Definitions

Question 1

Anti-Kickback Law

Answer 1

Prohibits the solicitation, receiving, offering, or paying of any remuneration directly or indirectly in cash or in kind in exchange

Question 2

Attestation

Answer 2

the affirmation by signature, usually on a printed form, that the action outlined has been accomplished by the individual signing

Question 3

Attorney-client Privilege

Answer 3

a legally accepted policy that communication between a client and attorney is confidential in the course of the professional relationship and that such communication cannot be disclosed without the consent of the client.

Question 4

Audit, baseline

Answer 4

A systematic inspection of records, policies, and procedures with the goal to establish a set of benchmarks for comparison for future inspections

Question 5

Audit, concurrent

Answer 5

An inspection of records, policies, and procedures at a given point in time in which identified potential problems are audited as they arise

Question 6

Audit, retrospective

Answer 6

An audit of historical events

Question 7

Balanced Budget Act of 1997

Answer 7

Legislation containing major reform of the Medicare and Medicaid programs especially in the areas of home health and patient transfers. It also mandated permanent exclusion from participation in federally funded health care programs of those convicted of three health care-related crimes (3 strikes and you’re out)

Question 8

Benchmarking

Answer 8

the measurement of performance against “best practice” standards

Question 9

Best Practices

Answer 9

Generally recognized superior performance by organizations in operational and/or financial processes

Question 10

Business Associate

Answer 10

A person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity.
Not a part of the covered entity’s workforce

Question 11

Business Associate Agreement (BAA)

Answer 11

The HIPAA Privacy Rule requires that, before PHI can be shared between a covered entity and a business associate, the business associate must sign a written agreement that gives satisfactory assurances that it will not use or disclose PHI in a manner that contradicts the Privacy Rule requirements. HIPPA also requires a Business Associate Agreement to define the function of the business associate and the limitations on their uses and disclosures of PHI. The business associate agreement must also define what will happen to the PHI held by the business associate upon termination of the agreement

Question 12

Caremark International Derivative Litigation

Answer 12

The 1996 U.S. civil settlement of Caremark International, Inc. in which an imposed corporate integrity agreement precluded Caremark from providing health care in certain forms for a period of 5 years. Also suggests that the failure of a corporate director to attempt in good faith to institute a compliance and ethics program in certain situations may be a breach of a director’s fiduciary obligation

Question 13

Centers for Medicare and Medicaid Services (CMS)

Answer 13

A component of the U.S. Department of Health and Human Services that administers the Medicare, Medicaid and State Children’s Health Insurance Programs

Question 14

Certified Professional Coder (CPC)

Answer 14

A coder who has satisfied certification requirements as established by the American Academy of Professional Coders

Question 15

Chain of Command

Answer 15

The hierarchy of reporting structure within an organization, which assumes all issues will be presented first to one’s immediate supervisor

Question 16

Civil Monetary Penalties Law (CMPL)

Answer 16

Regulations which apply to any claim for an item or service that was not provided as claimed or that was knowingly submitted as false and which provides guidelines for the levying of fines for such offences

Question 17

Compliance

Answer 17

Adherence to the laws and regulations passed by official regulating bodies as well as general principles of ethical conduct. In the U.S., such regulating bodies in the U.S. Congress; federal executive departments and federal agencies and commissions; and corresponding state-level entities

Question 18

Corporate Integrity Agreement (CIA)

Answer 18

A negotiated settlement between an organization and the government in which the provider accepts no liability but must agree to implement a strict plan of government-supervised corrective action

Question 19

Covered Entities

Answer 19

1. health plan
2. health care clearinghouse
3. health care provider who transmits any health information in electronic form in connection with a transaction covered by this subchapter

Question 20

Culpability Score

Answer 20

Part of the U.S. Sentencing Commission guidelines for the Sentencing of Organizations, a system that adds points for aggravating factors and subtracts points for mitigating factors in the determination of fines imposed for fraud and abuse

Question 21

Current Procedural Terminology (CPT)

Answer 21

A publication of the American Medical Association which lists and assigns codes to procedures and services performed by physicians

Question 22

Department of Labor

Answer 22

This federal agency administers and enforces laws and regulations that govern workplace activities, including wages and overtime pay (through the Wage and Hour Division), workers’ compensation, workplace safety and health (through the Occupational Safety and Health Administration), employee benefits, certain nonimmigrant visa programs, etc

Question 23

Designated Record Set

Answer 23

1. a group of records maintained by or for a covered entity, that is
   a. the medical records and billing records about individuals maintained by or for the covered health care provider
   b. the enrollment, payment, claims adjudication and case or medical management records systems maintained by or for a health plan
   c. used, in whole or in part, by or for the covered entity to make decisions about individuals
2. for purposes of this paragraph, the term record means and item, collection, or grouping of information that includes protected health information and is maintained, collected, used or disseminated by or for a covered entity

Question 24

Diagnosis-Related Groups (DRG)

Answer 24

Classifications of diagnoses determined by the average cost of treating a particular condition, regardless of the number of services rendered or the length of patient stay

Question 25

Disclosure

Answer 25

the release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information

Question 26

Employee Retirement Income Security Act (ERISA)

Answer 26

A 1972 federal act that exempts self-insured health plans from state laws governing health insurance and requires health plans to provide certain information to enrollees

Question 27

Equal Employment Opportunity Commission (EEOC)

Answer 27

US agency created in 1964 to end discrimination based on race, religion, sex, or national origin in employment. The commission reviews and investigates charges of discrimination and, if found to be true, attempts to remedy through conciliation or legal means.

Question 28

False Claims Act (FCA)

Answer 28

Originally adopted by the US Congress in 1863 during the Civil War to discourage suppliers from overcharging the federal government, legislation that prohibits anyone from knowingly submitting or causing to be submitted a false or fraudulent claim

Question 29

Federal Sentencing Guidelines

Answer 29

Guidelines developed by the US Sentencing Commision, an independent agency in the judicial branch of government established by the 1984 Sentencing Reform Act, to govern the sentencing of individual defendants (1987) and organizations (1991)

Question 30

Fiscal Intermediary, Fiduciary Intermediary

Answer 30

A person or organization that, under agreement with HHS under part A of Medicare, processes claims, provides services, and issues payments on behalf of private, federal, and state health benefits programs or other insurance organizations

Question 31

General Services Administration (GSA)

Answer 31

The federal agency that manages the federal government’s property and records, including the construction and operation of buildings and procurement and distribution of supplies, among other functions

Question 32

Health and Human Services (HHS)

Answer 32

the department of the executive branch of the US government with health care accountabilities, including responsibility for the Public Health Service, the Centers for Medicare and Medicaid Services (CMS) and the Social Security Administration

Question 33

Health Care

Answer 33

Care, services or supplies related to the health of an individual, including but not limited to;
1. preventative, diagnostic, rehabilitative, maintenance, or palliative care, counseling, services, assessment or procedure with respect to a physical or mental condition, or functional status of an individual or affective the structure or function of the body
2. sale or dispensing of a drug, device, equipment, or other item pursuant to a prescription

Question 34

Health Care Clearinghouse

Answer 34

public or private entity, including a billing service, repricing company, community health management information system or community health information system, and “value added” networks and switches, that does either of the following functions:
1. processes or facilitates the processing of health information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction
2. Receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard format or nonstandard data content for the receiving entity

Question 35

Health Care Compliance Association (HCCA)

Answer 35

the professional association dedicated to helping health care compliance professionals, through education, networking opportunities and other resources, create an ethical environment within their organizations and meet all legal and regulatory requirements related to Medicare reimbursement

Question 36

Health Care Provider

Answer 36

a provider of services, a provider of medical and health services, and any other person or organization who furnishes, bills, or is paid for, health care services or supplies in the normal course of business

Question 37

Health Information

Answer 37

any information, oral or recorded, in any form or medium that
1. is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
2. related to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.

Question 38

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

Answer 38

enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA)
Designed to encourage health care providers to adopt health information technology that establish electronic health records in a standardized manner that protects patients’ private health information. In addition, it requires the Department of Health and Human Services to modify the HIPAA Privacy, Security, and Enforcement Rules to strengthen health information privacy and security protections

Question 39

Health Insurance Portability and Accountability Act 1996 (HIPAA)

Answer 39

comprehensive legislation that ensures access to health coverage for those who change jobs or are temporarily out of work. It also provides the mechanism for funding the Department of Justice and the FBI for Medicare fraud investigations

Question 40

Health Plan

Answer 40

an individual or group plan that provides, or pays the cost of, medical care

Question 41

Hotline; Helpline

Answer 41

a common reporting system, administered in house or by outside consultants, giving anonymous telephone access to employees seeking to report possible instances of wrongdoing

Question 42

ICD-10-CM

Answer 42

a two part classification system in current use for coding patient medical information and for classifying patients into DRGs for Medicare and other third-party payers. The first part provides a comprehensive list of diseases with corresponding codes compatible with the WHO’s list of diseases codes. The second part contains procedure codes independent of the disease codes.
published by the Commision on Professional and Hospital Activities (CPHA) and federal government

Question 43

Individually Identifiable Health Information (IIHI)

Answer 43

Information that is a subset of health information, including demographic information collected from an individual and:
1. is created or received by a health care provider, health plan, employer, health care clearinghouse
2. related to past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual
a. that identifies the individual
b. with respect to which there is a reasonable basis to believe that the information can be used to identify the individual

Question 44

Inspector General (IG)

Answer 44

an officer of a federal agency whose primary function is to conduct and supervise audits and investigations relating to operations and procedures over which the agency has jurisdiction

Question 45

The Joint Commision

Answer 45

a not-for-profit organization that develops standards and performance measures, conducts regular on-site surveys based on those standards and measures, and awards accreditation decisions and certification for health care organizations and programs in the US

Question 46

Occupational Safety and Health Administration (OSHA)

Answer 46

a component of the Department of Labor that develops and administers standards relating to the well-being of workers at the job site, develops and issues regulations in this area, conducts investigations and inspections to determine status of compliance with safety and health standards and regulations, and issues citations and proposes penalties for noncompliance

Question 47

Office for Civil Rights (OCR)

Answer 47

A component of the Department of Health and Human Services that teaches health care workers about civil rights, health information privacy, and patient safety confidentiality laws; and investigates civil rights, health information privacy, and patient safety confidentiality complaints to enforce those regulations

Question 48

OIG

Answer 48

Office of inspector general

Question 49

OIG Compliance Program Guidance

Answer 49

Guidelines issued by the office of the inspector general for the suggested development of compliance programs. Compliance programs guidances have been issued for hospitals, home health agencies, clinical laboratories, third party billers, the durable medical equipment, prosthetics, orthotics and supply industry, hospice providers, physician practices, research, skilled nursing and Medicare+ Choice organizations

Question 50

Physician at Teaching Hospitals (PATH)

Answer 50

an HHS/OIG nationwide review of compliance with rules governing physicians at teaching hospitals. Records were reviewed to determine adequate physician involvement in patient care according to IL373, the Medicare rule that dictates that an attending physician must be present when supervising an intern or resident in order to bill for the care provided by the intern or resident

Question 51

Prospective Payment System (PPS)

Answer 51

the system for paying for services for Medicare patients whereby patients are classified into categories for which prices are negotiated or determined in advance

Question 52

Qui Tam

Answer 52

authorized by the false claims act
A qui tam suit is one filed by an employee of an organization, a whistleblower, with the federal government accusing an organization of fraud and abuse

Question 53

Safe Harbors

Answer 53

explicit regulatory exceptions to otherwise legally prohibited conduct. Federal safe harbor regulations specify certain joint ventures and other arrangements concerning hospitals and/or physicians which do not violate Medicare fraud and abuse laws

Question 54

Self-referral statute; Stark Law

Answer 54

the Omnibus Budget Reconciliation Act of 1989 (OBRA) bans physicians from referring lab specimens to any entity with which the physician has a financial relationship. Amended by OBRA90 to exclude financial relationships between hospitals and physicians unrelated to clinical laboratory services. OBRA93 (stark II) expanded to include 10 other designated health care services

Question 55

Self-reporting

Answer 55

having identified actual wrongdoing, the organization informs the government. Although not protected from civil or criminal action under the False Claims Act, providers disclosing fraud are advised in the government self-disclosure protocol that timely self-reporting of wrongdoing may offer mitigating factors in potential penalties and/or fines

Question 56

Seven Elements suggested by OIG

Answer 56

1. implementing written policies, procedures, and standards or conduct
2. Compliance oversight
3. developing effective lines of communication and screening
4. Conducting effective training and education
5. Conducting internal monitoring and auditing
6. Enforcing standards through well-publicized disciplinary guidelines
7. Responding promptly to detected offenses and undertaking corrective action

Question 57

Snapshot

Answer 57

the OIG guidances suggest that at inception of a compliance program, a review of operations from a compliance perspective be done in order to judge progress in reducing or eliminating potential areas of vulnerability

Question 58

TPO

Answer 58

Abbreviation for Treatment, Payment and Health care Operations, which are the primary areas where health care workers will have a need to use patients’ protected health information

Question 59

Treatment

Answer 59

the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultations between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another

Question 60

Upcoding

Answer 60

coding for a higher level than the documentation warrants

Question 61

Use

Answer 61

with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information

Question 62

Workforce

Answer 62

employees, volunteers, trainees, and other persons who conduct, in the performance of work for the covered entity, is under the direct control of such entity, whether or not they are paid by the covered entity