Act that created the Health Care Fraud and Abuse Control Program enacted to check for fraud and abuse in the Medicare and Medicaid programs, and private payers.
Health Insurance Portability and Accountabillity Act of 1996 (HIPAA)
2 Provisions of HIPAA:
1. Title I : Insurance Reform
2. Title II: Administrative Simplification.
Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim. It also protects and rewards persons involved in whistle-blower cases.
False Claims Act (FCA)
Developed by the CMS to promote national correct coding methodologies and to control improper coding that leads to inappripriate payment of Part B health insurance claims.
National Correct Coding Inititative (NCCI)
National Correct Coding Initiative (NCCI) includes 2 types of edits:
1. Column 1/column 2 (previously called Comprehensive/Component) Edits
2. Mutually Exclusive Edits
Edit that identifies code pairs that should not be billed together because one code (column 1) includes all the services described by another code (Column 2)
Column 1/Column 2 (Comprehensive/Component) Edits
Edit that identifies code pairs that, for clinical reason, are unlikely to be performed on the same patient on the same day.
Mutually Exclusive Edits
Who has the task to investigate and prosecute health care fraud and abuse.
Ofice of Inspector General (OIG)
Knowingly and intentionally deceiving or misrepresenting information that may result in unauthorized benefits.
Incidents or practices, not usually considered fraudulent, that are inconsistent with the accepted medical business or fiscal practices in the industry.
The process used to minimize danger, hazards, and liability.
Protected Health Information
Treatment, payment, operation
Literally means "let the master answer".
Means that an employee can be sued and brought to trial.
AKA Respondent Superior
Protection against loss of monies caused by failure through error or unintentional omission on the partof the individual or service submitting the insurance claim.
Errors and omissions insurance
Documentation on the patient's social and medical history, family history, physical examination findings, progress notes, radiology and lab results, consultation reports and correspondence to patient.
Part of the medical record and is a permanent legal document that formally states the consequences of the patient's examination or treatment in letter or report form. It is the record that provides the information needed to complete the insurance claim form
Date of Service
Place of Service
Type of Service
A pregnant woman who has had at least one previous pregnancy
A patient who has not received any medical services within the last three years.
A patient who has received medical services within the last 3 years from the physician or another physician of the smae specialty who belongs to the same group practice.
A brief statement describing the symptoms, problem, diagnosis, or condition that is the reason a patient seeks medical care
Supplementary classification codes used to identify health care encounters tha occur for reasons other than illness or injury or to identify patients whose illness is influenced by special circumstances or problems.
Supplementary Classification of Factors Influencing Health Status and COntact with Health Serivces
Supplementary classification codes used to describe the reason for external cause of injury, poisoning and other adverse effects.
Supplemental Classification of External Causes of Injury and Poisoning