CHAA Examination Preparation

1. CHAA Examination Preparation Pre-Encounter – Session III Pages 42-51 University of Mississippi Medical Center

2. What to Expect… • This module covers various aspects of Patient Access knowledge found on pages 42-51 of the Pre-Encounter section of the 2010 CHAA Study Guide. • A quiz at the end will measure your understanding of the knowledge covered.

3. The Joint Commission (TJC) • This goal of the TJC is to IMPROVE the QUALITY of healthcare for the public by providing ACCREDITATION to support PERFORMANCE IMPROVEMENT in healthcare. • They regulate or police healthcare organizations to ensure a nationwide standard of quality healthcare.

4. History of The Joint Commission (TJC) • TJC is the nation’s oldest and largest STANDARDS SETTING and health care ACCREDITATING body. • In 1965 Congress passed the Medicare Act stating that hospitals accredited by The Joint Commission are “deemed” to be in compliance with Medicare and Medicaid policies, and therefore able to participate in Medicare and Medicaid programs. • Without Joint Commission Accreditation, PROVIDERS MAY NOT PARTICIPATE in Medicare and Medicaid programs.

5. Joint Commission Basics • Joint Commission accreditation is a ‘VOLUNTARY’ process that hospitals pay a FEE to undergo. • By asking for accreditation, an organization agrees to be measured against NATIONAL STANDARDS set by health care professionals.

6. Compliance • The Office of Inspector General (OIG) defines COMPLIANCE as a process that helps hospitals behave ETHICALLY and meet the changing demands imposed on them by CONGRESS and PRIVATE INSURERS. • Compliant means to give cooperation or obedience. • Being compliant helps hospitals improve the quality of patient care, REDUCE FRAUD, WASTE, and ABUSE, and reduces the overall cost of healthcare.

7. Compliance in Action Results in: • Training programs which communicate compliance standards to staff • Developing lines of communication to reporting violations • Enforcing standards through well-publicized disciplined guidelines and procedures • Responding appropriately to detected offences

8. Health Insurance Portability and Accountability Act (HIPPAA) • PORTABILITY in HIPPAA means that once a person has insurance coverage, when they change health plans, (most commonly when changing jobs), the previous coverage may be used to reduce or eliminate any pre-existing condition exclusions that might apply under the new plan. • HIPPAA also aims to reduce the costs and administrative burdens of healthcare by ENCOURAGING ELECTRONIC administrative and financial transactions. • It also encourages SECURITY OF PERSONAL HEALTH INFORMATION (PHI).

9. Electronic Transactions and HIPPAA • Advances in technology, when used safely and appropriately provide many benefits to the health care industry and patients. • On the other hand, these advances reduce many obstacles that previously served to protect personal health information. • HIPPAA standards help restore patient confidence by requiring safeguards to protect PHI.

10. HIPPAA Privacy Standards In addition to training employees who will have access to PHI and making them sign a form stating they’ve received the guidelines and will abide by them, hospitals must take REASONABLE PHYSICAL and TECHNICAL SAFEGUARDS to ensure patient privacy. See examples below: • PHYSICAL – lock file cabinets or rooms with PHI. • TECHNICAL- provide additional security on computers that maintain PHI.

11. Information Services • Refers to obtaining, storing, organizing, and accessing information through computerized technology • Also known as the IT (Information Technology) Department, they are in charge of installing, supporting, and repairing all computers throughout the hospital. • A MAJOR part of their responsibility is ADVISING, MONITORING, and ENSURING DATA INTEGRITY through analysis and support.

12. Technical Knowledge and Information • Patient Access Staff should have a basic understanding of how information systems work in order to TROUBLESHOOT problems on their own or CLEARLY EXPLAIN the problem to IT staff. Hardware vs. Software • Hardware includes: keyboards, mouse, monitor, printer, cables, etc. • Software includes: system programs that make the computers run (Windows, SMS Invision, Microsoft Office, etc.)

13. Software Applications Two forms of data transmission: 1.) BATCH PROCESSING – many transactions are stored and sent on a pre-scheduled or demand basis (Outlook, AccuReg, etc.) 2.) INTERFACE – software is taken from one system and sent to another (Email on yahoo.com/gmail.com, SMS Invision, etc.)

14. Data Integrity • DATA INTEGRITY refers to the ACCURACY and COMPLETENESS of all information collected. • DATA INTEGRITY is crucial to Access Services because errors made in registration are transmitted to all other areas of the hospital and can NEGATIVELY IMPACT patient care and the financial health of the organization.

15. Master Patient Index • This is a list of the health system’s ENTIRE PATIENT POPULATION. • It stores KEY IDENTIFYING DATA on each patient.

16. Clinical Data Repository • This provides access to CLINICAL information from a VARIETY OF SOURCES within a healthcare delivery network. • It INTEGRATES medical information into a SINGLE, LONG-TERM RECORD for the patient that may provide doctors the ability to trend analysis over a period of time.

17. General Insurance Information • Health insurance is financial “coverage” for medical expenses a patient could incur as a result of an illness or injury. • Insurance policies have different levels of coverage. Some could pay 100% while others pay 80% and require the insured to pay the remaining 20%.

18. Determining the Policyholder • The policyholder (or subscriber) is the owner who contracts with the insurance company for health insurance coverage. • Determining the policy holder refers to distinguishing the owner of the policy from any family members that may be covered under the policy. • Determining the Policyholder is a common and costly mistake.

19. Determining the Policyholder • For most Blue Cross, Commercial, and PPO insurance, the policyholder is the person whose NAME APPEARS ON THE CARD. • HMO’s GIVE EACH INSURED PERSON THEIR OWN CARD. Therefore, the person on the card will be the patient, but he MAY NOT be the policy holder. You must ALWAYS ASK who the policy holder is with HMOs! • Worker’s Compensation will usually be the employer.

20. Determining the Policyholder • Most HMOs identify the relation to policyholder with a two digit suffix of 00 or 01. Spouses are usually 01, 02 with dependants being 03, 04, etc. • For Insurance, the policyholder will ALWAYS BE the sponsor or the person who is active or retired from the military. • and will ALWAYS BE the patient.

21. Centers for Medicare and Medicaid Services (CMS) • This is a government agency created to administer the largest federal health programs. It also works with CHIPS for uninsured children. • Their goal is to assure health security for their beneficiaries.

22. Centers for Medicare and Medicaid Services (CMS) • They do so by performing Quality Assessment and Performance Improvement for CMS accredited hospitals. • They promote Health Standards and Quality by assigning Peer Review Organizations (PRO) to monitor and improve healthcare in each state.