Term | Definition |
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 |