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CPB > Chapter 1 > Flashcards

Chapter 1 Flashcards

1
Q

Abuse

A

An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly

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2
Q

Anti-kickback

A

Knowingly and willfully offering or accepting rewards or remuneration for services that are billable to a federal healthcare plan

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3
Q

Beneficiary

A

An individual that is eligible for Medicare or Medicaid benefits based on the CMS guidelines

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4
Q

Conditions of Participation (CoP)

A

Conditions that healthcare organizations must meet in order to participate with the plan or program

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5
Q

Covered Entity

A

According to HIPAA, defined as health plans, healthcare clearinghouses, and healthcare providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards

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6
Q

Criminal Healthcare Fraud Act

A

Scheme to willingly defraud any healthcare benefit program

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7
Q

False Claims Act

A

Federal statute setting criminal and civil penalties for falsely billing the government, over-representing the amount of a delivered product, or under-stating an obligation to the government

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8
Q

Fraud

A

Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program

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9
Q

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

A

Federal law in which the primary goal is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information, and help the healthcare industry control administrative costs

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10
Q

Preferred Provider Organization (PPO)

A

Managed care organization of medical doctors, hospitals, and other healthcare providers who have agreed with an insurer or a third-party administrator to provide healthcare at reduced rates to the insurer’s or administrator’s clients

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11
Q

Protected Health Information (PHI)

A

Individually identifiable health information that includes many common identifiers, such as demographic data, name, address, birth date, and social security number. It also includes information that relates to an individual’s past, present, or future physical or mental health or condition; the provision of healthcare to the individual; or, the past, present, or future payment for the provision of healthcare to the individual, which reasonably may be used to identify an individual

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12
Q

Qui tam Action

A

A lawsuit brought by a private citizen against a person or company who is believed to have violated the law in the performance of a contract with the government or in violation of a government regulation, when there is a statute which provides for a penalty for such violations

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13
Q

Stark Law

A

A federal law that places limitations of certain physician referrals

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14
Q

Truth in Lending Act

A

Designed to assure that every customer who needs consumer credit is given meaningful information concerning the cost of such credit

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15
Q

1942 Stabilization Act

A

Wage and price controls placed on employers and adoption of employee insurance plans

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16
Q

1954 Internal Revenue Code

A

Employer contributions to employee health plans were exempt from employees taxable income

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17
Q

Health Maintenance Organization (HMO) Act of 1973

A

Help control healthcare costs

Requires employers with 25+ employees to offer HMO

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18
Q

Healthcare Fraud and Abuse Control Program (HCFAC)

A

Program intended to coordinate federal, state, and local law enforcement efforts to stop health care fraud and abuse

US Department of Health and Human Services (HHS) and Department of Justice (DOJ) are required to provide an annual report detailing the efforts and recoveries made by the HCFAC program.

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19
Q

Privacy Rule

A

HIPAA rule that establishes standards for how protected health information (PHI) is used

Protect individual privacy while promoting high quality healthcare and public health and well-being

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20
Q

Business Associates

A

Individuals or organizations that perform certain functions or activities involving the use or disclosure of PHI

21
Q

The Health Information Technology for Economic and Clinical Health (HITECH) Act

A

An organization that provides data transmission of PHI to a covered entity and requires access to PHI routinely will be treated as a business associate

Contract is required

22
Q

Minimum Necessary

A

Term referring to the limited amount of patient information that may be disclosed, depending on circumstances

23
Q

12 National Priority Purposes

A
  1. Required by law
  2. Public health activities
  3. Victims of abuse, neglect, domestic violence
  4. Health oversight activities
  5. Judicial and administrative proceedings
  6. Law enforcement purposes
  7. Decedents
  8. Cadaver organ, eye, tissue donation
  9. Research
  10. Serious threat to health or safety
  11. Essential government functions
  12. Workers’ comp
24
Q

Limited Data Set

A

PHI from which certain specified direct identifiers have been removed

25
Q

Security Rule

A

A national standard that requires health care professionals to take specific technical precautions to ensure that patient information stored or transmitted in an electronic format remains confidential, accessible, and of a high quality

26
Q

Transaction and Code Sets

A

Standardized codes used to represent health care concepts and procedures for health-care-related financial and administrative procedures

27
Q

6 Standardized Code Sets

A
  1. Healthcare Common Procedure Coding System (HCPCS)
  2. Current Procedure Terminology (CPT®)
  3. International Classification of Diseases, 10th Revision, Clinical Modification, (ICD-10-CM)
  4. National Drug Codes (NDC)
  5. Current Dental Terminology (CDT®)
  6. Place of Service Codes
28
Q

8 Standard Transactions for Electronic Data Interchange (EDI)

A
  1. Claims and encounter information
  2. Healthcare payment and remittance advice
  3. Healthcare claims status
  4. Eligibility for a health plan
  5. Enrollment and disenrollment in a health plan
  6. Referrals and authorizations
  7. Coordination of benefits
  8. Health plan premium payments
29
Q

CMS CoP Medical Retention

A

A medical record must be maintained for every individual evaluated or treated in the hospital for at least 5 years

10 years for managed care program

30
Q

Examples of Fraud

A
  • Billing for services and/or supplies that you know were not furnished or provided
  • Altering claim forms and/or receipts to receive a higher payment amount
  • Billing a Medicare patient above the allowed amount for services
  • Billing for services at a higher level than provided or necessary
  • Misrepresenting the diagnosis to justify payment
  • Falsifying documentation
31
Q

Examples of Abuse

A
  • Misusing codes on a claim
  • Charging excessively for services or supplies
  • Billing for services that were not medically necessary
  • Failure to maintain adequate medical or financial records
  • Improper billing practices
  • Billing Medicare patients a higher fee schedule than non-Medicare patients
32
Q

Penalties for Fraud and Abuse

A
  • Civil monetary penalties (CMP) may be imposed to varying amounts depending on the type of violation, ranging from $10,000 to $50,000
  • Exclusion from participation in the federal healthcare programs
  • Imprisonment
33
Q

Overpayment Returns

A

Provider must report and return an overpayment by the later of 60 days from the date when the overpayment was “identified” or the date “any corresponding cost report is due”

34
Q

Deliberate Ignorance of the Truth Penalties

A

$5,500 to $11,000 per claim

35
Q

Criminal Healthcare Fraud Statute

A

Prohibits knowingly or willingly executing of attempting to execute a scheme, such as defrauding any healthcare benefits program

36
Q

Quality Payment Program (QPP)

A

Established by the Medicare and CHIP Reauthorization Act of 2015 (MACRA), the QPP allows physicians to select participation in one of two CMS system options that define the way in which they will be reimbursed for services under Medicare: either the Medicare incentive payment program (MIPS) or the alternative payment model (APM).

37
Q

Merit-Based Incentive Payment System (MIPS)

A

Provide a single quality reporting system with a single payment adjustment factor based on individual or group performance in Medicare Part B

Combines former Physician Quality Reporting System (PQRS), Medicare Electronic Health Record Incentive Program or Meaningful Use, and Value-Based Payment Modifier (VM)

38
Q

Submitter Types

A

MIPS eligible clinicians

An individual
A group
A virtual group
An MVP
An APM entity

39
Q

Submission Types

A

CMS-approved submission mechanisms:

  • Self-reporting on the QPP website
  • Working with a third party intermediary such as a Qualified Clinical Data Registry (QCDR)
  • Medicare Part B claims
40
Q

Collection Types

A

Quality measure sets:

  • Electronic clinical quality measures (eCQMs)
  • MIPS clinical quality measures (CQMs)
  • Qualified clinical data registry (QCDR) measures
  • Medicare Part B claims measures
  • CMS Web Interface measures
  • Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS survey measure
  • Administrative claims measures
41
Q

4 MIPS Performance Categories

A
  1. Quality
  2. Promoting Interoperability (PI)
  3. Improvement Activities
  4. Cost
42
Q

Quality Performance Category

A

Assess the value of care to ensure patients get the right care at the right time

43
Q

Promoting Interoperability (PI) Performance Category

A

Promote the secure exchange of health information and the use of certified electronic health record technology (CEHRT) for coordination of care

44
Q

Improvement Activities Performance Category

A

Promote practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, participation in an APM, health equity, emergency preparedness and response, and integrated behavioral and mental health

45
Q

Cost Performance Category

A

Create efficiencies in Medicare spending, assess a patient’s total cost of care during the year or during a hospital stay, and/or during certain episodes of care

CMS analyzes data from both Part A and Part B claims to calculate the overall cost of patient care.

46
Q

MIPS Final Score

A

Determined based on overall performance compared to the CMS-established benchmark

Higher MIPS final scores = higher payment adjustment

47
Q

MIPS Value Pathways (MVPs)

A

Offer clinicians more meaningful groupings of measures and activities relevant to a specialty or medical condition

CMS has not set a timeframe for when MVP reporting will replace traditional MIPS reporting

48
Q

Advanced Alternative Payment Models (APM)

A

Group of clinicians who have voluntarily come together in an organized way to deliver coordinated high-quality care to Medicare patients

CPB (2 decks)

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