HCAD 650 UMGC Medicare Compliance CoP RAC And Interoperability Questions

Part 1: Critical Analysis of the Law

Medicare is a large payer of health care services as the health care payer for the elderly.

Evaluate the Conditions of Participation (CoP) for a hospital to participate with Medicare.  What are the pros and cons of a hospital being a Medicare provider? What are the consequences of non-participation with Medicare?

What is the role of the Joint Commission to obtain “deemed” status? Is Joint Commission a regulatory agency?  Why or why not?

State the specific legal risks related to Medicare CoP.  Discuss the COSO framework for internal controls and evaluate how it could be used to meet Medicare CoP.  Be specific and demonstrate understanding of the risks and how the compliance tool can be used specifically to control the risks.

Part 2:  Strategic Compliance with the Law

You work for a small managed care organization (MCO) “Splendid Healthcare” that owns a hospital and two provider clinics in.  Your MCO just received notice that it will be subject to a CMS Recovery Audit Contractor (RAC) audit on the following issues and has requested medical records from your hospital and provider clinics.

0001 Inpatient Hospital MS – DRG Coding Validation

0011 Inappropriate Billing of Home Visit Professional Service Evaluation and Management Codes during Inpatient

Name and describe the law and code section that gives CMS and RAC auditors the right to access your medical records. (Give the legal source of the right)

Discuss interoperability requirements. How do they apply to this situation? How could you prepare to have an interoperable electronic health record (EHR) that meets CMS standards? Describe the steps you would take to move towards interoperability.

Answer one of the questions.

What management actions would you take to work effectively with CMS administrators to ensure that you meet CMS CoP for Medicare?

What management actions would you take to work effectively with RAC auditors during an audit?

Week 4 and 5: Government Programs
Additional Resources
Medicare
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Medicare and Medicaid Conditions of Participation: https://www.cms.gov/Regulationsand-Guidance/Legislation/CFCsAndCoPs/index.html?redirect=/CFCsAndCoPs/
Conditions of Participation for Hospitals https://www.govinfo.gov/content/pkg/CFR2017-title42-vol5/xml/CFR-2017-title42-vol5-part482.xml
Conditions of Participation for Home Health Services https://www.ecfr.gov/cgi-bin/textidx?node=pt42.5.484&rgn=div5
Requirements for Long Term Care eCFR :: 42 CFR Part 483 Subpart B — Requirements
for Long Term Care Facilities
Accountable Care Organizations (ACOs): General
Information https://innovation.cms.gov/initiatives/ACO
Your Guide to Medicare Preventive Services Your Guide to Medicare Preventive
Services | Guidance Portal (hhs.gov)
Medicaid
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State Medicaid Plans and Waivers: https://www.cms.gov/Outreach-andEducation/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/info/state-medicaidpolicies.html
National Council on Disability: Chapter 1. An Overview of Medicaid Managed Care |
NCD.gov
The Urban Institute (2012). Medicaid and CHIP Risk-Based Managed Care in 20
States: https://www.urban.org/sites/default/files/publication/25646/412617-Medicaidand-CHIP-Risk-Based-Managed-Care-in-States.PDF
Medicaid A Primer (CRS): https://www.kff.org/medicaid/issue-brief/medicaid-aprimer/
Medicaid Financing: The Basics https://www.kff.org/medicaid/issue-brief/medicaidfinancing-the-basics/
Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier
https://www.kff.org/medicaid/state-indicator/federal-matching-rate-andmultiplier/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22so
rt%22:%22asc%22%7D
State Health Departments https://www.usa.gov/state-health
Maryland Department of Health https://health.maryland.gov/pages/home.aspx
Medicaid and the Affordable Care Act: https://www.medicaid.gov/affordable-careact/index.html
Medicaid Expansion: https://www.kff.org/health-reform/issue-brief/a-guide-to-thesupreme-courts-decision/
Food and Drug Administration (FDA)
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FDA https://www.fda.gov/
Drug Regulation https://www.fda.gov/drugs
Medical Device Regulation https://www.fda.gov/medical-devices
Radiation-Emitting Products https://www.fda.gov/radiation-emitting-products
Vaccines, Blood & Biologics https://www.fda.gov/vaccines-blood-biologics
Tobacco Products https://www.fda.gov/tobacco-products
State Department of Health
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State Health Departments https://www.usa.gov/state-health
Maryland Department of Health https://health.maryland.gov/pages/home.aspx
CDC https://www.cdc.gov/
Medicaid and the Affordable Care Act: https://www.medicaid.gov/affordable-careact/index.html
Affordable Care Act
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Affordable Care Act Tax Provisions for Large Employers
https://www.irs.gov/affordable-care-act/employers/affordable-care-act-tax-provisionsfor-large-employers
Summary of the Affordable Care Act https://www.kff.org/health-reform/factsheet/summary-of-the-affordable-care-act/
ACA Information Center for Applicable Large Employers
(ALE) https://www.irs.gov/affordable-care-act/employers/aca-information-centerfor-applicable-large-employers-ales
Preventive health care services https://www.kff.org/health-reform/fact-sheet/summaryof-the-affordable-care-act/
Burwell v. Hobby Lobby Stores (2014) https://www.oyez.org/cases/2013/13-354
Appealing Health Plan Decisions https://www.hhs.gov/healthcare/about-theaca/cancellations-and-appeals/appealing-health-plandecisions/index.html#:~:text=You%20have%20the%20right%20to,to%20terminate%2
0your%20health%20coverage.&text=You%20can%20appeal%20your%20insurance,fai
r%20review%20of%20its%20decision
CMS RAC Audits
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CMS Recovery Audit Contractors (RAC) https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program
The Recovery Audit Program and Medicare https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program/Downloads/The-Recovery-Audit-Program-andMedicare-Slides-051313.pdf
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Approved RAC Topics https://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-AuditProgram/Approved-RAC-Topics
Medicare Pard D RAC Appeals Process https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/recovery-audit-program-parts-c-andd/Appeals-Process
Interoperability and Information Blocking
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CMS Policies and Technology for Interoperability and Burden Reduction
https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index
CMS Interoperability Final Rule https://www.cmspatientaccessrule.com/
HIMSS Final CMS Interoperability Regulation: What you Need to Know
https://www.himss.org/news/final-onc-interoperability-regulation-what-you-needknow#:~:text=The%20CMS%20Interoperability%20and%20Patient%20Access%20Fina
l%20Regulation,more%20informed%20decision%20makers%20leading%20to%20bett
er-informed%20treatment.
Information Blocking https://www.healthit.gov/topic/information-blocking
Information Blocking FAQ https://www.healthit.gov/curesrule/resources/informationblocking-faqs
How do I comply with info blocking and where do I start? https://www.amaassn.org/system/files/2020-11/info-blocking-compliance.pdf
Understanding the Eight Exceptions to Information Blocking
https://journal.ahima.org/understanding-the-eight-exceptions-to-information-blocking/
Children’s Health Insurance Program (CHIP)
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The Children’s Health Insurance Program (CHIP)
https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/
Children’s Health Insurance Program Overview
https://www.ncsl.org/research/health/childrens-health-insurance-programoverview.aspx
Center for Disease Control
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CDC https://www.cdc.gov/
COSO
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COSO https://www.coso.org/
COSO Guidance https://www.coso.org/guidance-on-ic
COSO Guidance for Health care Providers https://www.coso.org/healthcare-providers
COSO: Governance https://www.coso.org/governance