HIM 105 Chapter 12: Risk Management, Quality Management, and Utilization Management | Chapter 14: Health Care Fraud and Abuse

Week 8

Agenda

Introduction

Welcome to Week 8!

Chapter 12, the study of Risk Management, Quality Management, and Utilization Management. Most legal issues concerning health information management focus on patient-specific health information given and obtained during the course of patient care. Accordingly, the focus of this book has centered on health information contained in patient health records. While the majority of a health information manager’s practice focuses on such information, such a practice focus is not exclusive. Health information management practice also addresses non-patient records.

Two non-patient record areas in which the health information professionals play a vital role are risk management and quality management. Both are methods of quality control that exist in virtually every hospital and health care facility. Both are distinct improvement techniques; the extent to which they are integrated varies by health care facility. This chapter will not provide an all-encompassing look at risk management and quality management; rather, it will concentrate on the legal bases and requirements for those programs. Further details regarding forms to use and exact methods to employ are left to the broader teaching of quality improvement and management. Closely related to quality management is utilization management, an activity that requires focus on both the health record and non-patient records. This chapter provides a description of the evolution of utilization management and the utilization review process.

Chapter 14, the study of Health Care Fraud and Abuse. During the past thirty years, health care fraud and abuse has become a front-burner issue. Federally funded health care programs such as Medicare and Medicaid have lost of billions of dollars through fraud and abuse, as have private insurance companies. In response, Congress and state legislatures have passed laws to address this problem, federal and state governments have increased their enforcement efforts of existing regulations and laws, and private insurance companies have escalated their efforts to expose fraudulent claims. Newspaper and journal articles are often filled with allegations in this area, and continuing education programs that provide updates on this topic are well attended.

The increase in scrutiny has caused health care providers and organizations to change their methods of operation and created new jobs that did not exist a decade ago. Because health information professionals manage many risk areas open to health care fraud and abuse, such as accurate documentation, coding, and billing, it is important for these professionals to know and understand this area of law. This understanding can assist the organization in preventing the submission of false or inaccurate claims to the government or private payers.

Resources

PowerPoint: Chapter 12: Risk Management, Quality Management, and Utilization Management

PowerPoint: Chapter 14: Healthcare Fraud and Abuse

TO DO

Week 8 To Do
Days and Due dates	To Do
Day 1, Monday	Read: Chapter 12: Risk Management, Quality Management, and Utilization Management. Read: Chapter 14: Healthcare Fraud and Abuse
Day 2, Tuesday	Discussion: Hypothetical Incident Report, Initial Post Due (25 points)
Day 3, Wednesday
Day 4, Thursday	Quiz 3 Chapters 10, 11, 12, and 14 Opens (40 points)
Day 5, Friday	Assignment: Case Study 5.7: Fraud and Abuse (15 points) Assignment: Case Study 5.8: Stark Anti Kickback (15 points)
Day 6, Saturday	Assignment: Case Study 5.9: Whistleblower (10 points)
Day 7, Sunday	Assignment: Case Study: Grand Rounds/Risk Management (Page 264) (75 points) Quiz 3 Chapters 10, 11, 12, and 14 Closes

Module Learning Outcomes

Chapter 12 Risk Management, Quality Management and Utilization Management

Compare and contrast RM with QM
Trace the growth and development of RM
Explain how the three components of patient record requirements relate to RM
Define Incident reports
List the purposes of incident report serves
Differentiate between discovery and admissibility of incident reports
Compose a scenario that illustrates how an incident report may be protected by attorney client privilege
Differentiate between the two aims of peer review statutes: privilege and immunity
Analyze the variations of peer review statutes
Identify the reporting requirements of the Health Care Quality Improvement Act
Describe the utilization review process

Chapter 14 Healthcare Fraud and Abused

Explain the meaning of fraud and abuse
Compare and contrast the major laws supporting a prosecution for healthcare fraud and abuse
List and describe the roles of various law enforcement agencies in the prosecution of healthcare fraud and abuse
Explain the meaning of compliance and compliance programs
List the components of the compliance program

Competencies:

II.1 Apply privacy strategies to health information
IV.2 Describe components of revenue cycle management and clinical documentation improvement
IV.3 Summarize regulatory requirements and reimbursement methodologies
V.1 Apply legal processes impacting health information
V.2 Demonstrate compliance with external forces
V.3 Identify the components of risk management related to health information management
VI.4 Utilize data driven performance improvement techniques for decision making
VI.7 Assess ethical standards of practice

Potential Points earned this week

180 Points

Weekly Time Expectations

All times are approximate, some activities may take less or more time, please plan accordingly.

Reading: 2 Hours
Discussion: Hypothetical Incident Report: 1 Hour
Assignment: Case Study 5.7: 1 Hour
Assignment: Case Study 5.8: 1 Hour
Assignment: Case Study: 5.9: 1 Hour
Assignment: Case Study: Grand Rounds/Risk Management: 1 Hour
Quiz 3: Chapters 10, 11, 12, and 14: 50 minutes