Health Insurance - Ch 5 (Legal & Regulatory Issues)
First-look Analysis for Hospital Outlier Monitoring (FATHOM)
A data analysis tool, which provides administrative hospital and state-specific data for specific CMS target areas to QIOs.
Interrogatory
A document containing a list of questions that must be answered in writing.
Federal register
A legal newspaper published every business day by the National Archives and Records Administration (NARA).
Check digit
A one-digit character, alphabetic or numeric, used to verify the validity of a unique identifier.
Listserv
A subscriber-based question-and-answer forum available through e-mail.
ANSI ASC X12N 837
A variable-length format that is used to bill institutional, professional, dental, and drug claims.
HIPAA Security Rule
Adopts standards and safeguards to protect health information that is collected, maintained, used, or transmitted electonically. Covered entities affected by this rule include halth plans, healthcare clearinghouses, and certain healthcare providers.
National Cancer Act - 1971
Amended the Public Health Service Act of 1798 to more effectively carry out the national effort against cancer. Part of President Nixon's "War on Cancer".
Qui tam
An abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, meaning "who as well for the king as for himself sues in this matter." A provision of the Federal False Claims Act, which allows a private citizen to file a lawsuit in the name of the U.S. government, charging fraud by government contractors and other entities that receive or us government funds, and to share in money recovered.
Statutes
(Statutory law) Laws passed by legislative bodies (e.g., federal Congress and state legislatures).
Case law
(common law) Based on court decisions that establish a precedent (or standard).
National Health PlanID (PlanID)
(formerly called PAYERID) is assigned to third-party payers;it has 10 numeric positions, including a check digit as the tenth position.
Code pairs
(or edit pairs) Codes that cannot be reported on the same claim for the same date of sevice, and they are based on coding conventions defined in CPT, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices.
National Individual Identifier
(patient identifier) has been put on hold. Several bills in Congress would eliminate the requirement to establish a National Individual Identifier.
Electronic transaction standards
(transactions rule) A uniform language for electronic data interchange.
Comprehensive Error Rate Testing (CERT) program
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Current Dental Terminology (CDT)
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Deficit Reduction Act of 2005
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Federal Register
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Hospital Payment Monitoring Program (HPMP)
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Improper Payments Information Act of 2002 (IPIA)
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Medicaid Integrity Program (MIP)
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Medicare administrative contractor (MAC)
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Patient Safety and Quality Improvement Act
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Payment Error Prevention Program (PEPP)
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Payment Error Rate Measurement (PERM) program
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Physicians at Teaching Hospitals (PATH)
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Privacy Act of 1974
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Program Safeguard Contracts (PSCs)
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Recovery Audit Contractor (RAC) program
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Stark I
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Tax Relief and Health Care Act of 2006 (TRHCA)
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authorization
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black box edit
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case law
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civil law
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common law
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criminal law
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decrypt
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deposition
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digital
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edit pairs
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encrypt
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interrogatory
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listserv
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medically unlikely edits (MUEs)
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message digest
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modifier
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overpayment
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physician self-referral law
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precedent
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program transmittal
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qui tam
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regulations
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statute
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statutory law
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subpeona
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subpeona duces tecum
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Conditions fo Participation (CoP) and Conditions of Coverage (CfC)
Federal regulations that healthcare facilities must comply with to participate in (receive reimbursement from) the Medicare and Medicaid programs; physicians must comply with billing and payment regulations published by CMS
Overpayments
Funds a provider or beneficiary receives in excess of amounts due and payable under Medicare and Medicaid.
Regulations
Guidelines written by administrative agencies (e.g., CMS)
Conditions of Participation (CoP)
Medicare - requires providers to keep copies of any government insurance claims and copies of all attachments filed by the provider for a period of five years, unless state law specifies a longer period.
Payment error rate
Number of dollars paid in error out of the total dollars paid for inpatient prospective payment system services.
Underpayments
Occur when submitted claims report codes simple procedures, when review of records indicate a more complicated procedure was performed.
Breach of Confidentiality
Often intentional. Involves the unauthorized release of patient information to a third party.
Federal Anti-Kickback Law - 1972
Protect patients and federal healthcare programs from fraud and abuse by curtailing the corrupting influence of money on healthcare decisions.
Migrant Health Act - 1962
Provided medical and support services to migrant and seasonal farm workers and their families.
Criminal law
Public law (statute or ordinance) that defines crimes and their prosecution.
False Claims Act (FCA) - 1863
Regulated fraud associated with military contractors selling supplies and equipment to the Union Army.
Federal Claims Collection Act - 1966
Required carriers (process Medicare Part B claims) and fiscal intermediaries (process Medicare Part A claims), (both of which were replaced by Medicare administrative contractors) (that administer the Medicare fee-for-program), to attempt the collection of overpayments under Medicare and Medicaid.
Drug Abuse and Treatment Act - 1972
Required that drug and alcohol abuse patient records be kept confidential and not subect to disclosure except as provided by law. Applied to federally assisted alcohol or drug abuse programs, which are those that provide diagnosis, treatment, and referral for treatment of drug and/or alcohol abuse.
Subpoena duces tecum
Requires documents (e.g., patient record) to be produced.
Social Security Amendments - 1972
Strengthened utilization review process by creating professional stndards review organizations (PSROs), which were independent peer review organizations that monitored the appropriateness, quality, and outcome of the services provided to beneficiaries of the Medicare, Medicaid, and Maternal and Child Health Programs.
National Standard Format
flat file format used to bill physician and noninstitution serves, such as services reported by a general practitioner on a CMS-1500
Protected Health Information (PHI)
information that is identifiable to an individual (individual identifiers) such as name, address, telephone numbers, social security number, and name of employer.
Upcoding
the assignment of an ICD-9-CM code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-9-CM heart attack when angina was actually documented in the health record)
Fraud
An intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.
Subpoena
An order of the court that requires a witness to appear at a particular time and place to testify.
Medicare administrative contractor (MAC)
An organization (e.g., insurance company) that contracts wtih CMS to process health care claims and perform program integrity tasks for both Medicare Part A and Part B.
Patient Safety Organization (PSO)
Analyze the problems, identify solutions, and provide feedback to aviod future healthcare errors. A database tracks national trends and reoccuring problems.
Privleged communication
Any information communicated by a patient to a healthcare provider.
National Standard Employer Identification Number (EIN)
Assigned to employers who, as sponsors of health insurance for their employees, must be identified in health care transactions. It is the federal employer identification number (EIN) assigned by the Internal Revenue Service (IRS) and has nine digits with a hypen.
National Provider Identifier (NPI)
Assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position.
National Plan and Provider Enumeraton System (NPPES)
Assigns unique identifiers to healthcare providers and health plans.
Food and Drug Act - 1906
Authorized federal government to monitor the purity of foods and the safety of medicine. (Now a responsibility of the FDA)
Program transmittals
Contain new and changed Medicare policies and/or procedures that are to be incorporated into a specific CMS program manual (e.g., Medicare Claims Processing Manual).
Program for Evaluating Payment Patterns Electronic Report (PEPPER)
Contains hospital-specific administrative claims data for a number of CMS-identified problem areas (e.g., specific DRGs, types of discharges). A hospital uses PEPPER data to compare their performance with that of other hospitals.
Social Security Ammendments - 1965
Created Medicare and Medicaid programs, making comprehensive health care available to millions of Americans. Established Conditions fo Participation (CoP) and Conditions of Coverage (CfC)
HIPAA Privacy Rule
Creates national standards to protect individuals' medical records and other personal health information.
Social Security Act - 1935
Included unemployment insurance, old-age assistance, aid to dependent children, and grants to states to provide various forms of medical care. (Ammended in 1965 to add disability coverage and medical benefits)
Abuse
Involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices.
Confidentiality
Involves restricting patient information access to those with proper authorization and maintaing the security of patient information.
Security
Involves the safekeeping of patient information by 1) controlling access to hard copy and computerized records, 2) protecting patient information from alteration, destruction, tampering, or loss, 3) providing employee training in confidentiality of patient information 4) requiring employees to sign a confidentiality statemnt that details the consequences of not maintaining patient confidentiality.
National Drug Code (NDC)
Maintained by the FDA. Identifies prescription drugs and some over-the-counter products. Each drug product is assigned a uniquie 11-digit, 3-segment number, which identifies the vendor, product, and trade package size.
Deposition
Testimony under oath taken outside of court (e.g., at the provider's office).
Electronic data interchange (EDI)
The process of sending data from one party to another using computer linkages.
Privacy
The right of individuals to keep their information form being disclosed to others.
Record retention
The storage of documentation for an established period of time, usually mandated by federal and/or state laws.
Clinical Data Abstracting Centers (CDASs)
These became responsible for initially requesting and screening medical records for PEPP surveillance sampling for medical review, DRG validtion, and medical necessity; medical review criteria were developed by peer review organizations.
Civil law
This deals with all areas of the law that are not classified as criminal.
