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

Unlock all answers in this set

Unlock answers
question
Statutes
answer
(Statutory law) Laws passed by legislative bodies (e.g., federal Congress and state legislatures).
question
Regulations
answer
Guidelines written by administrative agencies (e.g., CMS)
question
Case law
answer
(common law) Based on court decisions that establish a precedent (or standard).
question
Civil law
answer
This deals with all areas of the law that are not classified as criminal.
question
Criminal law
answer
Public law (statute or ordinance) that defines crimes and their prosecution.
question
Subpoena
answer
An order of the court that requires a witness to appear at a particular time and place to testify.
question
Subpoena duces tecum
answer
Requires documents (e.g., patient record) to be produced.
question
Deposition
answer
Testimony under oath taken outside of court (e.g., at the provider's office).
question
Interrogatory
answer
A document containing a list of questions that must be answered in writing.
question
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.
question
Federal register
answer
A legal newspaper published every business day by the National Archives and Records Administration (NARA).
question
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).
question
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.
question
Listserv
answer
A subscriber-based question-and-answer forum available through e-mail.
question
Overpayments
answer
Funds a provider or beneficiary receives in excess of amounts due and payable under Medicare and Medicaid.
question
Payment error rate
answer
Number of dollars paid in error out of the total dollars paid for inpatient prospective payment system services.
question
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.
question
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.
question
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.
question
Record retention
answer
The storage of documentation for an established period of time, usually mandated by federal and/or state laws.
question
Fraud
answer
An intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.
question
Abuse
answer
Involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices.
question
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.
question
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.
question
Check digit
answer
A one-digit character, alphabetic or numeric, used to verify the validity of a unique identifier.
question
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.
question
National Provider Identifier (NPI)
answer
Assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position.
question
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.
question
Electronic transaction standards
answer
(transactions rule) A uniform language for electronic data interchange.
question
Electronic data interchange (EDI)
answer
The process of sending data from one party to another using computer linkages.
question
False Claims Act (FCA) - 1863
answer
Regulated fraud associated with military contractors selling supplies and equipment to the Union Army.
question
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)
question
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)
question
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)
question
Migrant Health Act - 1962
answer
Provided medical and support services to migrant and seasonal farm workers and their families.
question
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.
question
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".
question
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.
question
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.
question
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.
question
National Plan and Provider Enumeraton System (NPPES)
answer
Assigns unique identifiers to healthcare providers and health plans.
question
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
question
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.
question
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.
question
Privacy
answer
The right of individuals to keep their information form being disclosed to others.
question
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
...
question
case law
answer
...
question
Comprehensive Error Rate Testing (CERT) program
answer
...
question
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
...
question
Medicare administrative contractor (MAC)
answer
...
question
message digest
answer
...
question
modifier
answer
...
question
overpayment
answer
...
question
Patient Safety and Quality Improvement Act
answer
...
question
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
...
question
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
...
Get an explanation on any task
Get unstuck with the help of our AI assistant in seconds
New