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Mod 1A UHI Ch. 5

Legal and Regulatory Issues

Statutes Laws
Regulations Guidelines written by administrative agencies.
Case Law Based on court decisions that establish a standard (Common Law)
Precedent A standard
Civil Law Law that is not classified as criminal.
Criminal Law Public law that defines crimes and their prosecution
Subpoena An order of the court that requires a witness to appear at a particular time and place to testify.
Subpoena Duces Tecum An order of the court that requires documents (e.g., patient record) to be produced.
Deposition A testimony under oath taken outside of court.
Interrogatory A document containing a list of questions that must be answered in writing.
Qui tam Abbreviation; 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.
Federal Register A legal newspaper published every business day by the National Archives and Records Administration (NARA).
Program Transmittals Contain new and changed Medicare policies and/or procedures that are to be incorporated into a specific CMS program manual.
Medicare Administrative Contractor (MAC) An organization that contracts with CMS to process fee-for-service healthcare claims and perform program integrity tasks for both Medicare Part A and Part B.
Record retention The storage of documentation for an established period of time usually mandated by federal and/or state law.
How long must patient records be retained in their original form? 7 years
How long does HIPAA require health insurance claims and accounting records to be retained? 6 years
How long must health insurance claims be retained after a patient's death? 2 years
What is fraud? an intentional deception or misrepresentation that someone makes, knowing it is false that could result in an unauthorized payment.
What is abuse? Actions that are inconsistent with accepted, sound medical business, or fiscal practices.
What are overpayments? Funds a provider or beneficiary receives in excess of amounts due and payable under Medicare and Medicaid statues and regulations.
What is recovery/how does it begin? Issuing an overpayment demand letter to the provider.
National Correct Coding Initiative? Regulations that govern privacy, security and electronic transaction standards for healthcare information.
Code Pairs Edi pairs included in the Correct Coding Iniative cannot be reported on the same claim if each has the same date of service.
Unique Identifiers That administrative simplification provision of HIPAA that requires establishment of standard identifiers for third party payers.
National Provider Identifier (NPI) A 10 digit numeric identifier that is assigned to healthcare providers by HIPAA.
Privileged Communication Any information communicated by a patient to a healthcare provider.
Protected Health Information (PHI) Information that is identifiable to an individual such as name, address, telephone numbers, date of birth.
Privacy The right of individuals to keep their information from being disclosed to others.
Confidentiality Restricting patient information access to those with proper authorization and maintaining the security of patient information.
Security The safekeeping of patient information.
Breach of Confidentiality The unauthorized release of patient information to a third party.
Federal Anti-Kickback Law Protects patients and federal healthcare programs from fraud and abuse by curtailing the corrupting influence of money on healthcare decisions.
When was the Occupational Safety and Health Act created? 1971
Occupational Safety and Health Act (OSHA) Act to ensure safe and healthful workplaces in America.
What year was the Correct Coding Initiative developed? 1996
Created by: ROSSMIBOA