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Health Insurance Portability and Accountability Act of 1996

"HIPPA did"

Created The Health Care Fraud and Abuse Control Program
to check for fraud and abuse in Medicare and Medicaid,Private Programs.

Compliance Regulations

most billing-related cases are based on HIPPA and False Claims Act

Insurance Reform Title !

-Primary purpose to provide continuous insurance coverage for workers and their dependents when they change or lose their jobs.
-Limits the use of preexisting conditions exclusions
-Prohibits discrimination for part or present poor health
-Guarantees cetraom employees and individuals the right to purchase health insurance coverage after losing a job
- Allows renewal of health insurance coverage regardless of an individual's health condition that is covered under the particular policy

Administrative Simplification

-The goal is to focus on the health care practice setting to reduce administrative cost and burdens.
Two parts:
1. Development and implementation of standardized health-related financial and administrative activities electronically.
2. Implementation of privacy and security procedures to prevent the misuse of health information by ensuring confidentiality.

False Claim Act ( FCA)

Federal Law that prohibits submiiting a fraudment claim or making a false statement or representation in connection with a claim


Protects and rewards whistle blowing.

National Correct Coding Initiative (NCCI)

Developed by CMS to promote national correct coding methodologies and control improper coding that leads to inappropriate payment of Part B health

Fraud 1

Knowingly and intentionally deceiving or misrepresenting info that may result in unauthorized benefits is known as fraud


is a felony and can result in fines and or prison, claims are audited by state and federal agencies as well as by private insurance companies. Services not furnished, unbundling and misrepresenting diagnosis to justify payment.


not medically nessesary, excessive charges for services eqiupment etc


Protected Health Information

HIPAA Privacy Rule

protects individually identifiable health information,witout specific authorization for treatment, payment and operation TPO

Employer Liability

Physicians are legally responsible for their own conduct and any actions of their employess( thier designee) performed within the context of their employement. this is referred to vicarious liability, responent superior,LET THE MASTER ANSWER...

Vicarious Liability

Liability imposed by law on one person for acts committed by another.

Employee Liability

"errors and omissions insurance" is protection against loss of monies caused by failure through error or unitentional omission on the part of the indivdual or service submitting insurance claim, Some physicians contract with a billing service to handle claims submission, and some agreements contain a clause stating that the physician will hold the company harmless from " liability resulting from claims
submitted by the service for any account."

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