Term
| Medicare defines fraud as? |
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Definition
| Medicare defines fraud as the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes it knowing that the deception could result in some unauthorized benefit. |
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Term
| What 9 forms does fraud take? |
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Definition
the most common forms of medicare fraud are:
1. billing for services not furnished
2. misrepresenting a diagnosis to justify a payment
3. soliciting, offering or receiving a kickback
4. unbundling or exploding charges
5. falsifying certificates of medical necessity, plans of treatment and medical record to justify payment
6. billing for additional services not furnished as billed
7. routine waiver of co-payment |
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Term
| who oversees medicare’s payment safeguard program, including carrier and intermediary operations related to fraud, audit, medical review, the collection of over payments and the imposition of civil monetary penalties for certain violations of medicare law? |
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Definition
| OBI or the Office of Benefits Integrity |
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Term
| who is responsible for developing an annual work plan that outlines the ways in which the medicare program is monitored to identify fraud and abuse? |
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Definition
| OIG or Office of the Inspector General |
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Term
| how has the patient-physician relationship has shifted? |
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Definition
| It has become a physician- third party payer relationship. Which leaves the patient at the mercy of the third party payer. |
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Term
| what is the practice of assigning a reimbursement code specifically for the purpose of obtaining a higher level of payment? |
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Definition
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Term
| what is a mechanism designed to detect & prevent illegal or inappropriate behavior in the work place? |
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Definition
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Term
| what are 3 reasons for corporate compliance? |
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Definition
prevents & detects healthcare fraud & abuse
helps hospitals avoid investigation and conviction
gives hospitals the ability to police themselves |
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Term
| what is regulated by the OIG and is stipulated by the federal false claims act? |
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Definition
| POLICIES AND PROCEDURES FOR CORPORATE COMPLIANCE |
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Term
| what is a strategy of the government to reduce fraud that is a federal-state-local community partnership to combat provider fraud and abuse in medicare and medicaid programs? |
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Definition
| Operation Restore Trust Project |
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Term
| what are the elements of an HIM compliance program? |
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Definition
•HIM mission statement
•Code of conduct
•Oversight
•Policies and procedures
•Training and education
•Communication
•Auditing and monitoring
•Enforcement
•Problem solution and corrective action |
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Term
| what is a recognized system of preferred terminology for recording disease processes that establishes the correct terms to be used in describing conditions? |
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Definition
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Term
| what is the latest version of the international classification of disease? |
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Definition
| Tenth Ed. ICD-10 released 1992 |
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Term
| what was developed by the NCHS – national center for health statistics – and is a derivative work of the ICD-9 developed by the WHO? |
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Definition
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Term
| what covers specific diagnostic areas (medical, surgical, chiropractic, etc) and depending on the requirements of each section, the seven characters are assigned different meanings? |
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Definition
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Term
| what serves as to provide a uniform language that accurately describes medical, surgical and diagnostic services and thereby serves as an effective means for reliable nationwide communication? |
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Definition
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Term
| what is used to report physician’s services provided to medicare recipients, it is administered by the CMS and includes three levels of codes? |
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Definition
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Term
| what is used for coding diagnoses of neoplasms in tumor and cancer registries and in pathology labs? |
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Definition
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Term
| what is a multiaxial coding system with five axes for coding mental illness? |
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Definition
| Diagnostic and statistical manual of mental diseases |
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Term
| what is a multiaxial coding system with five axes for coding mental illness? |
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Definition
| Diagnostic and statistical manual of mental diseases |
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Term
| what is developed, maintained and distributed by the college of american pathologists? |
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Definition
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Term
| what will read codes for recording and retrieving computerized primary care patient data? |
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Definition
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Term
| what is generally accepted as the exchange standard for laboratory results, enabling standards to be developed and adopted relatively quickly to meet a desperate need? |
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Definition
| logical observation identifier names and Codes |
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Term
| What is used to describe the nursing process, document nursing care and facilitate aggregation of data for comparisons at the local, regional, national and international levels? |
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Definition
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Term
| what is a government funded project from the national library of medicine; it is to help health professionals and researchers retrieve and integrate electronic biomedical information from a variety of source and to make it easy for users to link disparate information systems? |
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Definition
| Unified medical language system |
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Term
| what was originally created to permit the interchange of biomedical image wave forms and related information? |
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Definition
| digital imaging and communication |
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Term
| what is the branch of medical science that deals with classification issues; it is different from coding in that it is about all classification issues, whether they are related to reimbursement or other purposes? |
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Definition
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