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Medicare & Interoperability & Compliance with The Law Discussion

HCAD 650 UMDC Medicare & Interoperability & Compliance with The Law Discussion

Topic/Medicare and Interoperability


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?

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)

Your records 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.


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