Term
7 core elements of compliance |
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Definition
- monitoring and auditing
- practice standards and procedures
- designation of compliance officer
- training and education
- response to detected offenses
- open lines of communication
- enforcement of the standards
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Term
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Definition
| an intentional deception made for personal gain. Fraud is a crime, and it is a civil law violation |
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Definition
| an act that directly or indirectly results in unnecessary reimburesement without defined intent |
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Term
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Definition
part of the Compliance Plan to structure and maintain a practice's reliability, honesty, and integrity as required of a provider in federal, state and private health plans
denineates polices of the practice in regards to fraud, abuse and adherence to all statutes, regulatins and otehr program requirements governing federal, state and private health plans.
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Term
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Definition
| services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioniong of a malformed body member |
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Term
| medical necessity as it pertains to E/M services |
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Definition
| medical necessity related to the presenting problem should be the overarching factor in determining the level of service billed |
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Term
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Definition
imposes civil monetary penalties of between $5,500 - $11,000 + 3x value of each claim
prohibits the knowing submission of a false or fraudulent claim for pament to the US, the knowing use of a false record or statement to obain payment on a false or fraudulent claim, ora conspiracy to defraud the US by having a false or fraudulent claim allowed or paid |
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Term
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Definition
prohibits knwongly and willfully making or causing to be made any false statement or representation of material fact in any claims or application for benefits under federally funded health plans as well as commercial carriers.
Violations are felonies and are punishable by up to 5 years imprisonment and/or $25k in fines |
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Term
| Medicare/Medicaid Civil Monetary Penalties Law |
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Definition
| provides for imposition of civil monetary penalties up to $10k perfalse service claimed, plus assessments equal to 3x the amount claimed, for services that the provider knows or should know were not provided as claimed or for claims the provider knows or should know are false or fraudulent |
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Term
| OIG regulates many issues including |
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Definition
- Corporate Integrity Agreements
- Compliance Guidelines
- Safe Harbor Regulations
- False Claims Act
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Term
| OIG Self-Disclosure Protocol |
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Definition
| intended to facilitate matters the provider feels potentialy violate federal criminal, civil, or administrative laws. |
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Term
| Voluntary Disclosure Submission |
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Definition
- Substansive Information
- Effective Disclosure - must be made in writing
- Internal Investigation Guidelines
- Discovery and Response
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Term
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Definition
Corporate Integrity Agreement
detailed and restricitive agreements imposed on providers by the OIG when serious misconduct is discovered through an audit or self- disclosure |
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Term
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Definition
generally anything that involves:
- a substantial overpayment
- a matter that a reasonable person would consider a potential violation ofcriminal, civil, or adminsrative laws applicable to any federal health care program for which penalties or exclusion may be athorized
- the filing of a bankruptcy petition
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Term
| JHACO surveys for standards and requirements for accreditation in specific areas of health care including |
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Definition
- Ambulatory Care
- Behavioral Health Care
- Critical Access Hospitals
- Disease-Specific Care
- Health Care Staffing Services
- Home Care
- Hospitals
- Laboritories
- Long Term Care
- Office-Based Surgery Practices
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Term
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Definition
Clinical Laboratory Improvement Amendments
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Term
| A service performed by Dr Smith but billed under Dr Jones could represent |
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Definition
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Term
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Definition
- Formerly JCAHO
- private sector US based not for profit organization
- operates voluntary accreditation programs for hospitals and other health care organizations
- primary focus is patient safety
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Term
| Joint Commision standards and requirements pertain to specific areas of health care including: |
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Definition
- Ambulatory care
- behavioral health care
- critical access hospitals
- disease-specific care
- health care staffing services
- home care
- hospitals
- laboratories
- long term care
- office-based surgery practices
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Term
| When auditing a note in a Joint Commission setting that includes abbreviations from the "do not use" list |
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Definition
| note them as deficiencies |
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Term
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Definition
randomly select thousands of claims every year to check for provider compliance and payment errors
not designed to detect fraud
able to identify billing patterns that could indicate fraudulent behavior |
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Term
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Definition
Zone Program Integrity Contractors
organizations hired indirectly by CMS to perform a wide range of medical review, data analysis, Medicare evidence-based policy auditing activities |
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Term
| A practice must reply with a rebuttal to a RAC audit within |
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Definition
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