Balanced Budget Act of 1997

(BBA)

Benefits improvement and protectionact of 2000

(BIPA)

payment for items or services that are billed by mistake by providers, but should not be paid for by medicare. A range of the following improper behaviors or billing practices including, but not limited to: billing fora  no-covered service; misusing codes on the claim, for example, the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered; or inappropriately allocating costs on a cost report

Coe sets that characterize a general business situation rather than a medical condition or service. Under HIPAA, these are sometimes referred to as non clinical or non medical code sets. Under HIPAA, a "code set" is any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes, or medical procedure codes. 

is any set of codes used for encoding data elements such as tables of terms, medical concepts, medical diagnos codes or medical procedure coes.

used in the health care industry include coding systems for diseases, impairments, other health related problems and their manifestations; causes of injury; disease, impairment, or other health- related problems; actions taken to prevent, diagnose, treat, or manage diseases, injuries and impairments; and any substances, equpiment, supplies or other items used to perform these actions. Code sets for medical data are required for data elements in the administrative and financial healthcare transaction standards adopted under HIPAA for dx procedures and drugs

Title II, subtitle F, of HIPAA authorizes HHS to adopt:(1) standards for transactions and code sets that are used to exchange health data; (2) standard identifiers for health plans, health care providers, employers, and individuals for use on standard transactions; and (3) standards to protect the security and privacy of personally identifiable health information.

considers it a criminal offense to knowingly and willfully offer, pay or solicit, or receive any rememuneration to induce or reward referrals of items or services reimbursable by a federal healthcare program

a person or organization that performs a function or activity on behalf of a covered entity, but is not part of the coverd entity's work force. a business associate can also be a covered entity in its own right

An act passed by congress establishing quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results, regardless of where the test was performed

This act requires any medicare participating hospital that operates a hospital ED to provide an appropriate medical screening examination to any patient that requests such and exam. If the hospital determines that the patient has an emergency medical condition it must either stabilize the patient's condition or arrange for a transfer; however, the hospital may only trnaser the patient if the medical benefits of the transfer outweight the risks or if the patient requests the transfer

This act covers diverse schemes to obtain government funds in violation of contract as well as schemes to avoid paying for benefits and services received from the government

Is the Offical daily publication for rules, proposed rules, and notices of federal agencies and organizations, as well as executive orders and other presidential documents

The intentional deception or misrepresentation that an individual knows, or should know, to be false or does not believe to be true, an makes knowing the deception could result in some unauthorizedbenefit to himself or some other person(s). To purposely bill for services that were never given or to bill for a service that has a higer reimbursement than the service provided.

  a law that requires the U.S. Government to give out certain information to the public when it receives a written request; FOIA applies only to records of the executive branch of the federal government, not to those of the congress or federal courts, and does not apply to state governments, local governments, or private groups

a physician who involves residents in the care of his or her patients. The teaching physician must be present and document their participation in any patient service that is billed

A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry or podiatry

Legislation regarding financial kickbacks between hospitals and providers for referrals. Kickbacks between vendors and providers are also addressed. A kickback is a financial inducement or reward for sending business between either a provider and a hospital or a provider and a DME supplier, or a provider-to-provider situation. Providers and facilities that have joint ventures are advised to check ventures in regard to making sure there are no stark violations

individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate, identifies the individual or offers a reasonable basis for identification, is created or received by a covered entity or an employer, relates to a past, present or future physical or m ental condition and provision or payment of health care

physicians engaged in teaching activities are paid for their services through education funds, received by the medical school from CMS, endowments, and tuition monies. The residents and interns under supervision receive salaries from the hospital. When a physician, whose not following the teaching physician rules, bills for services performed by a resident or intern, the Medicare fund is doubly charged (double dipping) for that service. This practice is considered a form of frad. The OIG has been auditing teaching hospitals nationally for this fraudulent practice 

the OCR enforces HIPAA privacy rule, which protects the privacy of individually identifiable health information. The OCR released a document on HIPAA Administrative simplificaiton, which discusses the provider's responsibilites surrounding PHI for treatment, payment and health care operations (TPO). The OCR has been mandated to auditall HIPAA CE's and BAs on the protocols, which are subject to change over time based on audit results. The OCE publised the protocols in sept. 2012

a program launched by president clinton, designed to demonstrate new partnerships and approaches in finding and stopping fraud and waste in the medicare and medicaid program (federally funded)

the OIG is mandated by public law to engage in activites to test the efficiency and economy of government programs to include investigation of suspected healthcare fraud or abuse. The OIG publishes a work plan every year outlining its priorities for the fiscal year ahead. 

Kenedy Kassebaum Law or 

Kassebaum Kenedy law