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Ch. 5 Reimbursement

Legal and Regulatory Issues

Actions inconsistent with accepted, sound medical, business, or fiscal practices. Abuse
Variable-length file format used to bill institutional, professional, dental, and drug claims. ANSI ASC X12N 837
Document that provides official instruction, such as the customized document that gives covered entities permission to use specified protected health information (PHI) for specified purposes or to disclose PHI to a third party specified by the individual. Authorization
Nonpublished code edits, which were discontinued in 2000. Block Box Edits
Unauthorized release of patient information to a third party. Breach of Confidentiality
also called common law; based on a court decision that establishes a precedent. Case Law
One-digit character, alphabetic or numeric, used to verify the validity of a unique identifier. Check Digit
Area of law not classified as criminal. Civil Law
Requests and screens medical records for the Payment Error Prevention Program (PEPP) to survey samples for medical review, DRG validation, and medical necessity. Clinical Data Abstracting Center (CDAC)
also called case law; is based on a court decision that establishes a precedent Common Law
Assesses and measures improper Medicare fee-for-service payments (based on reviewing selected claims and associated medical record documentation). Comprehensive Error Rate Testing (CERT) Program
Restricting patient information access to those with proper authorization and maintaining the security of patient information. Confidentiality
Public law governed by statute or ordinance that deals with crimes and their prosecution. Criminal Law
Medical code set maintained and copyrighted by the American Dental Association. Current Dental Terminology (CDT)
To decode an encoded computer file so that it can be viewed. Decrypt
Created Medicaid Integrity Program (MIP), which increased resources available to CMS to combat abuse, fraud, and waste in the Medicaid program. Congress requires annual reporting by the CMS about the use and effectiveness of funds appropriated for the MI Direct Reduction Act of 2005
Legal proceeding during which a party answers questions under oath (but not in open court). Deposition
Application of a mathematical function to an electronic document to create a computer code that can be encrypted (encoded). Digital
also called transactions rule; a uniform language for electronic data interchange. Electronic Transaction Standards
To convert information to a secure language format for transmission. Encrypt
Passed by the federal government during the Civil War to regulate fraud associated with military contractors selling supplies and equipment to the Union Army. False Claims Act (FCA)
Requires Medicare administrative contractors (previously called carriers and fiscal intermediaries), as agents of the federal government, to attempt the collection of overpayments. Federal Claims Collection Act
Legal newspaper published every business day by the National Archives and Records Administration (NARA) Federal Register
Data analysis tool, which provides administrative hospital and state-specific data for specific CMS target areas. First-look Analysis for Hospital Outlier Monitoring (FATHOM)
Intentional deception or misrepresentation that could result in an unauthorized payment. Fraud
Developed to equip consumers with quality of care information so they can make more informed decisions about healthcare options; requires hospitals to submit specific quality measures data about health conditions common among Medicare beneficiaries Hospital Inpatient Quality Reporting (Hospital IQR) Program
Measures, monitors, and reduces the incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals. Hospital Payment Monitoring Program (HPMP)
Healthcare reform measure that promotes better clinical outcomes and patient experiences of care; effective October 2012, hospital receive reimbursement for inpatient acute care services based on care quality (instead of quantity of the services provided) Hospital Value-based Purchasing (VBP) Program
Established in the Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program and the State Children's Health Insurance Program (SCHIP); calculates the paid claims error rate for submitted Medicare claims Improper Payments Information Act of 2002 (IPIA)
Document containing a list of questions that must be answered in writing. Interrogatory
Subscriber-based question-and-answer forum that is available through e-mail. Listserv
Increased resources available to CMS to combat fraud, wast, and abuse in the Medicaid program; Congress requires annual reporting by CMS about the use and effectiveness of funds appropriated for the MIP. Medicaid Integrity Program (MIP)
Fraud and abuse detection program created by the Deficit Reduction Act of 2005. Medical Integrity Program (MIP)
Defined by CMS as a review of claims to determine whether services provided are medically reasonable and necessary, as well as to follow-up on the effectiveness of previous corrective actions. Medical Review (MR)
An organization that contracts with CMS to process claims and perform program integrity tasks for Medicare Part A and Part B; each contractor makes program coverage decisions and publishes a newsletter, which is sent to provider's who receive Medicare rei Medicare Administrative Contractor (MAC)
Authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program. Medicare Integrity Program (MIP)
Facilitate coordination and cooperation among providers to improve quality of care for Medicare fee-for-service beneficiaries and to reduce unnecessary costs Medicare Shared Savings Program
Representation of text as a single string of digits, which was created using a formula; for the purpose of electronic signatures, the message digest is encrypted (encoded) and appended (attached) to an electronic document. Message Digest
Maintained by the Food and Drug Administration (FDA); identifies prescription drugs and some over-the-counter products. National Drug Code (NDC)
Unique identifier, previously called PAYERID, that will be assigned to third-party payers and is expected to have 10 numeric positions, including a check digit in the tenth position. National Health PlanID (PlanID)
Unique identifier to be assigned to patients. National Individual Identifier
Developed by CMS to assign unique identifiers to healthcare providers (NPI) and health plans (PlanID). National Plan and Provider Enumeration System (NPPES)
Unique identifier to be assigned to healthcare providers as an 8- or possibly 10-character alphanumeric identifier, including a check digit in the last position. National Provider Identifier (NPI)
Unique identifier assigned to employers who, as sponsors of health insurance for their employees, need to be identified in healthcare transactions. National Standard Employer Identification Number (EIN)
Flat-file format used to bill physician and noninstitutional services, such as services provided by a general practitioner on a CMS-1500 claim. National Standard Format (NSF)
Funds a provider or beneficiary has received in excess of amounts due and payable under Medicare and Medicaid statutes and regulations Overpayment
also known as Part A/B Medicare Administrative Contractor; each contractor makes program coverage decisions and publishes a newsletter, which is sent to providers who receive Medicare reimbursement Part A/B Medicare Administrative Contractor (A/B MAC)
Provides for improved patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients; creates patient safety organizations (PSOs) to collect, aggregate, and analyze confidential information reported by provider Patient Safety and Quality Improvement Act
Required facilities to identify and reduce improper Medicare payments and, specifically, the Medicare payment error rate. The hospital payment monitoring program (HPMP) replaced PEPP in 2002./ Payment Error Prevention Program (PEPP)
Number of dollars paid in error out of total dollars paid for inpatient prospective payment system services. Payment Error Rate
Measures improper payments in the Medicaid program and State Children's Health Insurance Program (SCHIP). Payment Error Rate Measurement (PERM) Program
the Tax Relief and Health Care Act of 2006 (TRHCA) that established financial incentives for eligible professionals who participate in a voluntary quality reporting program Physician Quality Reporting System
Responded to physicians' conflicts of interest when referring Medicare patients for a variety of services; prevents kickbacks Physician Self-Referral Law
HHS implemented audits in 1995 to examine the billing practices of physicians at teaching hospitals; the focus was on compliance with Medicare rules and accuracy of billing and coding. Physicians at Teaching Hospitals (PATH)
Standard Precedent
Right of individuals to keep their information from being disclosed to others. Privacy
Forbids the Medicare regional payer from disclosing the status of any unassigned claim beyond the date received, date processed, and/or the reason for suspension. Privacy Act of 1974
HIPAA provision that creates national standards to protect individuals' medical records and other personal health information. Privacy Rule
Private information shared between a patient and healthcare provider; Privileged Communication
Contains hospital-specific administrative claims data for a number of CMS-identified problem areas; a hospital uses PEPPER data to compare its performance with that of other hospitals. Program for Evaluating Payment Patterns Electronic Report (PEPPER)
Responsible for fraud and abuse detection from carriers and fiscal intermediaries (FIs). Program Safeguard Contract (PSCs)
Document published by Medicare containing new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual; cover page summarizes new and changed material, and subsequent pages provide details Program Transmittal
Information that is identifiable to an individual such as name, address, telephone numbers, date of birth, Medicaid ID number, medical record number, SSN, and name of employer. Protected Health Information (PHI)
It is a provision of the False Claims Act that allows a private citizen to file a lawsuit in the name of the US government, charging fraud by government contractors and other entities. Qui Tam
Storage of documentation for an established period of time; its purpose is to ensure the availability of records for use by government agencies and other third parties. Record Retention
Mandated by the Medicare Prescription Drug,Improvement, and Modernization Act of 2003 to find and correct improper Medicare payments paid to healthcare providers participating in fee-for-service Medicare. Recovery Audit Contractor (RAC) Program
Guidelines written by administrative agencies Regulation
Requires the patient (or representative) to sign an authorization to release information, which is reviewed for authenticity and processed within a HIPAA-mandated 60-day time limit Release of Information (ROI)
Used to document patient information released to authorized requestors; data is entered manually or using ROI tracking software. Release of Information Log
Developed to equip consumers with quality of care information so they can make more informed decisions about healthcare options. Reporting Hospital Quality Data for Annual Payment Update Program
Involves the safekeeping of patient information by controlling access to hard copy and computerized records; protecting patient information from destruction, alteration, tampering, or loss; providing employee training in confidentiality Security
HIPAA standards and safeguards that protect health information collected, maintained, used, or transmitted electronically; covered entities affected by this rule include health plans, healthcare clearinghouses, and certain healthcare providers. Security Rule
Responded to concerns about physicians' conflicts of interest when referring Medicare patients for a variety of services; prohibits kickbacks. Stark I
also called statutory law; laws passed by legislative bodies. Statutes
also called statutes; laws passed by legislative bodies. Statutory Law
An order of the court that requires a witness to appear at a particular time and place to testify. Subpoena
Requires documents to be produced. Subpoena Duces Tecum
Created physician quality reporting initiative (PQR) system that establishes a financial incentive for eligible professionals who participate in a voluntary quality reporting program. Tax Relief and Health Care Act of 2006 (TRHCA)
Insurance claim or flat file used to bill institutional services, such as services performed in hospitals. UB-04
Computer code that creates an electronic signature message digest that is encrypted (encoded) and appended (attached) to an electronic document. Unique Bit String
Assignment of an ICD-9-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement. Upcoding
Individual who makes specified disclosures relating to the use of public funds, such as Medicare payments. Whistleblower
Program implemented in 2009 by CMS to review billing trends and patterns, focusing on providers whose billings for Medicare services are higher than the majority of providers in the community. Zone Program Integrity Contractor (ZPIC)
Created by: adale3171