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Chapter 05
Legal Aspects of Health Insurance and Reimbursement
| Question | Answer |
|---|---|
| statutes | also called statutory law; laws passed by legislative bodies (e.g., federal Congress and state legislatures). |
| regulations | mandated guideline written by administrative agencies (e.g., CMS); regulations interpret laws and mandates. |
| Case law | also called common law; based on a court decision that establishes a precedent. |
| precedent | based on a court decision that is legally binding and follows the doctrine of stare decisis for deciding subsequent cases involving identical or similar facts |
| Civil law | area of law not classified as criminal. |
| subpoena | an order of the court that requires a witness to appear at a particular time and place to testify. |
| subpoena duces tecum | requires documents (e.g., patient record) to be produced. |
| deposition | legal proceeding during which a party answers questions under oath (but not in open court). |
| interrogatory | document containing a list of questions that must be answered in writing. |
| Qui tam | It is a provision of the False Claims Act that allows a private citizen to file a lawsuit in the name of the U.S. government, charging fraud by government contractors and other entities. |
| Federal Register | legal newspaper published every business day by the National Archives and Records Administration (NARA). |
| CMS transmittals | document published by Medicare containing new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual |
| CMS quarterly provider update (QPU) | an online CMS publication that contains information about regulations and major policies currently under development, regulations and major policies completed or canceled, and new or revised manual instructions. |
| Medicare administrative contractor (MAC) | an organization (e.g., third-party payer) that contracts with CMS to process claims and perform program integrity tasks for Medicare Part A and Medicare Part B, and DMEPOS |
| Conditions of Participation (CoP) | health and safety regulations that health care organizations, such as hospitals, must meet in order to begin and continue participating in the Medicare and Medicaid programs. |
| Conditions for Coverage (CfC) | health and safety regulations that health care organizations, such as end-stage renal disease facilities, must meet in order to begin and continue participating in the Medicare and Medicaid programs |
| Record retention | storage of documentation for an established period of time, usually mandated by federal and/or state law |
| audit | objective evaluation to determine the accuracy of submitted financial statements. |
| compliance program | internal policies and procedures that an organization follows to meet mandated requirements. |
| Medicare Integrity Program (MIP) | 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. |
| Medical review (MR) | 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. |
| Medicaid Integrity Program (MIP) | combats fraud, waste, 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 contractors (MICs) | CMS-contracted entities that review provider claims, audit providers and others, identify overpayments, and educate providers |
| Medicaid Fraud Control Units (MFCUs) | investigates and prosecutes Medicaid provider fraud as well as patient abuse or neglect in health care facilities and board and care facilities in all 50 States |
| Recovery Audit Contractor (RAC) program | mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) to find and correct improper Medicare payments paid to health care providers participating in fee-for-service Medicare. |
| Health Care Fraud Prevention and Enforcement Action Team (HEAT) | joint effort between the Department of Health and Human Services and the Department of Justice to fight health care fraud by increasing coordination, intelligence sharing, and training |
| Medicare Shared Savings Program | mandated by the Patient Protection and Portable Care Act (PPACA) to facilitate coordination and cooperation among providers to improve quality of care for Medicare fee-for-service |
| Health Insurance Portability and Accountability Act (HIPAA) | mandates regulations that govern privacy, security, and electronic transactions standards for health care information. |
| fraud | intentional deception or misrepresentation that could result in an unauthorized payment. |
| Abuse | actions inconsistent with accepted, sound medical, business, or fiscal practices. |
| National Individual Identifier | unique identifier to be assigned to patients has been put on hold. Several bills in Congress would eliminate the requirement to establish a National Individual Identifier. |
| National Provider Identifier (NPI) | unique identifier assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position. |
| National Standard Employer Identification Number (EIN) | unique identifier assigned to employers who, as sponsors of health insurance for their employees, need to be identified in health care transactions |
| National Plan and Provider Enumeration System (NPPES) | developed by CMS to assign unique identifiers to health care providers (NPI). |
| electronic transaction standards | also called transactions rule; a uniform language for electronic data interchange. |
| digital | application of a mathematical function to an electronic document to create a computer code that can be encrypted (encoded). |
| unique bit string | computer code that creates an electronic signature message digest that is encrypted (encoded) and appended (attached) to an electronic document (e.g., CMS-1500 claim). |
| message digest | 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. |
| Encrypt | to convert information to a secure language format for transmission. |
| decrypts | to decode an encoded computer file so that it can be viewed; convert data to a language that can be read. |
| ANSI ASC X12N 837 | electronic format supported for health care claim transactions. |
| UB-04 flat file | series of fixed-length records used to bill institutional services, such as services performed in hospitals. |
| National Standard Format (NSF) | flat-file format used to bill provider and noninstitutional services, such as services reported by a general practitioner on a CMS-1500 claim |
| privileged communication | private information shared between a patient and health care provider; disclosure must be in accordance with HIPAA and/or individual state provisions regarding the privacy and security of protected health information (PHI). |
| Protected health information (PHI) | information that is identifiable to an individual (or individual identifiers) such as name, address, telephone numbers, date of birth, Medicaid ID number, medical record number, Social Security number (SSN), and name of employer. |
| authorization | 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 |
| Privacy | right of individuals to keep their information from being disclosed to others. |
| de-identification of protected health information | process that removes identifiers from health information to mitigate privacy risks for individuals and thus supports the secondary use of data for comparative effectiveness studies, policy assessment, life sciences research, and other endeavors. |
| Confidentiality | restricting patient information access to those with proper authorization and maintaining the security of patient information. |
| Security | involves the safekeeping of patient information by controlling access to hard copy and computerized records; protecting patient information from alteration, destruction, tampering, or loss |
| Breach of confidentiality | unauthorized release of patient information to a third party. |
| HIPAA Privacy Rule | HIPAA provision that creates national standards to protect individuals’ medical records and other personal health information. |
| Treatment, payment, and health care operations (TPO) | activities defined by the HIPAA Privacy Rule, including treatment (provision, coordination, or management of health care and related services among health care providers or by a health care provider with a third party, consultation between health care pro |
| Notice of Privacy Practices (NPP) | document that includes an individual’s health privacy rights related to protected health information (PHI) and communicates how health information may be used and shared. |
| minimum necessary standard | key protection of the HIPAA Privacy Rule based on sound current practice that protected health information should not be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. |
| designated record set | group of records maintained by or for a covered entity and includes medical and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, claims adjudication, and case or medical management |
| HIPAA Security Rule | HIPAA standards and safeguards that protect health information collected, maintained, used, or transmitted electronically; covered entities affected by this rule include health plans, health care clearinghouses, and certain health care providers. |
| breach notification | HIPAA rule that requires covered entities and their business associates to provide patient notification following a breach of unsecured protected health information. |
| medical identity theft | occurs when someone uses another person’s name and/or insurance information to obtain medical and/or surgical treatment, prescription drugs, and medical durable equipment |
| accounting of disclosures | HIPAA regulation that requires health care organizations to track medical information provided to third parties (e.g., attorneys, third-party payers, and Social Security disability offices) |
| Release of information (ROI) | ROI by a covered entity (e.g., provider’s office) about protected health information (PHI) requires the patient (or representative) to sign an authorization to release information |
| release of information log | used to document patient information released to authorized requestors; data is entered manually (e.g., three-ring binder) or using ROI tracking software. |
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