CHAA EXAM – Reading Guide
Pre-Encounter III
Pages 42-51
REGULATORY AGENCIES
1. The JOINT COMMISSION- the goal is to improve the quality of health care for the public by providing ______and related services that support ______improvement. It is an independent, not for profit organization that is the nation’s oldest and largest ______setting and health care accrediting body.
2. In 1965 with the passing of the Medicare Act, Congress added a provision saying that Joint Commission accredited hospitals are “deemed” to be in compliance with most Medicare and Medicaid provisions and thus ______to participate in Medicare and Medicaid.
3. Hospitals are charged a ______for this “voluntary” service, but without Joint Commission Accreditation, hospitals may not participate in ______and ______.
4. In 1972, when the Social Security Act was amended, a provision was added requiring the U.S. Secretary of the U.S. Department of Health and Human Services to ______the Joint Commission’s findings.
5. Standards have been established for psychiatric facilities, alcoholism and substance abuse programs and community mental health programs, ambulatory and managed care and long-term care organizations, hospice and home care, for health care networks, and for preferred provider organizations and labs.
6. By asking for accreditation, an organization agrees to be measured against ______set by health care professionals.
7. Joint Commission accreditation supplies: Enhanced ______confidence, a ______for the public, an objective evaluation of their ______, stimulates ______improvement efforts, aids in professional staff ______, provides staff ______tools, could help in meeting Medicare ______requirements, expedition of ______-______payments, often fulfills state requirements, may favorably influence liability insurance premiums, etc.
COMPLIANCE
Compliance - cooperation or obedience: Compliance with the law is expected of all (dictionary.com).
1. The Office of Inspector General (OIG) states that ______supports the hospital’s attempts to support ______behavior and to meet the changes and challenges imposed on them by ______and ______.
2. This ‘voluntary’ program improves the quality of ______care, reduces ______, ______and ______; and reduces the cost of health care to ______, ______, and ______health insurers.
3. Requirements for Compliance include that hospitals establish ______policies and procedures, hire a ______officer, communicate standards through ______programs, perform ______audits to prevent noncompliance within the hospital, develop lines of communication for reporting ______, enforce standards through well publicized ______guidelines and procedures.
4. Respond appropriately and immediately to detected ______in order to prevent further offense through corrective action.
HIPPA – Health insurance PORTABILITY Act of 1996
5. Initially, HIPPA focused on ______of health insurance, which means that once a person has insurance coverage, when they ______health plans (most commonly when changing jobs), the previous coverage may be used to reduce or eliminate _____- ______condition exclusions.
6. This Act also attempts to reduce the cost and administrative burden of providing healthcare by promoting standardized electronic ______and ______transactions.
7. It also helps ensure that any protected health information (PHI) that is collected, stored, or transmitted electronically is ______.
STANDARDS FOR PRIVACY
8. Maintaining the exchange of individually ______health information is an important part of delivering quality health care. This is an area of concern because patients want to insure their sensitive information will be protected not only during the course of their treatment but also in the ______as it is maintained and exchanged.
9. Health care providers and payers depend on patients to provide accurate, ______information about their personal health, ______, and other aspects of their lives.
10. They rely on the provision of such ______to accurately and promptly process ______for payment and for other administrative functions that directly affect a patient’s ability to receive needed care.
11. Patients are concerned because ______standards vary from state to state.
12. By using electronic data, integrated health information systems has increased the ability to ______and ______those at risk for disease, conduct research, detect fraud and abuse, and measure the quality of care delivered in the US.
13. Applying standards helps restore patient ______in the health care system. The ease of information ______, organization, ______, and exchanged made possible by the advances in ______and other electronic technology affords many ______to the health care industry and patients.
14. At the same time, these advances have reduced or eliminated many of the logistical ______that previously served to protect the confidentiality of health information.
TRAINING (to protect PHI)
15. Hospitals must ______all new employees who will have access to protected health information within a reasonable amount of time after beginning work. They must ______workers whenever a policy changes within a reasonable amount of time. All employees must ______a written statement certifying they have received privacy training. And each member must sign a new statement every ______years.
16. The hospital must have appropriate ______and ______safeguards in place to protect against unauthorized disclosures.
17. Physical safeguards include: speaking quietly when discussing sensitive information, avoiding the use of patient names in public hallways, isolating or ______file cabinets or record rooms.
18. Technical safeguards include: providing additional security on ______that maintain personal information.
INFORMATI0N SERVICES
19. This refers to all things IT (information technology/information services) which are computer related services used to improve patient care in all departments through technology.
20. It helps provide a unique identity to ______records.
21. It provides easier access to ______and ______data.
22. Their function is to: support installed technologies and provide ______and ______networks; to partner with customers to select, implement, and integrate new systems to meet changing needs of the hospital.
23. One of the most crucial duties of Information Services is to advise, monitor, and insure ______.
TECHNICAL INFORMATION
24. Access Staff must have a basic understanding how information systems work and the difference between hardware and software.
25. ______- keyboard, monitor, central processing unit (CPU), printers, servers, cables, cords, etc.
26. ______- system programs that make the computer run (Windows, Microsoft Word, Excel, Active Dashboard, SMS Invision, AccuReg, etc.)
27. The more Access Staff know about computers the more likely they will be able to ______problems on their own or easily explain the problem to the IT staff.
SOFTWARE APPLICATIONS
28. Most software applications transmit data in one of two ways
29. ______- many transactions stored and sent on pre-scheduled or demand basis.
30. ______- where data is taken from one system and sent to another.
31. Access data is shared with financial management systems, patient care systems, and administrative systems.
32. ______Integrity is an essential part of Access Services because errors made in registration are transmitted to all other systems.
HEALTHCARE SYSTEMS
33. As healthcare continues to ______from traditional independent hospitals to Integrated Healthcare Networks (IHN), there is a need to identify patients who travel between providers in a unique way and to make information gathered at one site available at ______sites.
MASTER PATIENT/PERSON INDEX (MPI)
37. MPI uniquely identify the HEALTH SYSTEM’S entire population and store key ______data on each patient.
38. Although the ______data will vary from one organization to another, an enterprise wide MPI will store at least all medical record numbers associated with that entity’s clients.
CLINICAL DATA REPOSITORY
34. A CDR provides ready access patient data from different ______of the healthcare network. Such data will be integrated into a single ______-______record for the patient and may provide the ability to trend analysis of lab results over time.
GENERAL INSURANCE INFORMATION
35. Insurance is “coverage” for medical expenses a patient could occur as a result of illness or injury. Patients may ______or ______for this coverage to insure themselves against significant ______loss.
36. There are different levels of coverage. Some policies may pay ______%, and others 80% requiring the patient to pay the remaining ____%. Some have deductibles and or co-pays.
37. A ______is coverage for a certain type of medical condition.
GUIDELINES FOR DETERMINING THE POLICYHOLDER
38. Another name for the policy holder is ______.
39. The policyholder will not always be the person whose name appears on the ______.
40. For most Blue Cross, Commercial, and PPO insurance, the policy holder is the person whose name is on the ______. So the PATIENT may not be the policyholder. The patient’s parent/spouse could be the policyholder and their name would be on the card.
41. Most HMO’s give each insured person his or her own card. In this instance, the patient (with his name on the card) may not be the ______, and the Access Staff must identify who is.
42. For most HMO’s the policy holder can be identified by a two digit suffix of 00 or 01. Spouses are usually identified by 01 or 02, and dependants are ______, ______, etc.
43. With ______insurance, the policy holder will be the sponsor or the person who is active or retired military.
44. Medicare and Medicaid, the policyholder will ______be the patient.
45. The policyholder for Worker’s Compensation is usually the ______.
CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)
The goals of CMS are to: (46-50)
46. Protect and improve beneficiary ______and ______.
47. Promote the ______integrity of CMS Programs
48. Purchase the best ______for beneficiaries
49. Promote beneficiary and public ______of CMS and its guidelines
50. Provide ______in the broader public interests to improve health
51. CMS provides ______assessment and ______improvement based on: developing and enforcing ______through surveillance, measuring and improving ______of care, educating healthcare providers about quality ______opportunities, and educating ______to make good healthcare choices.
52. CMS is a ______agency responsible for administering the largest federal health program. They are also involved with CHIPs programs for uninsured children in the US. CMS is also responsible for implementing federal ______assurance standards in labs, nursing homes, hospitals, and HH agencies as well as in ambulatory surgical centers, hospices, and other facilities that participate in the Medicare and Medicaid programs.
53. CMS administers the ______program through designed to monitor and improve care for ______beneficiaries.
54. This national network is a ‘watch dog’ type or organization responsible for ensuring the quality, ______, efficiency, and economy of health care services.