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| Centers for Medicare & Medicaid Services - The federal agency that runs the Medicare and Medicaid programs |
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| Current Procedural Technology - 5 numeric digits used to identify procedures and services performed by health care professionals |
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| Durable Medical Equipment - According to CMS "Medical equipment that is ordered by a doctor for use in the home" |
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Healthcare Common Procedure Coding System
a set of health care procedure codes based on the AMAs CPT |
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| Department of Health and Human Services |
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| health Insurance Portability and Accountability Act of 1996 |
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| History of Present Illness - this info is obtained from the patient, usually in their own words or symptoms, reason for visits, condition, and usually stated in the patient's own words |
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Intermediate Care Facilities -
a facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care available in a hospital or SNF |
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| Independent Diagnostic Testing Facility |
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| Medical Screening Examination |
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| Past, Family, Social History |
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a system implemented by CMS to identify improper payments, fraud and abuse in the Medicare Program
RAC = Recovery Audit Contractors |
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| Clinical Laboratory Improvement Amendments |
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| Quality Improvement Organizations |
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Health Care Fraud Prevention and Enforcement Action Team
HEAT Initiative marshals significant resources across the government to prevent health care fraud, waste and abuse; crack down on those who commit fraud; and enhance existing partnerships between HHS and DOJ |
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| Zone Program Integrity Contractor |
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Medicaid Integrity Contractor
similar to RACs but conduct audits of Medicaid claims
not paid on contingency fee
MICs can review Medicaid claims as far back as permitted under the laws of the states that have paid the claims
not limited to a number of claims |
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| Distinguish between RACs and MICs |
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Definition
RACs
- can go back and recover money for three years
- must use certified coders and have a medical director
- have to pay back continency payments if provider wins on any level appeal
- review hospitals, physician practices, nursing homes, home health, DME suppliers and any other provider or supplier that bills Medicare
MICs
- can go back as far as permitted by the state involved
- not paid on a contingency basis, and are eligivle for financial bonuses based on the effectiveness of their audits
- not limited to a set number of claims
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| How many records does the CMS permit the RAC program to request per level of provider group size? |
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Definition
<5 providers 10 per group
6-24 providers 25 per group
25-49 providers 40 per group
50+ providers 50 per group |
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| Stark Law pertains to a specific list of designated health services that are determined by CPT code |
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- Imaging, including MRI, CT, PET and nuclear medicine
- Physical and occupational therapy
- Radiation therapy
- Home health
- Outpatient prescription drugs
- Parental and enteral nutrition
- Durable medical equipment (DME)
- Prosthetics, orthotics and supplies
- Clinical Laboratory
- All inpaitent and outpatient hospital professional and surgical services
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Physicians at Teaching Hospitals
ensure that teaching physicians are billing appropriately and reimbursements are allocated appropriately
Part of Stark law
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| to prevent over-utilization of medical services for financial gain, as well as undervaluing or overhauling medical services for financial gain |
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