HAC Healthcare Analyst Systems & Regulations 2 — Questions and Answers
Question 1: Under HIPAA's Minimum Necessary Standard, a covered entity must limit PHI disclosures to the:
- Entire patient record upon any request
- Minimum amount reasonably needed to accomplish the intended purpose (Correct answer)
- Amount specified by the requesting provider regardless of purpose
- Full dataset available in the EHR system
Correct answer: Minimum amount reasonably needed to accomplish the intended purpose
The Minimum Necessary Standard requires covered entities to make reasonable efforts to limit PHI use, disclosure, and requests to the minimum needed to accomplish the intended purpose.
Question 2: Which CMS program uses a 5-star quality rating system for Medicare Advantage and Part D plans?
- Hospital Compare
- Physician Compare
- Medicare Plan Finder Star Ratings (Correct answer)
- HEDIS Benchmarks
Correct answer: Medicare Plan Finder Star Ratings
CMS's Medicare Plan Finder Star Ratings uses a 1-to-5-star system to rate Medicare Advantage and Part D plans on quality and performance measures.
Question 3: In an EHR system, a Continuity of Care Document (CCD) is based on which standard?
- HL7 FHIR R4
- ANSI X12 837
- HL7 CDA (Clinical Document Architecture) (Correct answer)
- NCPDP SCRIPT
Correct answer: HL7 CDA (Clinical Document Architecture)
The CCD is an implementation guide built on HL7's Clinical Document Architecture (CDA) standard for sharing patient summary information.
Question 4: Which regulatory body enforces the False Claims Act in healthcare fraud cases?
- The Joint Commission
- CMS Office of Inspector General (OIG)
- Department of Justice (DOJ) (Correct answer)
- State Insurance Commission
Correct answer: Department of Justice (DOJ)
The Department of Justice (DOJ) enforces the False Claims Act, which imposes civil liability on those who submit fraudulent claims to federal healthcare programs.
Question 5: A healthcare analyst notices a sudden spike in ED visits coded as 'chest pain unspecified.' Which data quality issue does this most likely indicate?
- Upcoding for higher reimbursement
- Undercoding due to coder fatigue
- Lack of specificity or incomplete clinical documentation (Correct answer)
- Intentional DRG manipulation
Correct answer: Lack of specificity or incomplete clinical documentation
A spike in unspecified codes typically signals incomplete clinical documentation rather than fraud, indicating physicians did not document enough detail for coders to assign specific codes.
Question 6: In value-based care, a Hierarchical Condition Category (HCC) model is primarily used to:
- Set episode-of-care bundled payment rates
- Risk-adjust per-member-per-month capitation payments (Correct answer)
- Calculate hospital DRG weights
- Determine pharmacy benefit tiers
Correct answer: Risk-adjust per-member-per-month capitation payments
HCC models risk-adjust capitation payments in Medicare Advantage and ACO programs so that plans caring for sicker patients receive higher payments.
Question 7: Which provision of the 21st Century Cures Act specifically prohibits practices that unreasonably restrict access to electronic health information?
- Meaningful Use Stage 3
- The Anti-Information Blocking Rule (Correct answer)
- HIPAA Security Rule Amendment
- Stark Law Safe Harbor
Correct answer: The Anti-Information Blocking Rule
The Anti-Information Blocking Rule, implemented under the 21st Century Cures Act, prohibits actors from engaging in practices that interfere with access, exchange, or use of electronic health information.
HAC Healthcare Analyst Systems & Regulations 2
Under HIPAA's Minimum Necessary Standard, a covered entity must limit PHI disclosures to the: