Definitions Flashcards
Prohibits the solicitation, receiving, offering, or paying of any remuneration directly of indirectly in cash or in kind exchange
Anti-kickback law
The affirmation by signature, usually on a printed form, that the action outlined has been accomplished by the individual signing e.g., the individual has read the code of conduct and agreed to adhere to its principles
Attestation
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. it’s purpose is to encourage full and frank communication between attorneys and their clients
Attorney-Client Privilege
A systematic inspection of records, policies, and procedures with the goal to establish a set of benchmarks for comparison for future inspections.
Audit, Baseline
An ongoing inspection of records, policies, and procedures at a given point in time in which identified potential problems are investigated as they arise (e.g., pre-published financial statements
Audit, Concurrent
A comprehensive inspection of records, policies, and procedures done usually in anticipation of launching a compliance and ethics program. All potential problems are identified and then investigated (e.g., published financial statements, historical audit).
Audit, Retrospective
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
Balanced Budget Act of 1997
The measurement of performance against “best practice” standards
Benchmarking
Generally recognized superior performance by organizations in operational and//or functional processes.
Best Practices
A person or organization that performs or assist in the performance of a function or activity involving the use or disclosure of individually identifiable health information on behalf of a covered entity or provides services such as legal, actuarial, accounting, consulting, data aggregation, management administration, accreditation or financial services to or for a covered entity.
Business Associate
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 five 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.
Caremark International Derivative Litigation
A component of the U.S. Department of Health and Human Services that administers the Medicare, Medicaid, and State Children’s Health Insurance Programs.
Centers for Medicare a& Medicaid Services (CMS)
A coder who has satisfied certification requirements as established by the American Academy of Professional Coders
Certified Professional Coder (CPC)
The hierarchy of reporting structure within an organization, which assumes all issues will be presented first to one’s immediate supervisor
Chain of Command
Regulations which apply to a claim for an item of service that was not provided as claims or that was knowingly submitted as false and which provides guidelines for the levying of fines for such offences.
Civil Monetary Penalties Law (CMPL)
Adherence to the laws and regulations passed by official regulating bodies as well as general principles of ethical conduct. In the US, such regulating bodies include the U.S. Congress; federal executive departments and federal agencies and commissions; and corresponding state-level entities
Compliance
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
Corporate Integrity Agreement (CIA)
or
Consent Decrees
Health Plan, healthcare clearinghouse, helath care provider who transmits any health information in electronic form in connection with transaction covered by this subchapter
Covered Entities
Part of the U.S. Sentencing Commission guidelines for the Sentencing or Organizations, a system that adds points for aggravating factors and subtracts points for mitigating factors in the determination of fines imposed for fraud or abuse
Culpability Score
An internet-based, OIG produced report listing healthcare providers who have been excluded from participation in the Medicare and Medicaid programs
Cumulative Sanction Report
A publication of the American Medical Association which lists and assigns codes to procedures and services performed by physicians
Current Procedural Terminology 2000 (CPT 2000)
- A group of records maintained by or for a covered entity, that is: i. The medical records and billing records about individuals maintained by or for the covered health care provider
ii. The enrollment, payment, claims adjudication and a case of medical management records systems maintained by or for a health plan.
iii. Used, in whole or in part, by or for the covered entity to make decisions about individuals - For purposes of this paragraph, the term record means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used or disseminated by or for a covered entity.
Designated Record Set
Classification 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; Medicare reimbursement is assigned by DRG
Diagnosis- Related Groups (DRG)
Illegal practice of intentionally billing using a DRG which provides a higher payment rate than the DRG that accurately reflects the diagnosis and treatment actually provided
DRG Creep
The release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information
Disclosure
A 1974 federal act that exempts self-insured health plans from state law governing health insurance and requires health plans to provider certain information to enrollees
Employee Retirement Income Security Act (ERISA)
