QUALITY ASSURANCE Exam 23 Questions with Verified Answers,100% CORRECT

QUALITY ASSURANCE Exam 23 Questions with Verified Answers Regulatory compliance is achieved how - CORRECT ANSWER By setting up processes and systems such as training personnel, implementing Quality Assurance (QA) processes, auditing, or designating depts to direct compliance efforts 4 factors that healthcare is so regulated - CORRECT ANSWER 1. involves life and death issues. 2. it is expensive. 3. people and companies want to be protected from fraud and abuse. 4. government subsidizes billions of dollars for it. Dept of Health and Human Services (DHHS) - CORRECT ANSWER governs and regulates healthcare in US Dept of Justice (DOJ) - CORRECT ANSWER prosecutes fraud and abuse Centers for Medicare and Medicaid (CMS) - CORRECT ANSWER develops rules and regulations Office of Inspector General (OIG) - CORRECT ANSWER monitors for compliance and turns suspected fraud and abuse over to the DOJ audit - CORRECT ANSWER an evaluation of provided healthcare services to ensure all aspects are in compliance with industry rules and regulations concurrent review - CORRECT ANSWER review done while the patient is actively receiving care retrospective review - CORRECT ANSWER review done after the patient has received care the key to successful internal auditing program for regulatory compliance - CORRECT ANSWER is ensuring that the facility or provider makes changes when problems arise or issues are discovered undercoding - CORRECT ANSWER selecting codes at a lower level than the service documented upcoding - CORRECT ANSWER selecting codes at a higher level than the service documented unbundling - CORRECT ANSWER billing 2 or 3 procedures when the services are typically covered by a single comprehensive code External audits fall under two categories - CORRECT ANSWER reactive and proactive external audit - CORRECT ANSWER when an audit is performed by a regulatory agency or by an independent auditor outside of the healthcare organization - at the request of the provider, or at the request of an individual, company or agency outside of the healthcare provider proactive audit - CORRECT ANSWER a routine or random audit to check the healthcare provider's compliance with rules and regulations for providing services, documenting services, and billing services Joint Commission - CORRECT ANSWER an independent, not-for-profit organization that accredits and certifies more than 15,000 healthcare organizations and programs in the US reactive external audits - CORRECT ANSWER are conducted as a result of complaint, concern, or suspicion of wrongdoing erroneous claim - CORRECT ANSWER claim filed with innocent errors on them due to faulty processes, misinterpretation, or other negligence fraudulent claim - CORRECT ANSWER claim filed with the knowledge of falsity of the claim qualitative analysis - CORRECT ANSWER review that deals with accuracy quantitative analysis - CORRECT ANSWER review that deals with completeness Recovery Audit Contractor (RAC) - CORRECT ANSWER performs audits for Medicare and Medicaid to determine improper payments