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PHI Patient info: demographics, identifying information, diagnoses, etc.
OIG Identifies and combats waste, fraud, and abuse. Develops work plan to identify areas of focus for the upcoming year.
HIPAA Law that protects patient privacy - Portability and Accountability Act
HMO Type of insurance plan - select PCP, must stay in network, need referral for specialist visit
EPO Type of insurance plan - no need to select PCP, must stay in network, no referral for specialist visit
PPO Type of insurance plan - no need to select PCP, not required to stay in network, no referral necessary
Federal Register Publication for rules, proposed rules, and notices of the Federal Government
CMS Centers for Medicare and Medicaid Services - website includes manuals and guidelines for billing
MAC Private health care insurer that processes Medicare claims - MACS vary by geographic location.
RVU Value assigned to each code which represents cost for providing service.
Three components that make up RVU Work involved, practice expenses (rent, etc.), and malpractice insurance.
Conversion Factor (CF) Dollar multiplier that converts the RVU into an actual dollar amount.
GPCI (Geographic Practice Cost Indices Accounts for differences in the cost of practice across the country according to location.
Medicare Part A Hospital coverage
Medicare Part B Supplementary coverage (office visits, etc)
Medicare Part D Prescription drug coverage
Medicare Part C Medicare Advantage Organizations (beneficiaries choose their providers & type of coverage)
CPT Book Includes codes for all types of physician services - procedures, office visits, lab work, radiology, etc.
ICD-10 Includes diagnosis codes
EMR Electronic Medical Record
Fraud The intentional deception or misrepresentation of information in order to receive unauthorized benefit
OBRA Includes provisions establishing physician fee schedule, standard rates for increases, etc.
Medical Necessity The reason for receiving medical services
Created by: kducey