Government Programs

WK 4 – Look for tool applications beyond those already discussed.

Complete the discussion using classroom tools only – the textbook, course web links, Classroom Law Library, and Compliance Library

Group 1/Medicare and Interoperability

Question – 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 in Medicare. What are the pros and cons of a hospital being a Medicare provider? What are the consequences of non-participation in Medicare?

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

Discuss the COSO framework for internal controls and evaluate how it could be used to meet Medicare CoP. Be specific and demonstrate an 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. 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 request)

Your documents are electronic but not transferrable electronically in an interoperable fashion. How could you best meet the medical record request?

Discuss interoperability requirements. 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.