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Medical Insurance Chapter 2

Terms in this set (49)

abuse
Actions that improperly use another person's resources.
American Recovery and Reinvestment Act (ARRA) of 2009
Federal law containing additional provisions concerning the standards for the electronic transmission of health care data; also known as the Stimulus Package.
audit
Methodical review; in medical insurance, a formal examination of a physician's accounting or patient medical records.
breach notification
The document notifying an individual of a breach.
breach
An impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI and also that could pose significant risk of financial, reputational, or other harm to the affected person.
bundling
A single procedure code that covers a group of related procedures.
Centers for Medicare and Medicaid Services (CMS)
Federal agency within the Department of Health and Human Services (HHS) that runs Medicare, Medicaid, clinical laboratories (under the CLIA program), and other government health programs.
compliance plan
A medical practice's written plan for the following: the appointment of a compliance officer and committee; a code of conduct for physicians' business arrangements and employees' compliance; training plans; properly prepared and updated coding tools such as job reference aids, encounter forms, and documentation templates; rules for prompt identification and refunding of overpayments; and ongoing monitoring and auditing of claim preparation.
de-identified health information
Medical data from which individual identifiers have been removed; also known as a redacted or blinded record.
designated record set (DRS)
A covered entity's records that contain protected health information (PHI); for providers, the designated record set is the medical/financial patient record.
electronic data interchange (EDI)
The system-to-system exchange of data in a standardized format.
electronic health record (EHR)
A running collection of health information that provides immediate electronic access by authorized users.
electronic medical record (EMR)
A computerized record of one physician's encounters with a patient over time.
encounter
An office visit between a patient and a medical professional.
encryption
A method of scrambling transmitted data so it cannot be deciphered without the use of a confidential process or key.
evaluation and management (E/M) codes
Procedure codes that cover physicians' services performed to determine the optimum course for patient care; listed in the Evaluation and Management section of CPT.
fraud
Intentional deceptive act to obtain a benefit.
Health Care Fraud and Abuse Control Program
Government program to uncover misuse of funds in federal health care programs; run by the Office of the Inspector General.
Health Information Technology for Economic and Clinical Health (HITECH) Act
Law that guides the use of federal stimulus money to promote the adoption and meaningful use of health information technology, mainly using electronic health records.
Health Insurance Portability and Accountability Act (HIPAA) of 1996
Federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.
HIPAA Electronic Health Care Transactions and Code Sets (TCS)
The HIPAA rule governing the electronic exchange of health information.
HIPAA final enforcement rule
Single HIPAA rule that covers all administrative simplification provisions and reconciles differences in enforcement procedures that had existed between the privacy and the security standards.
HIPAA National Identifier
HIPPA-mandated identification systems for employers, health care providers, health plans, and patients; the NPI, National Provider System, and employer system are in place; health plan and patient systems are yet to be created.
informed consent
The process by which a patient authorizes medical treatment after discussion about the nature, indications, benefits, and risks of a treatment a physician recommends.
malpractice
Failure to use an acceptable level of professional skill when giving medical services that results in injury or harm to a patient.
medical record
A file that contains the documentation of a patient's medical history, record of care, progress notes, correspondence, and related billing/financial information.
medical standards of care
State-specified performance measures for the delivery of health care by medical professionals.
National Provider Identifier (NPI)
Under HIPAA, unique ten-digit identifier assigned to each provider by the National Provider System.
Office for Civil Rights (OCR)
Government agency that enforces the HIPAA Privacy Act.
Office of the Inspector General (OIG)
Government agency that investigates and prosecutes fraud against government health care programs such as Medicare.
password
Confidential authentication information composed of a string of characters.
protected health information (PHI)
Individually identifiable health information that is transmitted or maintained by electronic media.
qui tam
Whistle-blower cases in which a relator accuses another party of fraud or abuse against the federal government.
relator
Person who makes an accusation of fraud or abuse in a qui tam case.
respondeat superior
Doctrine making the employer responsible for employees' actions.
subpoena
A order of a court for a party to appear and testify in a court of law.
subpoena duces tecum
An order of a court directing a party to appear, to testify, and to bring specified documents or items.
transaction
Under HIPAA, structured set of data transmitted between two parties to carry out financial or administrative activities related to health care; in a medical billing program, financial exchange that is recorded, such as a patient's copayment or deposit of funds into the provider's bank account.
treatment, payment, and health care operations (TPO)
Under HIPAA, patients' protected health information may be shared without authorization for the purposes of treatment, payment, and operations.
HIPAA Privacy Rule
Law that regulates the use and disclosure of patients' protected health information (PHI).
authorization
(1) Document signed by a patient to permit release of particular medical information under the stated specific conditions. (2) A health plan's system of approving payment of benefits for services that satisfy the plan's requirements for coverage; see preauthorization.
minimum necessary standard
Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure.
business associate (BA)
A person or organization that performs a function or activity for a covered entity but is not part of its workforce.
clearinghouse
A company (billing service, repricing company, or network) that converts nonstandard transactions into standard transactions and transmits the data to health plans; also handles the reverse process, changing standard transactions from health plans into nonstandard formats for providers.
Notice of Privacy Practices (NPP)
A HIPAA-mandated description of a covered entity's principles and procedures related to the protection of patients' health information.
code set
Alphabetic and/or numeric representations for data. Medical code sets are systems of medical terms that are required for HIPAA transactions. Administrative (nonmedical) code sets, such as taxonomy codes and Zip codes, are also used in HIPAA transactions.
HIPAA Security Rule
Law that requires covered entities to establish administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of health information.
covered entity (CE)
Under HIPAA, a health plan, clearinghouse, or provider who transmits any health information in electronic form in connection with a HIPAA transaction; does not specifically include workers' compensation programs, property and casualty programs, or disability insurance programs.
documentation
The systematic, logical, and consistent recording of a patient's health status—history, examinations, tests, results of treatments, and observations—in chronological order in a patient medical record.
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