NHA CPT Study Guide: Revenue Cycle and Regulatory Compliance

Vocabulary flashcards covering the Revenue Cycle, Regulatory Compliance, communication, stakeholders, data management, and legal requirements for phlebotomy technicians.

Interpersonal Communication

A process including self-expression and active listening to develop an understanding of what people are saying, which is the priority interaction in health care.

Point of Service

The stage of registration and scheduling where information is gathered from the patient to create an account and verify insurance benefits.

Initial Nursing Facility Care

The correct terminology according to the CPT manual for an encounter that providers may colloquially call an initial H&P (history and physical).

Patients

Primary stakeholders also known as consumers who receive health care services.

Providers

Licensed professionals, such as physicians or nurse practitioners, who administer care, coordinate patient health information, and submit claims for reimbursement.

Third-party payers

Organizations such as health care insurance companies, government programs, or employers that reimburse services provided by providers or health care organizations.

Policymakers

Individuals within regulatory agencies who establish the framework determining eligibility for care, what services are provided, and how they are paid.

CMS-1500

The current paper form used for billing, which was previously called the HCFA-1500 form.

CMS Data Retention Requirement

A federal regulation requiring providers to retain health insurance claims for $6$ years, consistent with the potential for audits.

HIPAA Administrative Simplification Rules

Regulations requiring covered entities to retain HIPAA-related documents for $6$ years, and for at least $2$ years after a patient’s death.

Medicare Managed Care Data Retention

Provider organizations with these types of patients must keep medical records for $10$ years.

Covered Entity

An entity that transmits health information in electronic form, such as providers, health plans, and clearinghouses.

Practice Management System

A collective source of administrative data including technological tools for operational tasks and EHR components like demographics and insurance plan information.

Clinical Health Care Data

Data used to maintain population well-being, determine treatment cost-effectiveness, and establish reimbursement strategies.

Healthcare Effectiveness Data and Information Set (HEDIS)

Measures that identify clinical services performed by organizations to provide information about the type and quality of care.

Data Storage

The physical or digital preservation of records, files, and documents for future reference, often kept off-site for catastrophe protection.

Data Transmission

The process of sending digital information over secure communication channels, allowing devices and tools to communicate.

Electronic Data Interchange (EDI)

Computer technology that facilitates the exchange of data between the health care provider and the payer.

Data Reporting

The process of collecting facts about patient care and outcomes for security analysis or reporting performance measures for incentive programs.

Office of Inspector General (OIG)

A division of the Department of Health and Human Services (HHS) responsible for investigating insurance fraud and abuse in federally funded programs.

Fraud

Intentionally billing for services not performed, reporting fraudulent diagnoses, or making medical coding errors.

Abuse

Billing patterns and practices that are excessive or unnecessary but do not meet the criteria for fraud.

HIPAA Breach Notification Rule

Regulation governing the reporting of impermissible use or disclosure of Protected Health Information (PHI).

Compliance Plan

A formal policies and procedures manual specific to an organization that addresses government and private payer regulations.

Provider Self-Disclosure Protocol (SDP)

A program developed by the OIG that allows health care providers to voluntarily reveal instances of potential fraud.