Healthcare Regulations and Compliance Flashcards

A case manager is completing an admission assessment for a 78-year-old client being admitted to a skilled nursing facility. To comply with the Patient Self-Determination Act (PSDA), which of the following actions is required?

Answer: Informing the client of their right to accept or refuse medical treatment and asking if they have an advance directive.

The Patient Self-Determination Act (PSDA) of 1990 requires healthcare institutions like hospitals and skilled nursing facilities that receive Medicare/Medicaid funding to inform patients of their rights under state law to make decisions concerning their medical care. This includes the right to accept or refuse treatment and the right to formulate advance directives. The facility must also ask if the patient has an advance directive and document this in the medical record.

A hospital case manager is participating in a multidisciplinary rounds meeting in a busy, open-style nursing station. The team begins discussing a well-known local celebrity's complex diagnosis and challenging social situation. This action constitutes a potential violation of which federal regulation?

Answer: Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule protects all individually identifiable health information. Discussing a patient's protected health information (PHI) in a public or semi-public area where the conversation can be overheard by those not involved in the patient's care is a common HIPAA violation. Care coordination discussions should occur in a private setting to protect patient confidentiality.

A person presents to a hospital emergency department with acute abdominal pain but has no identification or insurance information. According to the Emergency Medical Treatment and Labor Act (EMTALA), what is the hospital's primary obligation?

Answer: Provide a medical screening examination to determine if an emergency medical condition exists.

EMTALA, also known as the "anti-dumping" law, requires Medicare-participating hospitals with emergency departments to provide a medical screening examination (MSE) to any individual who comes to the emergency department seeking treatment, regardless of their ability to pay or insurance status. If an emergency medical condition is found, the hospital must provide stabilizing treatment or an appropriate transfer if they lack the capability to stabilize the patient.

A hospital-employed physician refers a Medicare patient for home health services to an agency in which the physician has a direct financial ownership interest. This arrangement is most likely to be scrutinized under which federal law?

Answer: The Physician Self-Referral Law (Stark Law)

The Physician Self-Referral Law, commonly known as the Stark Law, prohibits physicians from referring Medicare or Medicaid patients for certain designated health services (DHS), such as home health, to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception applies. The law is intended to prevent financial incentives from influencing a physician's medical judgment.

A case manager is working with a client being treated at a federally-assisted substance use disorder (SUD) program. The client's employer calls the case manager directly, requesting confirmation of the client's treatment dates for an FMLA claim. According to 42 CFR Part 2, what is the case manager's most appropriate action?

Answer: Inform the employer that the information can only be released with the client's specific written consent that meets Part 2 requirements.

42 CFR Part 2 provides stringent federal protections for the confidentiality of records related to substance use disorder treatment from federally assisted programs. Disclosure of any identifying information, including confirmation of patient status, requires specific written patient consent that is more rigorous than a standard HIPAA release. A general release, verbal permission, or even a standard subpoena is insufficient under these regulations.

Which program, established by the Affordable Care Act (ACA), directly penalizes hospitals by reducing Medicare payments for higher-than-expected rates of 30-day readmissions for specific conditions like heart failure and pneumonia?

Answer: Hospital Readmissions Reduction Program (HRRP)

The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program established under the ACA that reduces payments to hospitals with excess 30-day readmissions for targeted clinical conditions. The program's goal is to incentivize hospitals to improve care coordination, discharge planning, and post-discharge follow-up to prevent unnecessary readmissions.