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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
| A |
|
| AAMC |
American Association of Medical Colleges |
ABN
|
Advance Beneficiary Notice—Written notification to a Medicare patient, before
a service is rendered, that payment may be denied or reduced, because the
service(s) may not be covered as medically reasonable and necessary according
to the Medicare program.
|
| Abuse |
Payment for items or services when there is no legal entitlement to that payment
and the provider has not knowingly and/or intentionally misrepresented facts to
obtain payment. Some inappropriate practices may initially be considered
abusive, but later involve into fraud. See also fraud. |
| Act |
Usually refers to the Social Security Act |
| ADA |
Americans with Disabilities Act |
| Adjudication |
Process of determining whether a claim is paid |
| Adjustment |
Additional payment or correction of records on a previously processed claim |
| Advisory Opinion |
OIG issued opinion to an individual or entity regarding the legality of specific
activities and transactions under the Anti-Kickback Statute. |
| ALJ |
Administrative Law Judge—Hears appeals of denied claims, as well as appeals
from proposed OIG exclusions |
| AMA |
American Medical Association |
| Anti-Kickback |
Statute under the Social Security Act that prohibits the offer, payment,
solicitation or receipt of any form of remuneration for services rendered. |
| Anti-Trust |
Related to price information, referrals and discriminatory pricing |
| APC |
Ambulatory Payment Classification—Result of Balanced Budget Act. Outpatient
prospective payment system that transfers financial risk from Medicare to the
provider of outpatient services. APC’s group similar clinical services together for
reimbursement purposes. |
| B |
|
| Balance Bill |
Difference between billed amount and amount approved by insurer. |
| BBA |
Balance Budget Act of 1997—Law that changes sections of the Social Security
Act, including several anti-fraud and abuse provisions and improvements to
protect the Medicare programs integrity. |
| Beneficiary |
Person eligible to receive Medicare or Medicaid payment and/or services. |
| C |
|
| Carrier |
An insurance company that contracts with CMS and determines reasonable
charges, accuracy and coverage for Medicare Part B services and processes Part B claims and payments. |
| CMS |
Centers for Medicare & Medicaid Services (formerly known as HCFA)—Federal
agency, part of DHHS that administers and oversees the Medicare program and a
portion of the state Medicaid program. Responsibilities include managing
contractor claims payment, fiscal audit and/or overpayment revention and
recovery and developing and monitoring payment safeguards necessary to detect
and respond to payment errors or abusive patterns of service delivery. |
| CFR |
Code of Federal Regulations |
| Civil Monetary Penalty |
Regulations which apply to any claim for services that was not provided as
claimed or that was knowingly submitted as false and which provides guidelines for levying fines for such offenses. |
| Claim |
Request for payment of benefits or services rendered by a provider or received by
an insured individual |
| CLIA |
Clinical laboratory Improvement Amendments—1988 legislation that set quality
and performance standards for all laboratory testing. CLIA standards are
national and are not Medicare exclusive. CLIA applies to all providers rendering
clinical laboratory and certain other diagnostic services, whether or not claims
are filed to Medicare. |
| COBRA |
Consolidated Omnibus Budget Reconciliation Act |
| Compliance |
Adherence to the requirements of applicable laws and regulations. |
| Co-insurance |
Amount that insurance will not pay. The patient or the patient’s secondary
insurance company is responsible for this amount. |
| Co-payment |
See coinsurance |
| Corporate Integrity Agreement |
A negotiated settlement between a health care provider and the government in
which the provider accepts no liability but must agree to implement a strict plan
of government-supervised corrective action. |
| Covered Service |
Reasonable and medically necessary services rendered to patients and Se
reimbursable to the provider |
| CPT |
Current Procedural Terminology—System of uniform medical procedure codes
to identify specific healthcare services performed. Developed by the AMA and
used by most insurers and providers for billing purposes. |
| D |
|
| Deductible |
Amount a patient must pay before insurance begins to pay for covered services
and supplies. |
| DHHS |
United States Department of Health and Human Services—Administers many of
the federal “social” programs dealing with the health and welfare of the citizens
of the USA. Parent of the Centers for Medicare and Medicaid Services (CMS). |
| DRG |
Diagnosis Related Group—System that groups patients according to principal
diagnosis, presence of a surgical procedure, age, presence or absence of
significant complications, etc. |
| DRG Creep |
Illegal practice of intentionally billing using a DRG which provides a higher
payment rate than the DRG that accurately reflects the diagnosis and treatment
actually provided. |
| DOD |
United States Department of Defense |
| DOJ |
United States Department of Justice |
| DRG Creep |
Unlawful practice of billing using a DRG code that provides a higher payment
rate than necessary. |
| E |
|
| EEOC |
Equal Employment Opportunity Commission – U.S. agency created in 1964 to
end discrimination based on race, religion, sex or national origin in employment.
The commission reviews and investigates charges of discrimination and, if found
to be true, attempts to remedy through conciliation or legal means. |
| E/M |
Evaluation and Management Services |
| ERISA |
Employee Retirement Income Security Act – A 1974 federal act that exempts
self-insured health plans from state laws governing health insurance and requires
health plan to provide certain information to enrollees. |
| Exclusion |
Situation or condition where coverage is disallowed by a subscriber’s contract.
DHHS/OIG penalty imposed on a provider prohibiting the provider from billing
Medicare or other government programs. |
| Exclusion List |
OIG list of providers, individuals and entities that are excluded from Medicare
reimbursement. Includes identifying information about the sanctioned party,
specialty, notice date, sanction period and sections of the Social Security Act
used in arriving at the determination to impose a sanction. The OIG sanctioned
provider list is available on the Internet at http://oig.hhs.gov/fraud/exclusions.html and click “search”. Debarment, exclusion and suspension lists for
all federal agencies are available on the Internet at http://epls.gov under
“EPLS Reports Menu”. |
| Executive Order 127 |
Mandates mandatory disclosure of anyone attempting to influence SUNY
persons in bid proposals by prospective contractors. |
| Experimental |
Any treatment, procedure, equipment, drug, drug usage, device or supply not
generally recognized as accepted medical practice. Includes services or supplies
requiring federal or other government approval not granted at the time services
were rendered. |
| F |
|
| FCA |
False Claims Act—Federal legislation that prohibits knowingly filing a false or
fraudulent claim to the government for payment, knowingly using a false record
or statement to obtain payment on a false or fraudulent claim paid by the
government and conspiring to defraud the government by getting a false or
fraudulent claim allowed or paid. |
| FI |
Fiscal Intermediary—CMS contractor that determines reasonable charges,
accuracy and coverage for Medicare Part A services and processes Part A claims
and payments. |
| Fraud |
Knowing and willful execution, or attempt at execution, of a scheme or artifice to
defraud any healthcare benefit program, or to obtain, by means of false or
fraudulent pretenses, representations, or promises, any money or property owned
by, or under the custody or control of any healthcare benefit program. See also
abuse. |
| Fraud Alert |
OIG issuances regarding practices that the OIG considers suspect or of particular
concern. |
| G |
|
| Global Fee |
Combined technical (equipment) and professional (physician) charges or
payment. |
| GSA |
General Services Administration – Federal agency that manages the federal
governments property and records, including the construction and operation of
buildings and procurement and distribution of supplies, among other functions. |
| H |
|
| HCFA |
Health Care Financing Administration—Former name of Centers for Medicare &
Medicaid Services. See CMS. A component of the U.S. Department of Health
and Human Services that administers the Medicare program and some aspects of
state Medicaid programs. |
| HCPCS |
Healthcare Common Procedure Coding System—Uniform method for providers
and suppliers to report professional services, procedures and supplies. HCPCS
includes CPT codes (Level I), national alphanumeric codes (Level II) and local
codes (Level III) assigned and maintained by local Medicare contractors. |
| HIPAA |
Health Insurance Portability and Accountability Act of 1996—One provision
imposes significant changes to fraud and abuse controls. Another provision
protects health insurance coverage for workers and their families when they
change or lose their jobs, including those with pre-existing conditions. |
| HMO |
Health Maintenance Organization—Organizations that combine the functions of
insurers and providers of care, giving most necessary medical care for a prepaid
fee and placing emphasis on prevention and careful assessment of medical
necessity. |
| Hotline |
A common reporting system giving anonymous telephone access to employees
seeking to report possible instances of wrong-doing. |
| I |
|
| ICD-9-CM |
International Classification of Diseases, 9th revision-Clinical Modification—A
national coding method to enable providers to effectively document the medical
condition, symptom or complaint that is the basis for rendering a specific service.
The coding system consists of 3-5 character numeric or alphanumeric codes for
reporting purposes. |
| Incident To |
Services rendered by employees of physicians or physician-directed clinics, when
the services provided are integral, though incidental, to the physician’s
professional service. |
| J |
|
| K |
|
| Kickback |
Situation in which a business agrees to pay a physician for every patient referred
for a specific study or other service. This is prohibited by federal law. |
| L |
|
| LMRP |
Local Medical Review Policy—Formal document developed through a
specifically defined process that provides criteria for claim and review of
payment decisions to ensure that suitability of the carrier’s medical policies,
medical care and review guidelines are consistent with standards of medical
practice. |
| M |
|
| Medicaid |
Joint federal and state program established by Title XIX of the Social Security
Act which helps with medical costs for some people of all ages who have low
incomes and limited resources. The program varies from state to state. |
| Medicare Integrity Program |
Created by Congress as part of the HIPAA Act of 1996 to provide a stable source
of funding for program integrity efforts to support the Medicare program via cost
report audits, medical review, anti-fraud activities and Medicare Secondary Payer
review. |
| Medicare Mill |
Provider group that aggressively seeks out Medicare patients |
| Medicare Part A |
Title XVIII of the Social Security Act which provides insurance for hospital,
skilled nursing facility, home healthcare and hospice costs to workers and
beneficiaries insured under Social Security, certain dependants and certain
disabled Social Security beneficiaries. |
| Medicare Part B |
Title XVIII of the Social Security Act which provides insurance for physician
services, outpatient hospital care and various other services such as ambulance
and laboratory services. DME and PT/OT to workers and beneficiaries insured
under Social Security, certain dependants and certain disabled Social Security
beneficiaries. |
| Medical Necessity |
Services determined to be consistent with symptoms or diagnosis and treatment
of the patient’s condition, disease, ailment or injury that is appropriate with the
standards of good medical practice. Services are not provided primarily for the
convenience of the insured, the hospital or the physician and the most appropriate
level of service that can be safely provided are utilized. |
| MSP |
Medicare Secondary Payer—Statutory requirement that under certain
circumstances private or other government insurance programs available to
beneficiaries be exhausted before Medicare must pay. |
| N |
|
| National Practitioner Data Bank |
A federal repository established pursuant to the Health Care Quality
Improvement Act of 1986 that contains information regarding physicians and
other health care providers relating to professional competence malpractice claim
settlements or judgments. |
| O |
|
| OBRA |
Omnibus Budget Reconciliation Act of 1995—Extension of Stark law regarding
self-referrals |
| OIG |
Office of the Inspector General—An organizational component of the Office of
the Secretary, DHHS. Responsible for conducting and supervising audits,
investigations and inspections relating to the programs and operations of DHHS,
including Medicare and Medicaid. OIG provides leadership and coordination,
recommends policies and corrective actions, prevents and detects fraud and abuse
in DHHS programs and operations and is responsible for all DHHS criminal
investigations including Medicare fraud whether committed by contractors,
grantees, beneficiaries or providers of service. |
| Operation Restore Trust |
Federal program that investigates, identifies and reduces/eliminates health care
fraud. Focused on fraud/abuse in Medicare billing practices, physician/hospital
relationships to labs and other providers. |
| ORT |
Operation Restore Trust—Federal/State partnership to fight Medicare/Medicaid
fraud, waste and abuse. |
| OSHA |
Occupational Safety and Health Administration – A component of the
Department of Labor that develops and administers standards relating to the wellbeing
of workers at the job-site, develops and issues regulations in this area,
conducts investigations and inspections to determine status of compliance with
safety and health standards and regulations and issues citations and proposes
penalties for non-compliance. |
| Outlier |
Anything that falls outside a considered norm |
| P |
|
| PIN |
Provider Identification Number—Unique individual provider number issued to a
provider by the local Medicare contractor allowing the physician or patient to
receive reimbursement for claims filed to the contractor. |
| PPS |
Prospective Payment System – The system for paying services for Medicare
patients (see DRG) whereby patients are classified into categories for which
prices are negotiated or determined in advance. /td>
|
| Progressive Corrective Action |
Used by CMS to identify and target problem providers based on data. Emphasis
is on education. Formerly known as focused medical review. |
| PRO |
Peer Review Organization—Organization contracting with CMS to review
medical necessity and quality of care provided to Medicare beneficiaries. |
| Provider |
generic term for any person i.e. physician or entity i.e. home health agency,
skilled nursing facility, hospital etc. approved to provide/give care to Medicare
beneficiaries and to receive payment from Medicare. |
| Q |
|
| Qui Tam |
The “Whistle Blower” provision that allows any person having knowledge of a
false claim against the government to bring action against the suspected
wrongdoer on behalf of the United States Government. |
| R |
|
| RICO |
Racketeer Influenced and Corrupt Organizations Act |
| S |
|
| Safe Harbor |
Provisions that protect certain individuals, providers or entities from criminal
prosecution and/or civil sanctions when certain requirements are met for actions
which may appear as unlawful or inappropriate according to Medicare law. |
| Sanction |
See “Exclusion” |
| Sarbanes-Oxley Act |
Acts to prevent, detect and address misconduct within an organization with
emphasis on auditing, accounting and financials. |
| SSA |
Social Security Administration—Federal Agency that administers various
programs funded under the Social Security Act and determines eligibility for
Medicare benefits. |
| Stark Law |
implemented in 1995 that prohibits a physician or his immediate family
from having a financial relationship with an entity to which Medicare patients are
referred to receive a designated health service. |
| T |
|
| Title XVIII |
Part of the Social Security Act that has statutory authority for the Medicare
program |
| Title XIX |
Part of the Social Security Act that has statutory authority for the Medicaid
program |
| U |
|
| Unbundling |
Unlawful practice of submitting bills piecemeal in order to maximize the
reimbursement for tests/procedures that should be billed together at a lower rate.
|
| Upcoding Unlawful |
practice of using a billing code that provides a higher payment rate
than the billing code that should be used for the service furnished to the patient.
Major focus of OIG enforcement. |
| V |
|
| W |
|
| X |
|
| Y |
|
| Z |
|
| |
Reference Material:
Compliance 101, Debbie Troklus & Greg Warner, HCCA, 2001.
Medicare Resident and New Physician Training Manual, 6th edition, CMS, 2002.
Medicare Fraud and Abuse, 2nd edition, First Coast Service Options, 1999.Last Update: 02/05/05 |
