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