PMPC Designation flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Seven Elements of Compliance

Written policies and procedures, designated compliance officer and committee, training and education, communication lines, internal monitoring and auditing, enforcement and discipline, and corrective action.

Compliance Officer Reporting Line

The compliance officer reports to the governing body or board, not to the billing or revenue-cycle manager, to preserve independence and authority to investigate and report misconduct.

LEIE Screening Frequency

The OIG List of Excluded Individuals/Entities should be checked at hire and monthly thereafter; results are documented and retained for at least 10 years.

Sixty-Day Overpayment Rule

Under ACA Section 6402, an identified overpayment must be reported and returned to the payer within 60 days of identification; failure creates False Claims Act liability.

Corporate Integrity Agreement

A negotiated agreement between a provider and OIG that imposes compliance obligations, independent review organization audits, and annual certifications for a defined term.

False Claims Act Penalties

The FCA imposes treble damages plus per-claim civil penalties for knowingly submitting false claims; liability can attach to reckless disregard, not only intentional fraud.

Compliance Committee Charter

A document specifying the committee's membership, quorum, meeting frequency, reporting lines to the board, and authority to investigate and recommend corrective action.

Risk Assessment Matrix Scoring

Each compliance risk is scored by likelihood and impact on a 1–5 scale; the two scores are multiplied, and risks scoring 12 or higher receive priority auditing and monitoring.

Red Flag Audit Triggers

Patterns such as upcoding, high modifier 25 or 59 use, duplicate claims, services without orders, unbundling, and same-day discharge and readmission patterns warrant investigation.

Corrective Action Plan Elements

A CAP documents root cause, corrective steps, responsible person, target completion date, and a validation re-audit; it is closed only after sustained compliance is demonstrated.

Audit Sample Size

For a 95% confidence interval with a 5% margin of error in a large population, approximately 385 records are sampled; OIG RAT-STATS may be used to calculate sample size.

Conflict of Interest Disclosure

Board members, executives, and medical staff annually disclose financial interests; conflicted individuals recuse from related decisions, and gifts are tracked under Open Payments.

Non-Retaliation Policy

A policy protecting good-faith reporters from retaliation; hotline reports are logged, triaged within five business days, investigated, and tracked to documented resolution.

HIPAA Breach Notification Timing

Affected individuals must be notified within 60 days of discovery; breaches affecting 500 or more individuals also require notice to HHS and the media.

Documentation Integrity Requirement

The medical record must support the code billed, the medical necessity, and the identity of the provider; late entries are dated and labeled as addenda.

Medical Necessity Coverage Rule

Medicare pays only for services that are reasonable and necessary, documented in the medical record, and within a covered benefit category with required orders or certifications.

E/M Level Selection

Under 2021 and later office/outpatient guidelines, the E/M level is selected by medical decision making or total time on the date of the encounter; history and exam no longer determine level.

Modifier 25 Use

Modifier 25 is appended to a significant, separately identifiable evaluation and management service provided on the same day as a procedure; documentation must support both services.

Incident-To Billing Requirements

The physician must initiate the course of treatment, provide direct supervision, and the auxiliary personnel must be employed by the physician or practice; the service must be integral to the plan.

ABN Form CMS-R-131

The Advance Beneficiary Notice of Noncoverage is issued before a service the provider expects Medicare to deny as not reasonable and necessary; the beneficiary selects an option and the form is retained.

LCD and NCD Coverage

National Coverage Determinations apply nationwide; Local Coverage Determinations apply in a contractor's jurisdiction and list covered and noncovered ICD-10-CM diagnoses plus documentation requirements.

NCCI PTP and MUE Edits

Procedure-to-Procedure edits prevent improper code pairs, and Medically Unlikely Edits cap units per code; modifier 59 or X{EPSU} may bypass PTP edits only when clinically appropriate.

Medicare Physician Fee Schedule Formula

Payment equals (Work RVU × Work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × Conversion Factor; sequestration reduces Medicare payments by 2%.

Teaching Physician Documentation

The teaching physician must document presence and participation in the key components of the service; a student note alone is not billable to Medicare.

Exclusion Payment Prohibition

No federal health care program payment may be made for any item or service furnished, ordered, or prescribed by an excluded individual, even if the employer is not excluded.

Mandatory Versus Permissive Exclusion

Mandatory exclusion follows conviction for program-related fraud or patient abuse or neglect; permissive exclusion follows other offenses, license revocation, or health education loan default.

Civil Monetary Penalties for Exclusion

Employing an excluded person can trigger civil monetary penalties per item or service plus up to three times the amount claimed, and the entity itself may be excluded.

Excluded Individual Employment Limits

An excluded individual may not work in any capacity involving federal health care program billing, ordering, prescribing, or direct patient care; other roles require legal review.

OIG Self-Disclosure Protocol

The SDP is used to disclose potential fraud to OIG before government discovery; CMS's SRDP is used for Stark law self-disclosures; both can reduce penalties.

Exclusion Reinstatement

An excluded individual may apply to OIG for reinstatement after the minimum period, commonly five years for mandatory exclusions and three years for permissive exclusions.

SAM.gov Exclusion Screening

SAM.gov lists active federal exclusions; screening at hire and monthly, with documented results, prevents billing for services furnished by excluded persons.

Exclusion Screening Hit Response

A screening hit requires immediate removal of the individual from federal-program duties, verification of identity and exclusion status, and legal review before any reinstatement.