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| Question | Answer |
| Audit Trail | A type of security control used to record system activities and detect security breaches of clinical systems |
| Auditing | Reviewing to identify deviations from established guidelines, procedures, or baselines of a healthcare organization |
| Law where definition of medical necessity can be found | Social Security Act, Section 1862 |
| Medical necessity | Healthcare service that is reasonable and necessary for the diagnosis and/or treatment of illness or injury of a patient |
| Process of determining if healthcare services performed on a patient is necessary | Utilization review |
| Utilization management provides information on ___________ and __________ ______________ of a healthcare organization. | efficiency, cost effectiveness |
| Organization that requires implementation of a utilization management program in acute care hospitals to ensure accreditation | Joint Commission |
| Three functions of utilization management are: | 1) Utilization review 2) Case management 3) Discharge planning |
| Retrospective utilization review | Review conducted after the patient was discharged |
| Admission review | Review conducted at the time of admission |
| An __________ __________ can show which employee accessed an electronic health record (EHR) and what operations he/she performed on it. | audit trail |
| Upcoding | Assigning a diagnosis or procedure for getting a higher level of payment |
| Which agency defines the essential elements of a Corporate Compliance program? | Office of Inspector General (OIG) |
| Unbundling | Using multiple codes to describe a procedure rather than using the appropriate single code |
| True/False: Compliance programs are required to include complete and accurate coding. | True |
| Three types of medically unnecessary services are: | 1) Upcoding 2) Unbundling 3) Billing for service not done |
| False Claim Act (FCA) | Law which mandates prosecution of healthcare fraud |
| This law authorizes investigations, audits, and evaluations of health care fraud | Health Insurance Portability and Accounting Act (HIPAA) of 1996 |
| This agency is authorized to conduct healthcare fraud and abuse investigations in Medicare, Medicaid, and other programs in Health and Human Services (HHS) | Office of Inspector General (OIG) |
| True/False: Audit trails are not very important because they cannot assist with preserving data confidentiality and integrity. | False (Audit trails are very important because they are automatic checks to assist with data confidentiality and integrity). |
| PEPPER | Program for Evaluating Payment Patterns Electronic Report (PEPPER) It is a resource that provides data on discharges and helps to resolve non-compliance issues. |
| Senior Medicare Patrol | Program that helps seniors to understand healthcare programs thus protecting them from fraud |
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