B&C Chapter 5: Legal Aspects of Health Insurance and Reimbursement Flashcards
abuse
actions inconsistent with accepted, sound medical business, or fiscal practices.
ANSI ASC X12N 837
electronic format supported for health care claim transactions
audit
objective evaluation to determine the accuracy of submitted financial statements
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 or to disclose PHI to a third party specified by the individual.
black box edit
nonpublished code edits, which were discontinued in 2000.
breach of confidentiality
unauthorized release of patient information to a third party.
case law
also called common law; based on a court decision that establishes a precedent.
civil law
area of law not classified as criminal.
Clinical Data Abstracting Center (CDAC)
requests and screens medical records for the Payment Error Prevention Program (PEPP) to survey samples for medical review, DRG validation, and medical necessity.
CMS Internet-only manual (IOM)
includes program issuances, day-to-day operating instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives; used by CMS program components, providers, contractors, Medicare Advantage organizations, and state survey agencies to administer CMS programs; also called CMS Online Manual System.
CMS Online Manual System
see CMS Internet-only 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 cancelled, and new or revised manual instructions.
CMS transmittal
document published by Medicare containing new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual (e.g., Medicare Claims Processing Manual); cover page (or transmittal page) summarizes new and changed material, and subsequent pages provide details; transmittals are sent to each Medicare administrative contractor.
common law
also called case law; is based on a court decision that establishes a precedent.
compliance program
internal policies and procedures that an organization follows to meet mandated requirements.
Comprehensive Error Rate Testing (CERT) program
assesses and measures improper Medicare fee-for-service payments (based on reviewing selected claims and associated medical record documentation).
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.
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.
confidentiality
restricting patient information access to those with proper authorization and maintaining the security of patient information.
criminal law
public law governed by statute or ordinance that deals with crimes and their prosecution.
Current Dental Terminology CDT
medical code set maintained and copyrighted by the American Dental Association.
decrypt
to decode and encoded computer file so that it can be viewed.
deeming
CMS recognition of accreditation organization (e.g., The Joint Commission) standards that meet or exceed CoP and CfC requirements.
Deficit Reduction Act of 2005
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 CMS about the use and effectiveness of funds appropriated for the MIP.