Chapter 1 Flashcards
An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly.
Abuse
Conditions that healthcare organizations must meet to participate with the plan or program.
Conditions of Participation (CoP)
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.
Covered Entity
Knowingly and willfully offering or accepting
rewards or remuneration for services that are billable to a
federal healthcare plan.
Anti-kickback
An individual that is eligible for Medicare or
Medicaid benefits based on the CMS guidelines
Beneficiary
Scheme to willingly defraud
any healthcare benefit program
Criminal Healthcare Fraud Act
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
False Claims Act
Making false statements or misrepresenting facts
to obtain an undeserved benefit or payment from a federal
healthcare program
Fraud
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
Health Insurance Portability and Accountability Act of 1996
HIPAA
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
Preferred Provider Organization (PPO)
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
Protected Health Information (PHI)
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
Qui Tam Action
A federal law that places limitations of certain
physician referrals
Stark Law
Designed to assure that every customer
who needs consumer credit is given meaningful information
concerning the cost of such credit
Truth in Lending Act
