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Cards In This Set
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False Claims Act (abbrev)
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FCA
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False Claims Act
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Passed by fed gov during the Civil War to regulate fraud associated with military contractors selling supplies and equipment to the Union Army
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Upcoding
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Assigning a ICD-9-CM diagnosis code that does not match patient record documentation to increase reimbursement
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Federal Claims Collection Act
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Requires Medicare administrative contractors, as agents of the fed gov, to attempt the collection of overpayments.
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Overpayments
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Funds a provider or beneficiary has received in excess of amounts due and payable under Medicare and Medicaid statutes and regulations
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Privacy Act of 1974
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Forbids the Medicare regional payer from disclosing the status of any unassigned claim beyond the following: date the claim was received by the payer; date the claim was paid, denied, or suspended; or general reason the claim was suspended
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Physician self-referral law
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Also known as Stark 1;
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Stark 1
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Responded to concerns about physicians' conflicts of interest when referring Medicare patients for a variety of services; prohibits physicians from referring Medicare patients to clinical lab services in which the physician has a financial investment interest
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Physicians at Teaching Hospitals - abbrev
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PATH
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Physicians at Teaching Hospitals
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HHS implemented audits in 1995 to examine the billing practices of physicians at teaching hospitals; focus on two issues: 1) compliance with Medicare rule affecting payment for physician services provided by residents, and 2) whether the level of the physician service was coded and billed properly
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Payment Error Prevention Program - abbrev
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PEPP
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PEPP
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Required facilities to ID and reduce improper Medicare payments and, specifically, the Medicare payment error rate. The hospital payment monitoring program (HPMP) replaced PEPP in 2002.
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Payment error rate
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The number of dollars paid in error out of the total dollars paid for inpatient prospective payment system services
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Clinical Data Abstracting Centers - abbrev
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CDACs
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CDACs
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Reponsible for initially equesting and screening medical records for PEPP surveillance sampling for medical review, DRG validation, and medical necessity
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