicare =
Federal coverage for people over 65, certain people under 65 with disabilities and
people of any age with end stage renal disease
Medicaid =
Cooperative federal and state healthcare coverage for low-income adults, pregnant
women, and children
Medicare part
Part A
Part B
Part C
Part D
Part A-Hospital Insurance
Part B-Medical Insurance
Part C- Medicare Advantage (HMO includes A&B)
Part D- Prescription Drug
Qualified Medicare Beneficiary (QMB) Program:
Helps pay premiums, deductibles, coinsurance, and copayments for Part A, Part B,
or both programs
Specified Low-Income Medicare Beneficiary (SLMB) Program:
Helps pay Part B premiums
Qualifying Individual (QI) Program:
Helps pay Part B premiums
Qualified Disabled Working Individual (QDWI) Program:
Pays the Part A premium for certain disabled and working beneficiaries who have
disabilities<\/p>\n\n\n\n
Medicare Part A helps cover what
Inpatient hospital care \u25cf Skilled nursing facility care \u25cf Hospice care \u25cf Home
health care
Medicare Part B helps cover what
Services from doctors and other health care providers \u25cf Outpatient care \u25cf Home
health care \u25cf Durable medical equipment \u25cf Many preventive services
Medicare Part C covers what
includes all benefits and services covered under Part A and Part B and may include
extra benefits and services for an extra cost.
Medicare part D covers
helps cover the cost of Prescription drugs
Name other types of healthcare coverage
Private insurance coverage (such as group health plan or retiree coverage) \u25cf
TRICARE \u25cf COBRA \u25cf Workers’ Compensation \u25cf Liability insurance coverage
Bundled payments
Bundle payments or episode payment models (EPMs) are an alternative means of
payment that encourage organizations to coordinate services to improve the
efficiency of care. Bundled payments are negotiated by CMS and third-party
payors to identify the total allowable expenditures (target price) for a specific
group of services. These payments are predetermined and agreed upon by the
payor and payee. If Medicare and Medicaid billing is acceptable to the
organization, then bundled payment services are already established.
Value based services
Value-based services assist in keeping the cost down. Organizations work to
provide services without exceeding the established cost. If possible, the
organization will attempt to increase its payment by providing less expensive
services. This has allowed organizations to work together to form purchasing
groups. Due to the discounts received, organizational profitability is improved
TPA
Third Party Administrator<\/p>\n\n\n\n
Why are medical bills rejected by insurance?
Rejections can occur for many reasons but usually occur when there is not enough
documentation to support the claim or when information is misfiled in a chart.
Insurance Rejections
error was caught early in the claim’s lifecycle and the claim won’t be accepted into
the system. (Could be due to incorrect name, DOB, address, ID# etc)
Insurance Denials
The claim has been entered into the payer’s system for adjudication, was reviewed
by their claim department, and was denied.
How would you follow up on a denied claim?
Submit a corrected claim
Social Security Act governs what
governs funding and requirements for Medicare, Medicaid, CHIP, and more.
HIPAA and the HITECH Act protect what?
protect patient privacy, requiring healthcare organizations to implement measures
to keep patient records secure.
The False Claims Act
makes it illegal to file a false claim for funds from a federal program.
hat information should you supply when you are calling to discuss a claim?
Client’s date of birth, the organization’s tax ID or NPI, info from the claim about
date of service and coding, how much is being billed.
Clinical care review
Clinical care review is the process of retrospectively examining potential errors or
gaps in medical care, aiming for future practice improvement (other names for it
are peer review, adverse event review, sentinel event review, and root cause
analysis)
NCQA<\/p>\n\n\n\n