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Statutes

answer

(Statutory law) Laws passed by legislative bodies (e.g., federal Congress and state legislatures).

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Regulations

answer

Guidelines written by administrative agencies (e.g., CMS)

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Case law

answer

(common law) Based on court decisions that establish a precedent (or standard).

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Civil law

answer

This deals with all areas of the law that are not classified as criminal.

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Criminal law

answer

Public law (statute or ordinance) that defines crimes and their prosecution.

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Subpoena

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An order of the court that requires a witness to appear at a particular time and place to testify.

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Subpoena duces tecum

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Requires documents (e.g., patient record) to be produced.

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Deposition

answer

Testimony under oath taken outside of court (e.g., at the provider's office).

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Interrogatory

answer

A document containing a list of questions that must be answered in writing.

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Qui tam

answer

An abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, meaning "who as well for the king as for himself sues in this matter." A provision of the Federal False Claims Act, which allows a private citizen to file a lawsuit in the name of the U.S. government, charging fraud by government contractors and other entities that receive or us government funds, and to share in money recovered.

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Federal register

answer

A legal newspaper published every business day by the National Archives and Records Administration (NARA).

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Program transmittals

answer

Contain new and changed Medicare policies and/or procedures that are to be incorporated into a specific CMS program manual (e.g., Medicare Claims Processing Manual).

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Medicare administrative contractor (MAC)

answer

An organization (e.g., insurance company) that contracts wtih CMS to process health care claims and perform program integrity tasks for both Medicare Part A and Part B.

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Listserv

answer

A subscriber-based question-and-answer forum available through e-mail.

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Overpayments

answer

Funds a provider or beneficiary receives in excess of amounts due and payable under Medicare and Medicaid.

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Payment error rate

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Number of dollars paid in error out of the total dollars paid for inpatient prospective payment system services.

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Clinical Data Abstracting Centers (CDASs)

answer

These became responsible for initially requesting and screening medical records for PEPP surveillance sampling for medical review, DRG validtion, and medical necessity; medical review criteria were developed by peer review organizations.

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First-look Analysis for Hospital Outlier Monitoring (FATHOM)

answer

A data analysis tool, which provides administrative hospital and state-specific data for specific CMS target areas to QIOs.

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Program for Evaluating Payment Patterns Electronic Report (PEPPER)

answer

Contains hospital-specific administrative claims data for a number of CMS-identified problem areas (e.g., specific DRGs, types of discharges). A hospital uses PEPPER data to compare their performance with that of other hospitals.

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Record retention

answer

The storage of documentation for an established period of time, usually mandated by federal and/or state laws.

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Fraud

answer

An intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.

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Abuse

answer

Involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices.

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Code pairs

answer

(or edit pairs) Codes that cannot be reported on the same claim for the same date of sevice, and they are based on coding conventions defined in CPT, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices.

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National Health PlanID (PlanID)

answer

(formerly called PAYERID) is assigned to third-party payers;it has 10 numeric positions, including a check digit as the tenth position.

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Check digit

answer

A one-digit character, alphabetic or numeric, used to verify the validity of a unique identifier.

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National Individual Identifier

answer

(patient identifier) has been put on hold. Several bills in Congress would eliminate the requirement to establish a National Individual Identifier.

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National Provider Identifier (NPI)

answer

Assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position.

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National Standard Employer Identification Number (EIN)

answer

Assigned to employers who, as sponsors of health insurance for their employees, must be identified in health care transactions. It is the federal employer identification number (EIN) assigned by the Internal Revenue Service (IRS) and has nine digits with a hypen.

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Electronic transaction standards

answer

(transactions rule) A uniform language for electronic data interchange.

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Electronic data interchange (EDI)

answer

The process of sending data from one party to another using computer linkages.

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False Claims Act (FCA) - 1863

answer

Regulated fraud associated with military contractors selling supplies and equipment to the Union Army.

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Upcoding

answer

the assignment of an ICD-9-CM code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-9-CM heart attack when angina was actually documented in the health record)

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Food and Drug Act - 1906

answer

Authorized federal government to monitor the purity of foods and the safety of medicine. (Now a responsibility of the FDA)

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Social Security Act - 1935

answer

Included unemployment insurance, old-age assistance, aid to dependent children, and grants to states to provide various forms of medical care. (Ammended in 1965 to add disability coverage and medical benefits)

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Migrant Health Act - 1962

answer

Provided medical and support services to migrant and seasonal farm workers and their families.

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Social Security Ammendments - 1965

answer

Created Medicare and Medicaid programs, making comprehensive health care available to millions of Americans. Established Conditions fo Participation (CoP) and Conditions of Coverage (CfC)

question

Conditions fo Participation (CoP) and Conditions of Coverage (CfC)

answer

Federal regulations that healthcare facilities must comply with to participate in (receive reimbursement from) the Medicare and Medicaid programs; physicians must comply with billing and payment regulations published by CMS

question

Federal Claims Collection Act - 1966

answer

Required carriers (process Medicare Part B claims) and fiscal intermediaries (process Medicare Part A claims), (both of which were replaced by Medicare administrative contractors) (that administer the Medicare fee-for-program), to attempt the collection of overpayments under Medicare and Medicaid.

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National Cancer Act - 1971

answer

Amended the Public Health Service Act of 1798 to more effectively carry out the national effort against cancer. Part of President Nixon's "War on Cancer".

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Federal Anti-Kickback Law - 1972

answer

Protect patients and federal healthcare programs from fraud and abuse by curtailing the corrupting influence of money on healthcare decisions.

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Drug Abuse and Treatment Act - 1972

answer

Required that drug and alcohol abuse patient records be kept confidential and not subect to disclosure except as provided by law. Applied to federally assisted alcohol or drug abuse programs, which are those that provide diagnosis, treatment, and referral for treatment of drug and/or alcohol abuse.

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Social Security Amendments - 1972

answer

Strengthened utilization review process by creating professional stndards review organizations (PSROs), which were independent peer review organizations that monitored the appropriateness, quality, and outcome of the services provided to beneficiaries of the Medicare, Medicaid, and Maternal and Child Health Programs.

question

Underpayments

answer

Occur when submitted claims report codes simple procedures, when review of records indicate a more complicated procedure was performed.

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National Plan and Provider Enumeraton System (NPPES)

answer

Assigns unique identifiers to healthcare providers and health plans.

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National Standard Format

answer

flat file format used to bill physician and noninstitution serves, such as services reported by a general practitioner on a CMS-1500

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ANSI ASC X12N 837

answer

A variable-length format that is used to bill institutional, professional, dental, and drug claims.

question

National Drug Code (NDC)

answer

Maintained by the FDA. Identifies prescription drugs and some over-the-counter products. Each drug product is assigned a uniquie 11-digit, 3-segment number, which identifies the vendor, product, and trade package size.

question

Privleged communication

answer

Any information communicated by a patient to a healthcare provider.

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Protected Health Information (PHI)

answer

information that is identifiable to an individual (individual identifiers) such as name, address, telephone numbers, social security number, and name of employer.

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Privacy

answer

The right of individuals to keep their information form being disclosed to others.

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Confidentiality

answer

Involves restricting patient information access to those with proper authorization and maintaing the security of patient information.

question

Security

answer

Involves the safekeeping of patient information by 1) controlling access to hard copy and computerized records, 2) protecting patient information from alteration, destruction, tampering, or loss, 3) providing employee training in confidentiality of patient information 4) requiring employees to sign a confidentiality statemnt that details the consequences of not maintaining patient confidentiality.

question

Breach of Confidentiality

answer

Often intentional. Involves the unauthorized release of patient information to a third party.

question

HIPAA Privacy Rule

answer

Creates national standards to protect individuals' medical records and other personal health information.

question

HIPAA Security Rule

answer

Adopts standards and safeguards to protect health information that is collected, maintained, used, or transmitted electonically. Covered entities affected by this rule include halth plans, healthcare clearinghouses, and certain healthcare providers.

question

Patient Safety Organization (PSO)

answer

Analyze the problems, identify solutions, and provide feedback to aviod future healthcare errors. A database tracks national trends and reoccuring problems.

question

Conditions of Participation (CoP)

answer

Medicare - requires providers to keep copies of any government insurance claims and copies of all attachments filed by the provider for a period of five years, unless state law specifies a longer period.

question

authorization

answer

...

question

black box edit

answer

...

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case law

answer

...

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Comprehensive Error Rate Testing (CERT) program

answer

...

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civil law

answer

...

question

common law

answer

...

question

criminal law

answer

...

question

Current Dental Terminology (CDT)

answer

...

question

decrypt

answer

...

question

Deficit Reduction Act of 2005

answer

...

question

deposition

answer

...

question

digital

answer

...

question

edit pairs

answer

...

question

encrypt

answer

...

question

Federal Register

answer

...

question

Hospital Payment Monitoring Program (HPMP)

answer

...

question

Improper Payments Information Act of 2002 (IPIA)

answer

...

question

interrogatory

answer

...

question

listserv

answer

...

question

Medicaid Integrity Program (MIP)

answer

...

question

medically unlikely edits (MUEs)

answer

...

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Medicare administrative contractor (MAC)

answer

...

question

message digest

answer

...

question

modifier

answer

...

question

overpayment

answer

...

question

Patient Safety and Quality Improvement Act

answer

...

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Payment Error Prevention Program (PEPP)

answer

...

question

Payment Error Rate Measurement (PERM) program

answer

...

question

physician self-referral law

answer

...

question

Physicians at Teaching Hospitals (PATH)

answer

...

question

precedent

answer

...

question

Privacy Act of 1974

answer

...

question

Program Safeguard Contracts (PSCs)

answer

...

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program transmittal

answer

...

question

qui tam

answer

...

question

Recovery Audit Contractor (RAC) program

answer

...

question

regulations

answer

...

question

Stark I

answer

...

question

statute

answer

...

question

statutory law

answer

...

question

subpeona

answer

...

question

subpeona duces tecum

answer

...

question

Tax Relief and Health Care Act of 2006 (TRHCA)

answer

...

question

UB-04

answer

...

question

unique bit string

answer

...

question

Zone Program Integrity Contractor (ZPIC)

answer

...

Health Insurance – Ch 5 (Legal & Regulatory Issues) – Flashcards

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