Regulatory Compliance Flashcards
A self assessment and external peer assessment process used by healthcare organizations to accurately assess their level of performance in relation to established standards and implement ways to continuously improve
Accreditation
Written notice issued to a fee for service (original/traditional Medicare) beneficiary before furnishing items or services that are usually covered by Medicare but are not to be paid in a specific instance for certain reasons, such as lack of medical necessity
Advance Beneficiary Notice
ABN
A legal document in which a person has outlined what they would like to be done if they are no longer able to make decisions for themselves due to incapacity or illness
Advance Directive
Anti fraud federal criminal statute that prohibits offering or exchange of anything of value in exchange for healthcare business referrals
Anti-kickback statute
Federal agency under the Department of Health and Human Services that administers Medicare and partners with state governments for administration of Medicaid and other programs
CMS
Centers for Medicare and Medicaid services
CMS code used to track and monitor occurrences where a Medicare beneficiary is admitted to a hospital as an inpatient but ,upon internal review, the hospital determines the services did not meet inpatient criteria and admission is changed to observation
Condition code 44
An insurance program for the families of veterans
CHAMPVA
Civilian Heath and Medical Program for the Veterans Administration
Accreditation organization approved by CMS
DNV Healthcare
A real time, digitized version of a patients medical history that allows secure information access to authorized users
EHR
Electronic Health Record
Anti-dumping statute. Federal law protecting patients against discrimination regardless of ability to pay; mandates patients receive a medical screening exam and stabilizing treatment when seeking emergency medical care or when in active labor
EMTALA
emergency medical treatment and labor act
Federal law prohibiting debt collectors from using unfair deceptive practices while attempting to collect from a consumer
FDCPA
fair debt collection practices act
Federal law that targets fraud against the government. “Whistleblower’s” or qui tam provision allows non-government individuals to report fraud against the government in good faith who may receive up to 30% of any recovered damages
False claims act
Federal law stimulating the adoption of electronic health records and providing financial incentives for demonstrating meaningful use; also expanded HIPPA security and privacy rules and increased penalties; established data breach notification rules
HITECH
health information technology for economic and clinical health act
Regulations related to health insurance portability; focused on administration simplification and reduction of cost through the protection and standardization of electronic and financial records. Most known for the privacy and security rules defining standards for healthcare and protected health information
HIPAA
health insurance portability and accountability act
An accreditation organization tied to Medicare conditions of participation coverages
HFAP
healthcare facilities accreditation program
This update to HITECH Act revised provisions that focused on an individual’s right to request restrictions on the disclosure of PHI and on an individual’s right to access their PHI stored in an EHR
HITECH Omnibus of 2013
A form given to all Medicare beneficiaries who are inpatients in participating hospitals explaining their rights and what to do if they feel they are being discharged early
IMM
important message from Medicare
An independent not for profit organization that evaluates and accredits healthcare organizations in the us
TJC
the joint commission
Incentive program established to provide monetary incentives for the adoption and use of health information technology and qualified electronic health records
Meaningful use
Covers low income adults, children, pregnant women, elderly adults and individuals with disabilities
; single largest source of health coverage in the us
Medicaid
Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, or disease or its symptoms and that meet the accepted standards of medicine
Medically necessary
A private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare part a and part claims for Medicare original/traditional beneficiaries
MAC
Medicare administrative contractor
Form given to Medicare beneficiaries to inform them of their outpatient observation status and explain what that may mean financially
MOON
Medicare outpatient observation notice
A program in which Medicaid pays Medicare premiums, deductibles, and/or coinsurance costs for beneficiaries eligible for both programs “duel eligible”
Medicare savings program
Medicare required questions to determine if there are any other payers that may pay primary to Medicare
MSPQ
Medicare secondary payer questionnaire
CMS rule stating that for a hospital admission to be paid for under Medicare part A the patient had to stay across two midnights; anything less is paid for under Medicare part B
Medicare two midnight rule
Concept that people should only access, use, or disclose health information that is minimally necessary to accomplish a given task or purpose
Minimum necessary standard
Methodology established by the affordable care act to deter income eligibility based on taxable income and tax filing relationships
MAGI
modified adjusted gross income
Included reforms to affordability, quality, availability of healthcare; goal to increase the number of Americans who have access to affordable health insurance; provided assistance for those with preexisting conditions; extended dependent coverage up to 26; required coverage of preventative services and immunizations; expanded Medicaid coverage to more low income Americans
PPACA
patient protection and affordable care a act of 2010
“Obamacare”
Any type of information that can be used to identify a person
PII
personally identifiable information
Health information identified under HIPAA that is produced, saved, received, transferred
PHI
protected health information
Hospitals and qualified physicians have the option of screening patients to see if they qualify for Medicaid and they may be granted this temporary coverage but must complete the application process in order to keep the coverage
Presumptive eligibility
A patients right to restrict PHI disclosure under HITECH omnibus of 2013
Restricted disclosure
A group of federal laws that prohibit physician self referral
The Stark Law
Federal law regulating the use of prerecorded messages and auto dialers
TCPA
Telephone consumer protection act
Healthcare program for military active, reservists, retirees, survivors, Medal of Honor recipients and families. Beneficiary has Primary Care Manager who provides most of their care, refers to specialist if they can’t provide,
TRICARE Prime
Fraudulent practice of breaking down services currently being bundled together into one CPT close into individual codes for the purpose of higher reimbursement
Unbundling
Fraudulent process of assigning an inaccurate billing code for a medical procedure or treatment to increase reimbursement
Upcoding
Largest integrated healthcare system in America serving veterans who served in active military for at least 24 continuous months and were discharged or released under any condition other than dishonorable discharge
VA
Veterans administration
Program where the VA enrolled member is authorized to receive care from community based providers
Veterans Choice Program
Division of Department of health and human services That is the enforcement arm of CMS mandated to fight waste, fraud, and abuse
OIG
office of the inspector general
Active duty family members, retired service members and their families, survivors, Medal of Honor recipients; beneficiary can schedule appointments with any TRICARE authorized provider, referrals not required,
TRICARE Select
Medicare wraparound coverage for TRICARE eligible beneficiaries who have Medicare part a and part b
TRICARE for life
