HIM Domain 3

What comprises the healthcare delivery system in terms of education and research?

Medical schools, professional associations, and nursing education.

Who are the suppliers in the healthcare delivery system?

Big Pharma and biotech companies.

What are the types of insurers mentioned in the healthcare delivery system?

BCBS, Medicare, Medicaid, Managed Care, VA, and Tricare.

Who are considered providers in the healthcare delivery system?

Primary care doctors, HMOs, specialists, and hospitals.

Who are the payers in the healthcare delivery system?

BCBS, State Agencies, and Commercial Insurers (e.g., Aetna, Kaiser).

What role will a Certified CMAA play in the healthcare delivery system?

They will submit claims to payers on behalf of the provider.

What does 'PHI' stand for in healthcare?

Protected Health Information.

What must a Certified CMAA ensure is signed by all patients?

Notice of Privacy Practices (NPP).

What is the term for the explanation provided to patients detailing their healthcare benefits?

Explanation of Benefits (EOB).

What are the six dimensions of healthcare quality?

Safety, Timeliness, Accessibility, Equity, Effectiveness, and Patient-Centered Care.

What is one common quality indicator related to medication in healthcare?

Medication Errors.

What does a high complication rate indicate in a healthcare setting?

It may indicate a low quality of care or that high-risk procedures are being performed frequently.

What does 'AMA' stand for in a healthcare context?

Against Medical Advice.

What is tracked by the post-procedure death rate?

The number of deaths that occur after treatment.

What does a high readmission rate suggest about healthcare quality?

It can indicate low-quality care and ineffective treatment.

What does the average length of stay measure in healthcare?

The total time for patients to be admitted, treated, and discharged.

What does overall patient satisfaction assess?

Patients’ perception of their quality of care.

What is the Compliance term in healthcare?

Adherence to laws, regulations, and guidelines that protect patients and providers.

What is malpractice?

Treatment by a medical professional that does not follow standards of care.

What is negligence in healthcare?

When a patient does not receive adequate and appropriate care leading to suffering or harm.

What is patient abandonment?

When a provider stops treating a patient without reasonable cause or notice.

What is the primary focus of the HIPAA Act?

To protect patient privacy and security of health information.

What does OSHA stand for in healthcare?

Occupational Safety and Health Administration.

What is the role of the Joint Commission?

To improve healthcare for the public by evaluating healthcare organizations.

What is the Americans with Disabilities Act Amendments Act (ADAAA)?

It protects individuals with disabilities from discrimination.

What does NPP stand for?

Notice of Privacy Practices.

What does HITECH stand for?

Health Information Technology for Economic and Clinical Health.

What are Covered Entities in healthcare compliance?

Providers, hospitals, laboratories, health plans, and health care clearinghouses that transmit health information electronically.

What are non-covered entities?

Organizations that use individually identifiable health information but do not transmit electronic data.

What is the goal of Risk Management in healthcare?

To uncover, mitigate, and prevent risks in healthcare institutions.

What is a major component of compliance with HIPAA regulations?

Cybersecurity measures.

What is the purpose of Safety Data Sheets (SDS) in healthcare?

To provide information about the risks associated with chemicals.

What is the significance of incident reporting in healthcare?

To improve safety in the workplace for all employees.

What is scope of practice in healthcare?

The specific standards that a medical professional may perform within the limits of their qualifications.

What is implied consent?

Patient cooperation with medical care without written consent.

What is informed consent?

A thorough process explaining proposed treatment, alternatives, risks, and benefits leading to written consent.

What must be included in a HIPAA-compliant ROI form?

Patient name, provider receiving information, purpose of disclosure, patient signature, and expiration date.

What is upcoding in healthcare fraud?

Assigning a higher diagnosis code than the documentation supports.

What is unbundling in billing?

Using multiple codes for different components of a treatment instead of a single comprehensive code.

What is the primary focus of the National Patient Safety Goals (NPSG)?

To improve patient safety.

What is the role of the Office of Inspector General (OIG)?

To investigate fraud and abuse in federally funded medical programs.

What does the term 'audit' refer to in healthcare compliance?

Regular examination of procedures and practices to ensure adherence to regulations.

What does 'EHR' stand for?

Electronic Health Record.

What principle does the minimum necessary standard in HIPAA compliance relate to?

PHI should not be used or disclosed when it is not necessary for a specific purpose.

What are the penalties for violating HIPAA?

Fines vary from $50,000 to over $1 million depending on the severity and knowledge of the violation.

What constitutes an authorized release of PHI?

When the patient provides consent to share their health information.

What is the Affordable Care Act (ACA) focused on?

Removing restrictions for pre-existing conditions and ensuring patient choice of provider.

What is patient consent?

Authorization given by a patient for medical treatment.

What can be reported without patient consent under HIPAA?

Gunshot wounds, child abuse, communicable diseases, domestic violence.

Who can be held accountable for HIPAA violations?

Covered entities and business associates who fail to protect PHI.

What is the purpose of training employees on HIPAA?

To ensure everyone understands regulations related to patient privacy.

What does 'patient wait times by process step' measure?

The duration patients wait at various points in the healthcare process.

What should a healthcare facility's emergency plan include?

Reporting emergencies, evacuation procedures, and employee accountability.

What specific type of training must all employees undergo annually?

HIPAA training.

What is the role of a designated privacy officer in a healthcare facility?

To oversee policies and procedures regarding the security of PHI.

What is patient-centered care?

Care that is responsive to individual patient preferences, needs, and values.

How does the Joint Commission impact hospital operations?

Accreditation affects billing and reimbursement practices.

What are the implications of low patient satisfaction scores?

It may indicate problems with hospital operations or quality of care.

What is the purpose of patient complaints tracking?

To identify and address issues in the quality of care provided.

What are the main aspects of compliance monitoring in healthcare?

Audits, employee training, and adherence to laws and regulations.

What is the significance of high occupancy rates in hospitals?

Possible strain on resources and a drop in quality of service.

What does the term 'audit trail' refer to in healthcare?

Logs that track who accessed patient information and when.

What is an ethical standard in medicine?

Principles that guide professional conduct to differentiate right from wrong.

What type of policies must healthcare facilities have regarding workplace safety?

Policies that include emergency preparedness and safety protocols.

Why are compliance audits important?

They help identify areas of risk and ensure adherence to regulations.

What does the 'Social Security Act' provide regarding healthcare?

Payment and insurance for older retirees and individuals with disabilities.

What happens if a healthcare provider is found guilty of Medicare fraud?

They may face severe penalties, including fines and exclusion from federal healthcare programs.

What is the current emphasis on healthcare quality improvement?

Incorporating methods to improve efficiency and reduce waste.

What does the phrase 'patient confidentiality' mean?

The obligation to protect patient information from unauthorized access or disclosure.

What is the significance of documenting the release of information?

To maintain accountability for disclosures and protect patient privacy.

What does 'ICD-10-CM' refer to in healthcare?

International Classification of Diseases, 10th Revision, Clinical Modification.

What does 'compliance' mean in the healthcare context?

Adherence to laws, regulations, policies, and ethical standards.

What is the importance of continuing education units (CEUs) in healthcare?

They ensure healthcare professionals stay updated on their knowledge and skills.

What is the purpose of patient education in healthcare?

To inform patients about their health, treatment options, and rights.

What is the role of telemedicine in the healthcare industry?

Providing healthcare services remotely via technology.

What does 'quality assurance' in healthcare involve?

Continuous evaluation of services to improve patient outcomes.

What is a common ethical conflict in healthcare?

Balancing patient autonomy with the provision of appropriate care.

What is the risk management process in healthcare?

Identifying, analyzing, and addressing potential hazards to patients and staff.

What does a healthcare facility's compliance program include?

Policies and procedures to ensure adherence to laws and regulations.

What is a health information exchange (HIE)?

Systems that facilitate the sharing of healthcare information among providers.

What does the term 'business associate' refer to in healthcare?

An individual or entity that performs functions on behalf of a covered entity involving PHI.

What is the primary goal of the National Healthcare Integrity and Protection Data Bank?

To compile and share data on healthcare fraud and abuse.

What is the focus of Medicare quality improvement programs?

To enhance care quality and patient outcomes in Medicare-funded settings.

All fraud & abuse allegations must be compiled here 

National Healthcare Integrity and Protection Data Bank (HIPDB)

The Act that provides immunity to medical providers who do peer reviews to investigate potential fraud & ab

HCQIA - Healthcare Quality Improvement Act

When a pt does not receive adequate & appropriate care, which leads to suffering & harm

negligence 

Examples of information that is NOT private for authorities & health departments 

child abuse, STDs/STIs, gunshot wounds, HIV

Document that describes how PHI is used and disclosed by the facility

NPP (Notice of Privacy Practices)

Standardized electronic formats when sending administrative and financial data.

EDI - Electronic Data Interchange

Part of the U.S. Department of Labor with the mission to ensure workplace safety and a healthy working environment.

OSHA 

Oversees Medicare and Medicaid services 

CMS 

If NOT accredited by this organization, it could potentially affect billing of services

TJC - The Joint Commission 

Investigates all fraud & abuse cases suspected or reported for federally funded medical programs

OIG - Office of Inspector General 

Oversees the compliance of HIPAA 

OCR - Office of Civil Rights 

Three safeguards required to meet 

administrative, technical and physical 

Tier 2 of HIPAA violation 

Reasonable Cause 

• Tier 1

• : Lack of knowledge.

Tier 3

Willful neglect, corrected within 30 days.

Tier 4

Willful neglect, not corrected within 30 days.

All fraud & abuse allegations must be compiled here 

National Healthcare Integrity and Protection Data Bank (HIPDB)