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CHAPTER 5
LEGAL & REGULATORY ISSUES
| Question | Answer |
|---|---|
| abuse | actions inconsistent with accepted, sound medial, business, or fiscal practices |
| ANSI ASC X12N 837 | variable-length file format used to bill institutional, professional, dental and drug claims |
| authorization | document that provides official instruction, such as the customized document that gives covered entities permission to use specified protected health information (PHI) for specified purposed or to disclose PHI to a third party specified by the individual |
| black box edits | nonpublished code edits, which were discontinued in 2000 |
| breach of confidentiality | unauthorized release of patient information to a third party |
| case law; common law | based on a court decision that establishes a precedent |
| check digit | one-digit character, alphabetic or numeric, used to verify the validy of a unique identifier |
| civil law | area of law not classified as criminal |
| Clinical Data Abstracting Center (CDAC) | requests and screens medical records for the Payment Error Prevention Program (PEPP) to survey samples for medical review, DRG validation, and medical necessity |
| code pairs; edit pairs | edit pairs included in the Correct Coding Initiative (CCI) cannot be reported on the same claim if each has the same date of service |
| confidentiality | restricting patient information access to those with proper authorization and maintaining the security of patient information |
| criminal law | public law governed by statue or ordinance that deals with crimes and their prosecution |
| Current Dental Terminology (CDT) | medical code set maintained and copyrighted by the American Dental Association |
| decrypt | to decode an encoded computer file so that it can be viewed |
| deposition | legal proceeding during which a party answers questions under oath (but not in open court) |
| digital | application of a mathematical function to an electronic document to create a computer code that can be encrypted (encoded) |
| False Claims Act (FCA) | passed by the federal government during the Civil War to regulate fraud associated with military contractors selling supplies and equipment to the Union Army |
| Federal Claims Collection Act | requires Medicare administrative contractors (previously called carries and fiscal intermediaries), as agents of the federal government, to attempt the collection of overpayments |
| Federal Register | legal newspaper published every business day by the National Archives and Records Administration (NARA) |
| First-look Analysis for Hospital Outlier Monitoring (FATHOM) | data analysis tool, which provides administrative hospital and state-specific data for specific CMS target areas |
| fraud | intentional deception or misrepresentation that could result in an unauthorized payment |
| Hospital Payment Monitoring Program (HPMP) | measures, monitors, and reduces incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals |
| Improper Payments Information Act of 2002 (IPIA) | establised the Payment Error Rate Measurement (PERM) program to measure improper paymetns in the Medicaid program and State Children's Health Insurance Program (SCHIP) |
| interrogatory | document containing a list of questions that must be answered in writing |
| listserv | subscriber-based question-and-answer forum that is available through e-mail |
| Medicaid Integrity Program (MIP) | 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 this |
| Medical Integrity Program (MIP) | fraud and abuse detection program created by the Deficit Reduction Act of 2005 |
| Comprehensive Error Rate Testing (CERT) Program | |
| Deficit Reduction Act of 2005 | |
| Medically unlikely edits (MUEs) | |
| Medicare administrative contractor (MAC) | an organization that contracts with CMS to process claims and perform program integrity tasks for Medicare Part A and Part B and DMEPOS:Medicare is transitioning fiscal intermediariers and carriers to create this |
| message digest | representation of text as a single string of digits, which was created using a formula, and for the purpose of electronic signatures the message digest is encrypted (encoded) and appended (attached) to an electronic document |
| modifier | two-digit code attached to the main code; indicates that a procedure/service has been altered in some manner(e.g., bilateral procedure) |
| National Drug Code (NDC) | maintained by the Food and Drug Administration (FDA); identifies prescription drugs and some over-the-counter products |
| National Health Plan ID (PlanID) | unique identifier, previously called PAYERID, that will be assigned to third-party payers and is expected to have 10 numeric positions, including a check digit in the tenth position |
| National Individual Identifier | unique identifier to be assigned to patients |
| National Plan and Provider Enumeration System (NPPES) | developed by CMS to assign unique identifiers to healthcare providers (NPI) and health plans (PlanID) |
| National Provider Identifier (NPI) | unique identifier to be assigned to healthcare providers as an 8- or possible 10-character alphanumeric identifier, including a check digit in the last position |
| National Standard Employer Identification Number (EIN) | unique identifer assigned to employers who, as sponsors of health insurance for their employees, need to be identified in healthcare transactions |
| National Standard Format (NSF) | flat-file format used to bill physician and noninstitutional services, such as services reported by a general practitioner on a CMS-1500 claim |
| overpayment | funds a provider or beneficiary has received in excess of amounts due and payable under Medicare & Medicaid statutes and regulations |
| Patient Safety and Quality Improvement Act | 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 |
| Payment Error Prevention Program (PEPP) | 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 2002 |
| payment error rate | number of dollars paid in error out of total dollars paid for inpatient prospective payment system services |
| physician self-referral law; Stark I | responded to concerns about physicians' conflicts of interest when referring Medicare patients for a variety of services |
| Physicians at Teaching Hospitals (PATH) | HHS implemented audits in 1995 to examine the billing practices of physicians at teaching hospitals; the focus was on two issues |
| precedent | standard |
| privacy | right of individuals to keep their information from being disclosed to others |
| Privacy Act of 1974 | forbids the Medicare regional payer from disclosing the stauts of any unassigned claim beyond the following: date the claim was rec'd by the payer; date the claim was paid, denied, or suspended; general reason the claim was suspended |
| privacy rule | HIPAA provision that creates national standards to protect individuals' medical records and other personal health information |
| privileged communication | private information shared between a patient and healthcare provider; disclosures must be in accordance with HIPAA |
| Program for Evaluating Payment Patterns Electronic Report (PEPPER) | contains hospital-specific administrative claims data for a number of CMS-identified problem areas; hospitals use this to compare its performance with that of other hospitals |
| program transmittal | document published by Medicare containing new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual |
| protected health information (PHI) | 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, social security number (SSN), and name of employer |
| qui tam | abbreviation for Latin phrase, meaning "who as well for the king as for himself sues I this matter". Provision of the False Claims Act that allows a private citizen to file a lawsuit in the name of the U.S. government |
| record retention | 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 |
| Recovery Audit Contractor (RAC) program | mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) to find and correct improper Medicare payments paid to healthcare providers participating in fee-for-service Medicare |
| regulation | guidelines written by administrative agencies (e.g., CMS) |
| security | involves the safekeeping of patient information by controlling access to hard copy and computerized records |
| security rule | HIPAA standards and safeguards that protect health information collected, maintained, used, or transmitted electronically; covered entities affected by this rule include health plans, healthcare clearinghouses, and certain healthcare providers |
| statutes; statutory law | laws passed by legislative bodies (e.g., federal Congress and state legislatures) |
| subpoena | an order of the court that requires a witness to appear at a particular time and place to testify |
| subpoena duces tecum | requires documents (e.g., patient record) to be produced |
| Tax Relief and Health Care Act of 2006 (TRHCA) | created physician quality reporting initiative (PQRI) system that establishes a financial incentive for eligible professionals who participate in a voluntary quality reporting program |
| UB-04 | insurance claim or flat file used to bill institutional services, such as services performed in hospitals |
| unique bit string | 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) |
| upcoding | assignment of an ICD-9-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-9-CM code for heart attack when angina was actually documented in the record) |
Created by:
Tina Everett