Cbcs Study Guide 2.1 Chapter 1- Regulatory Compliance Vocabulary

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DOCUMENTATION:

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IS THE RECORD OF CLINICAL OBSERVATIONS AND CARE A PATIENT RECEIVES AT A HEALTH CARE FACILITY, IT MUST BE DETAILED, CURRENT AND ACCURATE

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INFORMED CONSENT:

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PROVIDERS EXPLAIN MEDICAL OR DIAGNOSTIC PROCEDURES, SURGICAL INTERVENTIONS, AND THE BENEFITS AND RISKS INVOLVED, GIVING PATIENTS AN OPPORTUNITY TO ASK QUESTIONS BEFORE MEDICAL INTERVENTION IS PROVIDED

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IMPLIED CONSENT:

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A PATIENT PRESENTS FOR TREATMENT, SUCH AS EXTENDING AN ARM TO ALLOW A VENIPUNCTURE (HAVE BLOOD DRAWN) TO BE PERFORMED

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PROTECTED HEALTH INFORMATION:

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INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION TRANSMITTED BY ELECTRONIC MEDIA, MAINTAINED IN ANY ELECTRONIC MEDIUM, OR MAINTAINED IN ANY OTHER FORM OR MEDIUM

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COVERED ENTITY:

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ARE ANY HEALTH CARE PLAN, CLEARING HOUSE, OR PROVIDER

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INDIVIDUALLY IDENTIFIABLE:

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DOCUMENTATION THAT EITHER IDENTIFIES THE PERSON OR PROVIDES ENOUGH INFORMATION THAT THE PERSON COULD BE IDENTIFIED.

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USE:

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THE WAY PERSONAL HEALTH INFORMATION IS HANDLED INTERNALLY BY A COVERED ENTITY OR ITS BUSINESS ASSOCIATE

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CLEARING HOUSE:

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AGENCY THAT CONVERTS CLAIMS INTO A STANDARDIZED ELECTRONIC FORMAT. LOOKS FOR ERRORS, AND FORMAT THEM ACCORDING TO HIPPA

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DISCLOSURE:

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THE WAY PATIENT HEALTH INFORMATION IS DISSEMINATED FROM A COVERED ENTITY OR IT’S BUSINESS ASSOCIATE (BA) TO AN OUTSIDE PERSON OR ORGANIZATION.

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NOTICE OF PRIVACY PRACTICES:

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THE LEGAL OBLIGATION OF PROVIDERS TO EXPLAIN HOW THEIR PERSONAL HEALTH INFORMATION WILL BE USED; MUST ALSO EXPLAIN THE PATIENT’S RIGHTS AND THE COVERED ENTITY’S LEGAL RESPONSIBILITIES WITH RESPECT TO PERSONAL HEALTH INFORMATION

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DE-IDENTIFIED INFORMATION:

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INFORMATION THAT DOES NOT IDENTIFY AN INDIVIDUAL BECAUSE UNIQUE AND PERSONAL CHARACTERISTICS HAVE BEEN REMOVED

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AUTHORIZATION:

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PERMISSION GRANTED BY THE PATIENT OR THE PATIENT’S REPRESENTATIVE TO RELEASE INFORMATION FOR REASONS OTHER THAN TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS

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CONSENT:

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A PATIENTS PERMISSION EVIDENCED BY SIGNATURE

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CLAIMS:

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A STATEMENT OF SERVICES AND MEDICAL CONDITIONS SUBMITTED BY HEALTH CARE PROVIDERS AND FACILITIES

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CLAIM:

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IS A RECORD OF THE MEDICAL AND SURGICAL SERVICES PROVIDED TO A PATIENT DURING AN EPISODE OF CARE

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REIMBURSEMENT:

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PAYMENT FOR SERVICES RENDERED FROM A THIRD PARTY

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AUDITING:

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THE REVIEW OF CLAIMS FOR ACCURACY AND COMPLETENESS

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UPCODING:

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WHEN A DIAGNOSIS OR PROCEDURE CODE IS ASSIGNED SPECIFICALLY TO RECEIVE A HIGHER LEVEL OF PAYMENT THAN THE DOCUMENTATION SUPPORTS

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UNBUNDLING:

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IS THE PRACTICE OF USING MULTIPLE CODES THAT DESCRIBE DIFFERENT COMPONENTS OF A TREATMENT INSTEAD OF USING THE CORRECT SINGLE CODE THE DESCRIBES ALL THE STEPS OF THE PROCEDURE

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FRAUD:

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MAKING FALSE STATEMENTS OF REPRESENTATION OF MATERIAL FACTS TO OBTAIN SOME BENEFIT OR PAYMENT FOR WHICH NO ENTITLEMENT WOULD OTHERWISE EXIST

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ABUSE:

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THE PRACTICE THAT EITHER DIRECTLY OR INDIRECTLY RESULT IN UNNECESSARY COSTS TO THE MEDICARE PROGRAM

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WHAT LAWS ARE IN PLACE TO MINIMIZE OCCURRENCES OF FRAUD AND ABUSE?

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HIPPA, THE STARK LAW, THE FAIR DEBIT COLLECTION PRACTICE ACT, AND THE FALSE CLAIMS ACT

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HEALTH INFORMATION PRIVACY AND PORTABILITY ACT:

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A LEGISLATION DESIGNED TO PROTECT THE PRIVACY AND SECURITY OF PATIENT INFORMATION

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FINAL RULE:

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EXTENSIVE CHANGES TO HIPPA IN REGARDS TO THE NATURE OF AGREEMENTS BETWEEN COVERED ENTITIES AND THEIR BUSINESS ASSOCIATES. UNDER THE FINAL RULE BUSINESS ASSOCIATES MUST ENSURE THE PERSONAL HEALTH INFORMATION REMAINS SECURE, AND THEY ARE EXPECTED TO REPORT ANY BREACHES IN SECURITY

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PHYSICIAN SELF-REFERRAL LAW ( STARK LAW):

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LAW THAT STATES THAT PHYSICIANS ARE NOT ALLOWED TO REFER PATIENTS TO A PRACTITIONER WITH WHOM THEY HAVE A FINANCIAL RELATIONSHIP, AND PROHIBITS THE REFERRED PHYSICIAN FROM PRESENTING CLAIMS TO MEDICARE

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FAIR DEBT COLLECTION PRACTICE ACT (FDCPA):

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THE LAW SAYS THAT DEBT COLLECTORS, INCLUDING COLLECTION AGENCIES, LAWYERS, OR COMPANIES WHO BUY UNPAID DEBTS, CANNOT USE UNFAIR OR ABUSIVE PRACTICES TO COLLECT PAYMENT

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BUSINESS ASSOCIATE:

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INDIVIDUALS, GROUPS, OR ORGANIZATIONS WHO ARE NOT MEMBERS OF A COVERED ENTITY’S WORKFORCE THAT PERFORM FUNCTIONS OR ACTIVITIES ON BEHALF OF OR FOR A COVERED ENTITY

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FALSE CLAIMS ACT:

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PROTECTS HE GOVERNMENT FROM BEING OVERCHARGED FOR SERVICES PROVIDED OR SOLD, OR SUBSTANDARD GOODS OR SERVICES