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Department of Health and Human Services; responsible for the administration of the medicare program.


Centers for Medicare and Medicaid Services; responsible for the daily operation of Medicare.


Medicare Administrative Contractors; handle the paperwork and are usually insurance companies


Quality Improvement Organizations; formerly known as PROs; organization that performs medical peer review of Medicare and Medicaid claims


Health Insurance Portability and Accountability Act of 1996; health coverage portability, health information privacy, administrative simplification, medical savings accounts, long-term care insurance

Administrative Simplification

Electronic transactions and code sets standard requirements, privacy, security and national identifier requirements


Activities involving the transfer of health care information


The movement of electronic data between two entities and the technology that supports the transfer


Electronic medical record; computerized health record limited to one practice


Electronic health record; the entire health record compiled from multiple sources

Federal Register

Official publication for all presidential documents, rules and regulations, proposed rules and notices. Hospital facilities - October edition. Outpatient facilities - November or December edition


Resource Based Relative Value Scale; decrease medicare expenditures, redistribute physicians' payments more equally, and ensure quality health care.


Omnibus Budget Reconciliation Act of 1989

Physician Fee Schedule

Updated April 15; RVUs for each service, geographic adjustment factor and national conversion factor


Relative Value Unit; work, overhead, and malpractice


The intentional deception or misrepresentation that an individual knows to be false and makes it knowing that it could result in some unauthorized benefit to himself


Unknowingly or unintentionally submitted an inaccurate claim; generally results from unsound medical, business, or fiscal practices


Office of the Inspector General; responsible for developing an annual work plan that outlines the ways in which the medicare program is monitored to identify fraud and abuse


The right of a patient to control disclosure of personal information.


The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss.


Managed Care Organization; responsible for the health care serviced offered to an enrolled group or person


Preferred Provider Organization; a group of providers who form a network and who have agreed to provide services to enrollees at a discounted rate.


Exclusive Provider Organization; providers are paid on a fee for service basis


Program for All-Inclusive Care for the Elderly; program developed to address the needs of long-term care clients, providers, and payers

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