Chapter 5: Legal And Regulatory Issues

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ABUSE

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actions inconsisten with accepted, sound medical, business or fiscal practices

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ANSI ASC X12N 837

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variable-length file format used to bill institutional, professional, dental, and drug claims

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AUTHORIZATION

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a document that provides official instruction, such as the customized document that gives covered entities permission to use specified protected health information (PHI) for specified purposes or to disclose PHI to a third party specified by the individual

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BLACK BOX EDIT

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nonpublished code edits, which were discontinued in 2000

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BREACH OF CONFIDENTIALITY

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unauthorized release of patient information to a third party

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CASE LAW

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also called common law; based on a court ecision that establishes a precedent

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CHECK DIGIT

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one-digit character, alphabetic or numeric, used to verify the validity of a unique identifier

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CIVIL LAW

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area of law not classified as criminal

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CLINICAL DATA ABSTRACTING CENTER (CDAC)

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requests and screens medical records for the Payment Error Prevention Program (PEPP) to survey samples for medical review, DRG validation, and medical necessity

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CODE PAIRS

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edit pairs included in the Correct Coding Initiative (CCI) cannot be reported on the same claim if each has the same date of service

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COMMON LAW

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also called case law; is based on a court decision that establishes a precedent

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CONFIDENTIALITY

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restricting patient information access to those with proper authorization and maintaining the security of patient information

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CRIMINAL LAW

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public law governed by statute or or ordinance that deals with crimes and their prosecution

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CURRENT DENTAL TERMINOLOGY (CDT)

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medical code set maintained and copyrighted by the American Dental Association

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DECRYPT

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to decode an encoded computer file so that it can be viewed

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DEPOSTION

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legal proceeding during which a party answers questions under oath (but not in open court)

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DIGITAL

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application of a mathematical function to an electronic document to create a computer code that can be encrypted (encoded

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ELECTRONIC TRANSACTION STANDARDS

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also called transaction rule; a uniform language for electronic data interchange

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ENCRYPT

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to convert information to a secure language format for transmission

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FALSE CLAIMS ACT (FCA)

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passed by the federal government during the Civil War to regulate fraud associated with military contractors selling supplies and equipment to the Union Army

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FEDERAL CLAIMS COLLECTION ACT

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requires carriers and fiscal intermediaries (as agents of the federal govenment) to attempt the collection of overpayments

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FEDERAL REGISTER

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legal newspaper published every business day by the National Archives and Records Administration (NARA)

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FIRST-LOOK ANALYSIS for HOSPITAL OUTLIER MONITORING (FATHOM)

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data analysis tool, which provides administrative hospital and state-specific data for specific CMS target areas to QICs

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FLAT FILE

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series of fixed-length records (e.g, 25 spaces for patient's name) submitted to third-party payers to bill for health care services.

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FRAUD

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intentional deception or misrepresentation that could result in an unauthorized payment

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HOSPITAL PAYMENT MONITORING PROGRAM (HPMP)

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measures, monitors, and reduces incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals; replaced PEPP

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INTERROGATORY

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document containing a list of questions that must be anwered in writing

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LISTSERV

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subscriber-based question-and-answer forum that is available through e-mail

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MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

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an organization (e.g., insurance company) that contracts with CMS to process claims and perform program integrity tasks for Medicare Part A and Part B and DMEPOS; each contractor makes program coverage decisions and publishes a newsletter, which is sent to proveders who receive Medicare reimbursement

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MESSAGE DIGEST

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representation of text as a single string of digits, which was created using a formula, and for the purpose of electronic signatures the message digest is encrypted (encoded) and appended (attached) to an electronic document

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MODIFIER

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two-digit code attached to the main code; indicates that a procedure/service has been altered in some manner (e.g., bilateral procedure)

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NATIONAL DRUG CODE (NDC)

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maintained by the Food and Drug Administration (FDA); identifies prescription drugs and some over-the-counter products.

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NATIONAL HEALTH PLANID (PLANID)

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unique identifier, previously called PAYERID, that will be assigned to thirdparty payers and is expected to have 10 numeric positions, including a check digit in the tenth position.

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NATIONAL INDIVIDUAL IDENTIFIER

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unique identifier to be assigned to patients.

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NATIONAL PLAN AND PROVIDER ENUMERATION SYSTEM (NPPES)

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developed by CMS to assign unique identifiers to health care providers (NPI) and health plans (PLANID)

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NATIONAL PROVIDER IDENTIFIER (NPI)

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unique identifier to be assigned to employers who, as sponsors of health insurance for their employees, need to be identified in health care transactions.

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NATIONAL STANDARD EMPLOYER IDENTIFICATION NUMBER (EIN)

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unique identifier assigned to employers who, as sponsors of health insurance for their employees, need to be identified in health care transactions.

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NATIONAL STANDARD FORMAT (NSF)

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flat-file format used to bill physician and noninstitutional services, such as services reported by a general practitioner on a CMS-1500 claim.

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OVERPAYMENT

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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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PATIENT SAFETY AND QUALITY IMPROVEMENT ACT

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amends Title IX of the Public Health Service Act to provie for improved patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients; creates patient safety organizations (PSOs) to collect, aggregate, and analyze confidential information reported by health care providers; and designates information reported to PSOs as privileged and not subject to disclosure (except when a court determines that the information contains evidence of a criminal act or each provider identified in the information authorizes disclosure.

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PAYMENT ERROR PREVENTION PROGRAM

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requires facilities to identify and reduce improper Medicare payments and, specifically, the Medicare payment error rate.

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PAYMENT ERROR RATE

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number of dollars paid in error out of total dollars paid for inpatient prospective payment system services.

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PHYSICIAN SELF-REFERRAL LAW

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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 laboratory services in which the physician or a member of the physician's family has a financial ownership/investment interest and/or compensation arrangement

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PHYSICIANS AT TEACHING HOSPITALS (PATH)

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HHS implemented audits in 1995 to examine the billing practices of physicians at teaching hospitals; focus was on two issues: (1) compliance with the Medicare rule affecting payment for physician services provided by residents (e.g., whether a teaching physician was present for Part B services billed to Medicare between 1990 and 1996), and (2) whether the level of the physician service was coded and billed properly.

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PRECEDENT

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standard

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PRIVACY

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right of individuals to keep their information from being disclosed to others.

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PRIVACY ACT OF 1974

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forbids the Medicare regional carrier from disclosing the status of any unassigned claim beyond the following: date the claim wa paid, denied, or suspended; general reason the claim was suspended

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PRIVACY RULE

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HIPAA provision that creates national standards to protect individuals' medical records and other personal health info

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PRIVILEDGED COMMUNICATION

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private information shared between a patient and health care provider; disclosure must be in accordance with HIPAA and/or individual state provisions regarding the privacy and security of protected health information (PHI)

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PROGRAM FOR EVALUATING PAYMENT PATTERNS ELECTRONIC REPORT (PEPPER)

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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 its performance with that of other hospitals

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PROGRAM TRANSMITTAL

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document published by Medicare that contains new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual (e.g., Medicare Claims Processing Manual); cover page (or transmittal page) summarizes new and changed material, and subsequent pages provide details; transmittals are sent to each Medicare administrative contractor.

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PROTECTED HEALTH INFORMATION (PHI)

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information that is identifiable to an individual (or individual identifiers) such as name, address, telephone numbers, date of birth, Medicaid ID number, medical record number, social security number (SSN), and name of employer

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QUI TAM

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abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, which means "who as well for the king as for himself sues I this matter." It is a provision of the False Claims Act that allows a private citizen to file a lawsuit in the name of the U.S. government, charging fraud by government contractors and other entities.

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RECORD RETENTION

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storage of documentation for an established period of time, usually mandated by federal and/or state law; its purpose is to ensure the availability of records for use by government agencies and other third parties

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REGULATIONS

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guidelines written by administrative agencies (e.g., CMS)

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SECURITY

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involves the safekeeping of patient information by controlling access to hard copy and computerized records; protecting patient information from alteration, destruction, tampering, or loss; providing employee training in confidentiality of patient information; and requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality.

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SECURITY RULE

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HIPAA standards and safeguards tha protect health information collected, maintained, used, or transmitted electronically; covered entities affected by this rule include health plans, health care clearinghouses, and certain health care providers.

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STATUTE

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also called statutory law; laws passed by legislative bodies (e.g., federal Congress and state legislatures)

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SUBPOENA

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an order of the court that requires a witness to appear at a particular time and place to testify.

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SUBPOENA DUCES TECUM

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requires documents (e.g., patient record) to be produced

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UB-04

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insurance claim or flat file used to bill institutional services, such as services performed in hospitals.

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UNIQUE BIT STRING

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computer code that creates an electronic signature message digest that is encrypted (encoded) and appended (attached) to an electronic document (e.g., CMS-1500 claim)

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UPCODING

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assignment of an ICD-9-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-9-CM code for heart attack when angina was actually documented in the record.