B&C Chapter 5: Legal Aspects of Health Insurance and Reimbursement

Question 1

abuse

Answer 1

actions inconsistent with accepted, sound medical business, or fiscal practices.

Question 2

ANSI ASC X12N 837

Answer 2

electronic format supported for health care claim transactions

Question 3

audit

Answer 3

objective evaluation to determine the accuracy of submitted financial statements

Question 4

authorization

Answer 4

document that provides official instruction, such as the customized document that gives covered entities permission to use specified protected health information (PHI) for specified purposes or to disclose PHI to a third party specified by the individual.

Question 5

black box edit

Answer 5

nonpublished code edits, which were discontinued in 2000.

Question 6

breach of confidentiality

Answer 6

unauthorized release of patient information to a third party.

Question 7

case law

Answer 7

also called common law; based on a court decision that establishes a precedent.

Question 8

civil law

Answer 8

area of law not classified as criminal.

Question 9

Clinical Data Abstracting Center (CDAC)

Answer 9

requests and screens medical records for the Payment Error Prevention Program (PEPP) to survey samples for medical review, DRG validation, and medical necessity.

Question 10

CMS Internet-only manual (IOM)

Answer 10

includes program issuances, day-to-day operating instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives; used by CMS program components, providers, contractors, Medicare Advantage organizations, and state survey agencies to administer CMS programs; also called CMS Online Manual System.

Question 11

CMS Online Manual System

Answer 11

see CMS Internet-only manual.

Question 12

CMS quarterly provider update (QPU)

Answer 12

an online CMS publication that contains information about regulations and major policies currently under development, regulations and major policies completed or cancelled, and new or revised manual instructions.

Question 13

CMS transmittal

Answer 13

document published by Medicare containing new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual (e.g., Medicare Claims Processing Manual); cover page (or transmittal page) summarizes new and changed material, and subsequent pages provide details; transmittals are sent to each Medicare administrative contractor.

Question 14

common law

Answer 14

also called case law; is based on a court decision that establishes a precedent.

Question 15

compliance program

Answer 15

internal policies and procedures that an organization follows to meet mandated requirements.

Question 16

Comprehensive Error Rate Testing (CERT) program

Answer 16

assesses and measures improper Medicare fee-for-service payments (based on reviewing selected claims and associated medical record documentation).

Question 17

Conditions for Coverage (CfC)

Answer 17

health and safety regulations that health care organizations, such as end-stage renal disease facilities, must meet in order to begin and continue participating in the Medicare and Medicaid programs.

Question 18

Conditions of Participation (CoP)

Answer 18

health and safety regulations that health care organizations, such as hospitals, must meet in order to begin and continue participating in the Medicare and Medicaid programs.

Question 19

confidentiality

Answer 19

restricting patient information access to those with proper authorization and maintaining the security of patient information.

Question 20

criminal law

Answer 20

public law governed by statute or ordinance that deals with crimes and their prosecution.

Question 21

Current Dental Terminology CDT

Answer 21

medical code set maintained and copyrighted by the American Dental Association.

Question 22

decrypt

Answer 22

to decode and encoded computer file so that it can be viewed.

Question 23

deeming

Answer 23

CMS recognition of accreditation organization (e.g., The Joint Commission) standards that meet or exceed CoP and CfC requirements.

Question 24

Deficit Reduction Act of 2005

Answer 24

Created Medicaid Integrity Program (MIP), which increased resources available to CMS to combat abuse, fraud, and waste in the Medicaid program. Congress requires annual reporting by CMS about the use and effectiveness of funds appropriated for the MIP.

Question 25

deposition

Answer 25

legal proceeding during which a party answers questions under oath (but not in open court).

Question 26

digital

Answer 26

application of a mathematical function to an electronic document to create a computer code that can be encrypted (encoded).

Question 27

electronic Clinical Quality Measure (eCQM)

Answer 27

processes, observations, treatments, and outcomes that quantify the quality of care provided by health care systems; measuring such data helps ensure that care is delivered safely, effectively, equitably, and timely.

Question 28

electronic transaction standards

Answer 28

also called transactions rule; a uniform language for electronic data interchange.

Question 29

encrypt

Answer 29

to convert information to a secure language format for transmission.

Question 30

False Claims Act (FCA)

Answer 30

passed by the federal government during the Civil War to regulate fraud associated with military contractors selling supplies and equipment to the Union Army.

Question 31

Federal Claims Collection Act (FCCA)

Answer 31

requires Medicare administrative contractors (previously called carriers and fiscal intermediaries), as agents of the federal government, to attempt the collection of overpayments.

Question 32

Federal Register

Answer 32

legal newspaper published every business day by the National Archives and Records Administration (NARA).

Question 33

First-look Analysis for Hospital Outlier Monitoring (FATHOM)

Answer 33

data analysis tool, which provides administrative hospital and state-specific data for specific CMS target areas.

Question 34

fraud

Answer 34

intentional deception or misrepresentation that could result in an unauthorized payment.

Question 35

Health Care Fraud Prevention and Enforcement Action Team (HEAT)

Answer 35

joint effort between the Department of Health and Human Services and the Department of Justice to fight health care fraud by increasing coordination, intelligence sharing, and training among investigators, agents, prosecutors, analysts, and policymakers; implemented as a result of the Patient Protection and Affordable Care Act (also called Obamacare).

Question 36

Hospital Inpatient Quality Reporting (Hospital IQR) program

Answer 36

developed to equip consumers with quality of care information so they can make more informed decisions about health care options; requires hospitals to submit specific quality measures data about health conditions common among Medicare beneficiaries and that typically result in hospitalization; eligible hospitals that do not participate in the Hospital IQR program will receive an annual market basket update with a 2.0 percentage point reduction; part of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003.

Question 37

Hospital Outpatient Quality Reporting Program (Hospital OQR)

Answer 37

a “pay for quality data reporting program” that was implemented by CMS for outpatient hospital services (as part of the Tax Relief and Health Care Act of 2006).

Question 38

Hospital Payment Monitoring Program (HPMP)

Answer 38

measures, monitors, and reduces the incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals.

Question 39

hospital value-based purchasing (VBP) program

Answer 39

health care reform measure that promotes better clinical outcomes and patient experiences of care; effective October 2012, hospitals receive reimbursement for inpatient acute care services based on care quality (instead of the quantity of the services provided).

Question 40

Improper Payments Information Act of 2002 (IPIA)

Answer 40

established the Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program and the Children’s Health Insurance Program (CHIP); Comprehensive Error Rate Testing (CERT) program to calculate the paid claims error rate for submitted Medicare claims by randomly selecting a statistical sample of claims to determine whether claims were paid properly (based on reviewing selected claims and associated medical record documentation); and the Hospital Payment Monitoring Program (HPMP) to measure, monitor, and reduce the incidence of Medicare fee-for-service payment errors for short-term, acute care at inpatient PPS hospitals.

Question 41

interrogatory

Answer 41

document containing a list of questions that must be answered in writing.

Question 42

listserv

Answer 42

subscriber-based question-and-answer forum that is available through e-mail.

Question 43

Medicaid integrity contractor (MIC)

Answer 43

CMS-contracted entities that review provider claims, audit providers and others, identify overpayments, and educate providers, managed care entities, beneficiaries and other with respect to payment integrity and quality of care.

Question 44

Medicaid Integrity Program (MIP)

Answer 44

increased resources available to CMS to combat fraud, waste, and abuse in the Medicaid program; Congress requires annual reporting by CMS about the use and effectiveness of funds appropriated for the MIP.

Question 45

medical identity theft

Answer 45

occurs when someone uses another person’s name and/or insurance information to obtain medical and/or surgical treatment, prescription drugs, and medical durable equipment; it can also occur when dishonest people who work in a medical setting use another person’s information to submit false bills to health care plans.

Question 46

medical review (MR)

Answer 46

defined by CMS as a review of claims to determine whether services provided are medically reasonable and necessary, as well as to follow up on the effectiveness of previous corrective actions.

Question 47

Medicare administrative contractor (MAC)

Answer 47

an organization (e.g., third-party payer) that contracts with CMS to process claims and perform program integrity tasks for Medicare Part A and Medicare Part B, home health and hospice, and DMEPOS; each contractor makes program coverage decisions and publishes a newsletter, which is sent to providers who receive Medicare reimbursement. Medicare transitioned fiscal intermediaries and carriers to create Medicare administrative contractors (MACs).

Question 48

Medicare Drug Integrity Contractors (MEDIC) Program

Answer 48

implemented in 2011 assists with CMS audit, oversight, anti-fraud, and anti-abuse efforts by identifying cases of Medicare Part D fraud, thoroughly investigating the cases, and taking appropriate action.

Question 49

Medicare Integrity Program (MIP)

Answer 49

authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program.

Question 50

Medicare Shared Savings Program

Answer 50

as mandated by the Patient Protection and Portable Care Act (PPACA), CMS established Medicare shared savings programs to facilitate coordination and cooperation among providers to improve quality of care for Medicare fee-for-service beneficiaries and to reduce unnecessary costs; accountable care organizations (ACOs) were created by eligible providers, hospitals, and supplies to coordinate care, and they are held accountable for the quality, cost, and overall care of traditional fee-for-service Medicare beneficiaries assigned to the ACO.

Question 51

merit-based incentive payment system (MIPS)

Answer 51

eliminated PQRS, value-based payment modifier, and the Medicare EHR incentive program, creating a single program based on quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology.

Question 52

message digest

Answer 52

representation of text as a single string of digits, which was created using a formula; for the purpose of electronic signatures, the message digest is encrypted (encoded) and appended (attached) to an electronic document.

Question 53

National Drug Code (NDC)

Answer 53

maintained by the Food and Drug Administration (FDA); identifies prescription drugs and some over-the-counter products.

Question 54

National Individual Identifier

Answer 54

unique identifier to be assigned to patients has been put on hold. Several bills in Congress would eliminate the requirement to establish a National Individual Identifier.

Question 55

National Plan and Provider Enumeration System (NPPES)

Answer 55

developed by CMS to assign unique identifiers to health care providers (NPI).

Question 56

National Practitioner Data Bank (NPDB)

Answer 56

implemented by Health Care Quality Improvement Act (NCQIA) of 1986 to improve quality of health care by encouraging state licensing boards, hospitals, and other health care entities and professional societies to identify and discipline those who engage in unprofessional behavior; restricts ability of incompetent physicians, dentists, and other health care practitioners to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history; impacts licensure, clinical privileges, and professional society memberships as a result of adverse actions; includes Health Integrity and Protection Data Base (HIPDB), originally established by HIPAA, to further combat fraud and abuse in health insurance and health care delivery by serving as a national data collection program for reporting and disclosing certain final adverse actions taken against health care practitioners, providers, and suppliers.

Question 57

National Provider Identifier (NPI)

Answer 57

unique identifier assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position.

Question 58

National Standard Employer Identification Number (EIN)

Answer 58

unique identifier assigned to employers who, as sponsors of health insurance for their employees, need to be identified in health care transactions; it is the federal employer identification number (EIN) assigned by the Internal Revenue Service (IRS) and has nine digits with a hyphen (00-0000000); EIN assignment by the IRS began in January 1998.

Question 59

National Standard Format (NSF)

Answer 59

flat-file format used to bill provider and noninstitutional services, such as services reported by a general practitioner on a CMS-1500 claim.

Question 60

overpayment

Answer 60

funds that a provider or beneficiary has received in excess of amounts due and payable under Medicare and Medicaid statutes and regulations.

Question 61

Part A/B Medicare administrative contractor (A/B MAC)

Answer 61

see Medicare administrative contractor.

Question 62

Patient Safety and Quality Improvement Act

Answer 62

amends Title IX of the Public Health Service Act to provide for improved patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients; creates patient safety organizations (PSOs) to collect, aggregate, and analyze confidential information reported by health care providers; and designates information reported to PSOs as privileged and not subject to disclosure (except when a court determines that the information contains evidence of a criminal act or each provider identified in the information authorizes disclosure).

Question 63

Payment Error Prevention Program (PEPP)

Answer 63

required facilities to identify and reduce improper Medicare payments and, specifically, the Medicare payment error rate. The hospital payment monitoring program (HPMP) replaced PEPP in 2022.

Question 64

payment error rate

Answer 64

number of dollars paid in error out of total dollars paid for inpatient prospective payment system services.

Question 65

Payment Error Rate Measurement (PERM) program

Answer 65

measures improper payments in the Medicaid program and the Children’s Health Insurance Program (CHIP).

Question 66

physician self-referral law

Answer 66

see Stark I.

Question 67

Physicians at Teaching Hospitals (PATH)

Answer 67

HHS implemented audits in 1995 to examine the billing practices of physicians at teaching hospitals; the focus was on two issues: (1) compliance with the Medicare rule affecting payment for physician services provided by residents (e.g., whether a teaching physician was present for Part B services billed to Medicare between 1990 and 1996), and (2) whether the level of the physician service was coded and billed properly.

Question 68

precedent

Answer 68

standard.

Question 69

privacy

Answer 69

right of individuals to keep their information from being disclosed to others.

Question 70

Privacy Act of 1974

Answer 70

forbids the Medicare regional payer from disclosing the status of any unassigned claim beyond the following: date the claim was received by the payer; date the claim was paid, denied, or suspended; or general reason the claim was suspended.

Question 71

privacy rule

Answer 71

HIPAA provision that creates national standards to protect individuals’ medical records and other personal health information.

Question 72

privileged communication

Answer 72

private information shared between a patient and health care provider; disclosure must be in accordance with HIPAA and/or individual state provisions regarding the privacy and security of protected health information (PHI).

Question 73

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

Answer 73

contains hospital-specific administrative claims data for a number of CMS-identified problem areas (e.g., specific DRGs, types of discharges); a hospital uses PEPPER data to compare its performance with that of other hospitals.

Question 74

protected health information (PHI)

Answer 74

information that is identifiable to an individual (or individual identifiers) such as name, address, telephone numbers, date of birth, Medicaid ID number, medical record number, medical record number, Social Security Number (SSN), and name of employer.

Question 75

qui tam

Answer 75

abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, which means “who as well for the king as for himself sues I this matter.” It is a provision of the False Claims Act that allows a private citizen to file a lawsuit in the name of the U.S. government, charging fraud by government contractors and other entities.

Question 76

record retention

Answer 76

storage of documentation for an established period of time, usually mandated by federal and/or state law; its purpose is to ensure the availability of records for use by government agencies and other third parties.

Question 77

Recovery Audit Contractor (RAC) program

Answer 77

mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) to find and correct improper Medicare payments paid to health care providers participating in fee-for-service Medicare.

Question 78

regulations

Answer 78

guidelines written by administrative agencies (e.g., CMS)

Question 79

release of information (ROI)

Answer 79

ROI by a covered entity (e.g., provider’s office) about protected health information (PHI) requires the patient (or representative) to sign an authorization to release information, which is reviewed for authenticity (e.g., comparing signature on authorization form to documents signed in the patient record) and processed within a HIPAA-mandated 60-day time limit; requests for ROI include those from patients, physicians, and other health care providers; third-party payers; Social Security Disability attorneys; and so on.

Question 80

release of information log

Answer 80

used to document patient information released to authorized requestors; data is entered manually (e.g., three-ring binder) or using ROI tracking software.

Question 81

security

Answer 81

involves the safekeeping of patient information by controlling access to hard copy and computerized records; protecting patient information from alteration, destruction, tampering, or loss; providing employee training in confidentiality of patient information; and requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality.

Question 82

security rule

Answer 82

HIPAA standards and safeguards that protect health information collected, maintained, used, or transmitted electronically; covered entities affected by this rule include health plans, health care clearinghouses, and certain health care providers.

Question 83

Stark I

Answer 83

responded to concerns about physician’s conflicts of interest when referring Medicare patients for a variety of services; prohibits physicians from referring Medicare patients to clinical laboratory services in which the physician or a member of the physician’s family has a financial ownership/investment interest and/or compensation arrangement; also called physician self-referral law.

Question 84

statutes

Answer 84

also called statutory law; laws passed by legislative bodies (e.g., federal Congress and state legislatures).

Question 85

statutory law

Answer 85

see statutes.

Question 86

subpoena

Answer 86

an order of the court that requires a witness to appear at a particular time and place to testify.

Question 87

subpoena duces tecum

Answer 87

requires documents (e.g., patient record) to be produced.

Question 88

Tax Relief and Health Care Act of 2006 (TRHCA)

Answer 88

created the Hospital Outpatient Quality Reporting Program (Hospital OQR) that is a “pay for quality data reporting program” implemented by CMS for outpatient hospital services.

Question 89

UB-04 flat file

Answer 89

series of fixed-length records used to bill institutional services, such as services performed in hospitals.

Question 90

unique bit string

Answer 90

computer code that creates an electronic signature message digest that is encrypted (encoded) and appended (attached) to an electronic document (e.g., CMS-1500 claim).

Question 91

upcoding

Answer 91

assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-10-CM code for heart attack when angina was actually documented in the record).

Question 92

whistleblower

Answer 92

individual who makes specified disclosures relating to the use of public funds, such as Medicare payments. ARRA legislation prohibits retaliation (e.g., termination) against such employees who disclose information that they believe is evidence of gross mismanagement of an agency contract or grant relating to covered funds, and so on.

Question 93

Zone Program Integrity Contractor (ZPIC)

Answer 93

program implemented in 2009 by CMS to review billing trends and patterns, focusing on providers whose billings for Medicare services are higher than the majority of providers in the community. ZPICs are assigned to the Medicare administrative contractor (MAC) jurisdictions, replacing Program Safeguard Contracts (PSCs).