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HCCA Compliance 101 > Definitions > Flashcards

Definitions Flashcards

1
Q

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

A

Anti-kickback law

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2
Q

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

A

Attestation

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3
Q

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

A

Attorney-Client Privilege

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4
Q

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

A

Audit, Baseline

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5
Q

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

A

Audit, Concurrent

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6
Q

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).

A

Audit, Retrospective

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7
Q

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

A

Balanced Budget Act of 1997

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8
Q

The measurement of performance against “best practice” standards

A

Benchmarking

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9
Q

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

A

Best Practices

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10
Q

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.

A

Business Associate

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11
Q

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.

A

Caremark International Derivative Litigation

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12
Q

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

A

Centers for Medicare a& Medicaid Services (CMS)

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13
Q

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

A

Certified Professional Coder (CPC)

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14
Q

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

A

Chain of Command

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15
Q

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.

A

Civil Monetary Penalties Law (CMPL)

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16
Q

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

A

Compliance

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17
Q

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

A

Corporate Integrity Agreement (CIA)
or
Consent Decrees

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18
Q

Health Plan, healthcare clearinghouse, helath care provider who transmits any health information in electronic form in connection with transaction covered by this subchapter

A

Covered Entities

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19
Q

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

A

Culpability Score

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20
Q

An internet-based, OIG produced report listing healthcare providers who have been excluded from participation in the Medicare and Medicaid programs

A

Cumulative Sanction Report

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21
Q

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

A

Current Procedural Terminology 2000 (CPT 2000)

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22
Q
  1. 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
  2. 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.
A

Designated Record Set

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23
Q

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

A

Diagnosis- Related Groups (DRG)

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24
Q

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

A

DRG Creep

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25
Q

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

A

Disclosure

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26
Q

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

A

Employee Retirement Income Security Act (ERISA)

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27
Q

U.S. 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.

A

Equal Employment Opportunity Commission (EEOC)

28
Q

Originally adopted by the U.S. 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

A

False claims Act (FCA)

29
Q

Guidelines developed by the U.S. Sentencing Commission, 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 (1191)

A

Federal Sentencing Guidelines

30
Q

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

A

Fiscal Intermediary , or Fiduciary Intermediary

31
Q

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.

A

General Services Administration (GSA)

32
Q

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

A

Health and Human Services (HHS)

33
Q

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, service, assessment or procedure with respect to a physical or mental condition, or functional status of an individual or affecting the structure or function of the body; and (2) sale or dispensing of a drug, device, equipment, or other item pursuant to a prescription.

A

Health Care

34
Q

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

A

Health care clearinghouse

35
Q

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

A

Health Care Compliance Association (HCCA)

36
Q

Any information, oral or recorded, in any form of 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 clearing house; 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

A

Health Information

37
Q

Enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA). HITECH is designed to encourage health care providers to adopt health information technology that establishes electronic health records in a standardize 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.

A

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

38
Q

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 health care fraud investigations.

A

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

39
Q

An individual or group plan that provides, or pays the cost of, medicare care (as defined in section 2791(a)(2) of the PHS act, 42 U.S.C. 300gg91 (a)(2) of the Act

A

Health Plan

40
Q

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

A

Hotline; Helpline

41
Q

A two-part classification system in current use for coding patient medication and for classifying patients into diagnosis-related groups (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 Commission on Professional and Hospital Activities (CPHA) and by the federal government

A

ICD-9/10

42
Q

Information that is a subset of health information, including demographic information collected from an individual

A

Individually Identifiable Health Information (IIHI)

43
Q

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

A

Inspector General (IG)

44
Q

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 for hospitals and other health care facilities.

A

Joint Commission on Accreditation for Healthcare Organizations (JCAHO)

45
Q

A component of the DOL that develops and administers standards relating to the well-being of works 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.

A

Occupational Safety and Health administration (OSHA)

46
Q

Office of the Inspector General

A

OIG

47
Q

Guidelines issued by the OIG for the suggested development of compliance programs.

A

OIG Compliance Program Guidance

48
Q

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 the resident.

A

Physicians at teaching hospitals (PATH)

49
Q

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

A

Prospective Payment System

50
Q

Individually identifiable health information

A

PHI

51
Q

An abbreviated term for “he who brings the action for the king as well as for himself”
This type of suit is one filed by an employee of an organization, a whistle blower, with the federal government accusing an organization o fraud or abuse

A

Qui Tam

52
Q

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

A

Safe Harbors

53
Q

The Omnibus Budget Reconciliation Act of 1987 (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.

A

Self-referral Statute; Stark Law

54
Q

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

A

Self-reporting

55
Q

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

A

Snapshot

56
Q

Abbreviation for treatment, payment and healthcare operations, which are the primary areas where health care workers will have a need to use patients’ protected health information

A

TPO

57
Q

The Provisionn, 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 or a patient for health care from one health care provider to another.

A

Treatment

58
Q

The illegal practice of submitting claims individually in order to maximize reimbursement for various tests or procedures which are required to be billed together. The government initiative investigating this issue is Project Bad Bundle.

A

Unbundling

59
Q

Coding for a higher level than the documentation warrents

A

Upcoding

60
Q

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

A

Use

61
Q

Employees, volunteers, trainees, and other persons whose 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

A

Workforce

62
Q

Using a billing code that provides a higher payment rate than the billing code that actually reflects the service furnished to the patient.

A

Upcoding

63
Q

Using a Diagnosis Related Group (DRG) code that provides a higher payment rate than the DRG code that accurately reflects the service furnished to the patient

A

DRG Creep

64
Q

Duplicate billing occurs when the hospital submits more than one claim for the same service or the bill is submitted to more than one primary payor at the same time.

A

Duplicate billing

65
Q

Submitting bills piecemeal or in fragmented fashion to maximize the reimbursement for various tests or procedures that are required to be billed together and therefore at a reduced cost

A

Unbundling

66
Q

Hospitals with an emergency department: (1) Provide for an appropriate medical screening examination to determine whether or not an individual requesting such examination has an emergency medical condition; and (2) if the person has such a condition, (a) stabilize that condition; or (b) appropriately transfer the patient to another hospital. (EMTALA)

A

Patient Dumping

HCCA Compliance 101 (8 decks)

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