| A | B |
|---|
| abuse | (in Federal Law): action that misuses government money allocated to certain uses, such as Medicare. "To bill when it's not necessary" |
| audit | investigators review selected records for compliance with accepted documentation standards |
| breach of contract | if eith "competent medical care" is not fairly exchanged by "payment of fee"as agreed by contract promise(IMPLIED legal contract) |
| compliance plan | to find compliance problems and correct them before a liability occurs |
| comfidential information | information including all but a few facts in the patient's medical record |
| contract | enforcible agreement in which specific promises are made |
| fraud | act of deception used to take advantage of another person or entity "to bill when the task was not done" |
| HIPPA | Health Insurance Portability and Accountibility Act:legislation for action against medical fraud and abuse in Medicare, Medicaid, and private payers |
| libel | written information given out with the intent to harm the reputation of the patient |
| medical professional liability | responsibility for providing the state-required standard of care to their patients |
| negligence | when health care professionals fail to perform their medical duties properly |
| nonconfidential information | a person's name, dates of service,verification of hospital admission |
| qui tam | "whistle blower" The accusor(=relator)is protected against employer retaliation & may be entitled to 15-25% of fine paid by accused |
| respondent superior | law in which employer is responsible for an employee's actions(physicians can be charged for fraudulent behavior of any staffmember) |
| slander | oral information given out with the intent to harm the reputation of the patient. |
| supoena | an order of the court directing a party to appear and testify |
| supoena tecum duces | directs the person and his medical record to appear in court |
| OBRA | Emergency Release of Information Without Consent"Omnibus Budget Reconsiliation Act" |
| 4 ways for release of information to be transmitted | faxing, telephone, mail,electronic transmission |
| HIPAA | governs fraud and abuse enforced by office of inspector general(OIG) |
| E &O insurance | Error and Ommission insurance (for coders) |
| Four examples of fraud and abuse | 1)billing for services not performed,2)billing at a higher level than was carried out,3)performing and billing for procedures not related to patient's condition and thus not medically necessary;5) billing twice for same service |
| Medical standard of care | using the care and expertise that under the circumstances could be reasonably expected of a professional with similar experience and training |
| Non-confidential information | Patient's name, dates of service, verification of hospital admission,physician's brief statement of condition |
| owner of patient medical records (progress notes, reports and other info) | provider entity that created them (could be a physician in private practice, or a facility, such as a clinic or hospital) |
| owner of patient medical record information | belongs to the patient, who also controls the amount and type of info. that is released |
| three guidelines BEFORE release of patient info. | 1)must be documented in patient's medical record;2)must be written, signed and dates;3)AHIMA suggests release should be w/i six mo. of date info. is disclosed |
| items specified in release of information | to whom;what;reason;conditions for authorization to expire |
| guidelines AFTER info. is authorized for release | originals not released, but numbered and photocopied;2)pertainent to specific request;3)fee charged for accessing and copying documents;4)patient's medical recod must document each release of info.;5)no release if situation is unclear |
| situations when authorization for R.O.I are unnecessary | when another provider in same practice/clinic has same patient & requires info;emergency treatment;when patients are transferred between institutions |
| exceptions to confidentiality requirements | court order;worker's comp. cases;statutory reports;research |
| reaease under court order (subpoena) | official(+court case # and attorney's name and phone#);2)trial date & time verified;3)verify patient's name was patient of physician;4)notify physician of subpoena;5)check subpoena for completeness and document number of pages and content;6)store records in locked safe;7)photocopy material, if permitted by state;9)testify regarding the record, if required |
| worker's comp cases | records can be released without authorization to employers in comp. cases ;Also to Worker's Compensation Administration board and to insurance companies handling claims for the state |
| statutory reports | patient's births, deaths and cases of abuse; also, communicable diseases like rabies, hepatitis and tuberculosis |
| research data | patient's medical records may be available to researchers approved by the practice, but patient's names may not be identified |
| release by fax | used when quick approval is needed (preauthorization request to third party payer to proceed with urgent procedure)Fax documents ALWAYS preceeded with a cover letter or memo, which should contain a confidentiality notice |
| release by mail | most common method:"certified letter" |
| telephone | must verify caller's ID and their need to know requested facts.All calls are documented to record person or organization requesting info;date;info supplied; and to whom supplied |
| electronic transmission | usually over special communication lines between patient billing systems to third party payers Sometimes by e-mail |
| medical practice compliance plan | audit and monitor compliance in coding and billing;2)develop written policies/procedures =consistant;3)provide ongoing staff training & communication;4)respond to and correct errors |
| additions to compliance plan | (EEO)hiring and promotion policies;2)OSHA.regs:(fire safety and handling of hazardous materials ;2) |
| strategies to avoid fraud/abuse | updated coding knowledge;read 3rd party regs;internal audits;file written correspondence with govern-ment sponsored and other payers;clarify coding/billing questions with physicians;use info from denied claims to modify procedures as needed |
| examples of negligence | physician's assistant may wrongfully dispense medication;2)RN may not act when situation needs it(failing to treat AIDS) |
