Healthcare Regulations & Compliance Flashcards

A care manager is auditing records and finds that a colleague improperly accessed the electronic health records of a celebrity patient out of curiosity. Under HIPAA, this constitutes:

Answer: A breach of unsecured PHI requiring notification

Unauthorized access to PHI without a permissible purpose constitutes a breach under HIPAA, triggering notification requirements to the affected individual, HHS, and potentially the media.

Under the Mental Health Parity and Addiction Equity Act (MHPAEA), health plans must ensure that:

Answer: Financial requirements for mental health benefits are no more restrictive than for medical/surgical benefits

MHPAEA requires that financial requirements (like copays and deductibles) and treatment limitations for mental health/substance use disorder benefits be no more restrictive than the predominant requirements for medical and surgical benefits.

When a care manager assists with prior authorization requests, which document is most critical in supporting medical necessity determinations?

Answer: Clinical documentation aligned with payer coverage criteria

Clinical documentation that clearly demonstrates how the patient's condition meets the payer's coverage and medical necessity criteria is essential for successful prior authorization.

The Anti-Kickback Statute (AKS) applies to which programs?

Answer: Federal healthcare programs including Medicare and Medicaid

The Anti-Kickback Statute is a federal criminal law that prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals of items or services covered by federal healthcare programs.

A patient covered by both Medicare (primary) and an employer group health plan (secondary) receives a bill. Under Medicare Secondary Payer (MSP) rules, who should be billed first?

Answer: The group health plan, then Medicare

Medicare Secondary Payer rules require that when a working-aged beneficiary (under 65) is covered by an employer group health plan with 20 or more employees, the group health plan is the primary payer and Medicare pays secondary.

Under the Patient Self-Determination Act (PSDA), healthcare organizations that receive Medicare/Medicaid funding must:

Answer: Inform adult patients of their rights to make decisions about care, including the right to have advance directives

The PSDA requires Medicare and Medicaid participating organizations to inform adult patients of their rights under state law to accept or refuse treatment and to formulate advance directives.

A care manager employed by a health plan is reviewing claims for a patient in a managed care plan. The patient's provider submitted a claim using an upcoded procedure code. This is an example of:

Answer: Upcoding fraud

Upcoding is submitting claims for higher-level or more expensive services than were actually provided, which is considered healthcare fraud under the False Claims Act.