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HCC Exam

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TermDefinition
Anti-Kickback Law Prohibits the solicitation, receiving, offering, or paying of any remuneration directly or indirectly in cash or in kind exchange.
Attestation The affirmation by signature, usually on a printed form, that the action outlined has been accomplished by the individual signing: e.g., the individual has read the code of conduct and agreed to adhere to its principles.
Attorney-Client Privilege A legally accepted policy that communication between a client and attorney is confidential in the course of the professional relationship and that such communication cannot be disclosed without the consent of the client.
Baseline audit a systematic inspection of records, policies, and procedures with the goal to establish a set of benchmarks for comparison for future inspections.
Concurrent Audit An inspection of records, policies, and procedures at a given point in time in which identified potential problems are audited as they arise (real time)
Retrospective Audit An audit of historical events
Balanced Budget Act of 1997 Major reform of the Medicare and Medicaid programs especially in area of home health and patient transfers. Mandated permanent exclusion from participation in federally funded health care programs of 3 health care related crimes
Benchmarking The measurement of performance against "best practice" standards.
Best Practices Generally recognized superior performance by organizations in operational and/or financial processes.
Business Associate A person or entity that performs certain functions or activities that involve the use or disclosure of protected health info. on behalf of or provides services to a covered entity.
Business Associate Agreement (BAA) Per HIPPA before PHI can be shared between a covered entity and a business associate, the business associate must sign a written agreement that gives satisfactory assurances that it will not disclose PHI where it contradicts the HIPPA law.
Caremark International Derivative Litigation 1996 U.S. Civil settlement that imposed corporate integrity agreement precluded them from providing care in forms for 5 years
Centers for Medicare and Medicaid Services (CMS) A component of the US Department of Health and Human Services that administers the Medicare, Medicaid and state Children's Health Insurance programs
Certified Professional Coder (CPC) A coder who has satisfied certification requirements as established by the American Academy of Professional Coders
Chain of Command The Hierarchy of reporting structure within an organization, which assumes all issues will be presented first to immediate supervisor
Civil Monetary Penalties Law (CMPL) Regulations which apply to claims for an item or service that was not provided as claimed or that was knowingly submitted as false and which provides guidelines for the levying of fines for such offences
Compliance Adherence to the laws and regulations passed by official regulating bodies as well as general principles of ethical conduct.
Corporate Integrity Agreement (CIA) A negotiated settlement between an organization and government in which the provider accepts no liability but must agree to implement a strict plan of government-supervised corrective action
Covered Entities Health plan; Health care clearinghouse; or Heath care provider who transmits any health information in electronic form in connection with a transaction covered by this subchapter.
Culpability Score Part of the sentencing commission guidelines for the sentencing of organizations, a system that adds points for aggravating factors and subtracts points for mitigating factors in determination of fines imposed for fraud or abuse
Current Procedural Terminology (CPT) A publication of the american medical association which lists and assigns codes to procedures and services performed by physicians
Department of Labor federal agency administers and enforces laws and regulations that govern workplace activities, including wages and overtime pay, workers' compensation, workplace safety and health, employee benefits,certain non-immigrant visa programs,etc.
Designated record set pt.1 1.Group of records maintained by or for a covered entity, that is about individuals maintained by/for the covered provider, management records systems by/for health to make decisions
Designated record set pt. 2 for purposes of this paragraph, the term record means any item, collection, or grouping of information that includes PHI and is maintained, collected, used or disseminated by or for a covered entity.
Diagnosis-Related Groups (DRG) Classifications of diagnoses determined by the average cost of treating a particular condition,regardless of the number of services rendered or the length of patient stay; medicare reimbursement is assigned by DRG
Disclosure The release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information.
Employee Retirement Income Security Act (ERISA) 1974 federal act that exempts self-insured health plans from state laws governing health insurance and requires health plans to provide certain information to enrollees.
Equal Employment Opportunity Commission (EEOC) Agency created in 1964 to end discrimination based on race, religion,sex, or national origin in employment. The commission reviews and investigates charges of discrimination and, if found to be true, attempts remedy through conciliation or legal means.
False Claims Act (FCA) Adopted in 1863 during the civil war to discourage suppliers from overcharging the federal government, legislation that prohibits anyone from knowingly submitting or causing to be submitted a false or fraudulent claim.
Federal Sentencing Guidelines Developed by the US sentencing commission and independent agency in the judicial branch established by the 1984 sentencing reform act, to govern the sentencing of individual defendants (1987) and organizations (1991)
Fiscal/Fiduciary Intermediary A person or organization that under HHS par A of medicare, processes claims, provides services, and issues payments on behalf of private, federal and state health benefit programs or other insurance programs.
General Services Administration (GSA) Federal agency that manages the federal governments's property and records, including the construction and operation of buildings and procurement and distribution of supplies, among other functions
Health and Human Services (HHS) Department of the executive branch with health care accountabilities, including responsibility for the Public Health service, the Centers for Medicare & Medicaid services (CMS) and the Social Security administration.
Health Care pt. 1 Care, services or supplies related to the health of an individual, including but not limited to preventative, diagnostic, rehabilitative, maintenance, or palliative care, counseling, assessment or procedure
Health Care pt. 2 Sale or dispensing of a drug, device, equipment, or other item pursuant to a prescription. All with respect to a physical or mental condition or functional status of an individual or affecting the structure or function of the body.
Health Care Clearinghouse pt. 1 A public or private entity, including a billing service, repricing company, community health management information system or community health information system, and "value added" networks and switches;
Health Care Clearinghouse pt. 2 1 Processes or facilitates processing of health information received from another entity in a nonstandard format or nonstandard data content into standard data elements or a standard transaction
Health Care Clearinghouse pt. 3 2 Receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard format or nonstandard data content for the receiving entity.
Health Care Compliance Association (HCCA) Professional Assoc. for helping health care compliance professionals, thru education, networking and other resources, create an ethical environment within their organizations and meet all legal and regulatory requirements related to Medicare reimbursement
Healthcare provider
Created by: Kokovelle