Domain 3: Utilization Management, Audit Trails, and Coding Compliance

Flashcards by abyrd7, updated more than 1 year ago
Created by abyrd7 over 5 years ago


This deck includes a combination of three compliance sub-topics: UTILIZATION MANAGEMENT, AUDIT TRAILS, CODING COMPLIANCE

Resource summary

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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