PMPC Designation key terms

A binding agreement between a healthcare organization and the OIG, usually negotiated to resolve a fraud investigation, requiring compliance program elements, monitoring, and periodic reporting for a set term.

The federal office within HHS that investigates fraud, waste, and abuse in federal healthcare programs, issues compliance guidance, and has authority to exclude individuals and entities.

The federal agency administering Medicare, Medicaid, and related programs; it issues coverage rules, payment policies, and conditions of participation that providers must satisfy to bill.

A federal statute imposing civil liability on persons who knowingly submit or cause submission of false or fraudulent claims to government payers, with treble damages and per-claim penalties.

A private person who files a False Claims Act suit on behalf of the government and may receive a share of any recovery; the government may intervene or decline to take over the case.

A criminal law prohibiting knowingly offering, paying, soliciting, or receiving remuneration to induce referrals of items or services reimbursed by federal healthcare programs, subject to regulatory safe harbors.

A regulatory provision that shields a specific payment or business arrangement from Anti-Kickback Statute liability when every element of the safe harbor is strictly satisfied.

A civil statute barring physicians from referring Medicare patients for designated health services to entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.

The specific categories of services, such as clinical laboratory, imaging, physical therapy, and durable medical equipment, that are subject to Stark Law referral restrictions and related billing rules.

The price an arrangement would bring in an arm's-length transaction between willing, knowledgeable parties who are not in a position to generate referrals, used to test compensation arrangements for compliance.

A sanction barring a person or entity from participating in federal healthcare programs; federal payers will not reimburse items or services furnished by an excluded party, directly or indirectly.

An exclusion the OIG must impose by statute, such as after a conviction for Medicare or Medicaid fraud or a program-related felony, and which generally carries a minimum five-year term.

An exclusion the OIG has discretion to impose for specified conduct, such as misdemeanor healthcare fraud, license revocation, or kickback involvement, rather than one required by statute.

The OIG's publicly searchable database of parties excluded from federal healthcare programs, which employers must screen against during hiring and at regular intervals thereafter.

The process of checking employees, contractors, and vendors against the LEIE and other exclusion or debarment lists before engagement and periodically afterward to prevent billing for excluded persons' services.

The rule that claims for items or services furnished by an excluded individual or entity, including services ordered or prescribed by an excluded provider, are not payable by federal healthcare programs.

Any funds a provider receives in excess of what is due under applicable payment rules; identified overpayments must generally be reported and returned within 60 days of identification.

A requirement that a person who receives an overpayment from a federal healthcare program report and return it by the later of 60 days after identification or the applicable cost report due date.

A False Claims Act theory imposing liability for knowingly using a false statement to avoid or decrease an obligation to pay money to the government, such as concealing an identified overpayment.

A statistical method that projects findings from an audited sample of claims across an entire population to calculate damages or overpayment amounts in audits and settlements.

A structured review of medical records and billing data to verify that services were documented, coded, medically necessary, and billed in accordance with payer requirements and internal policies.

Ongoing compliance activities such as audits, chart reviews, and data analytics that detect billing errors, policy deviations, and risk trends before they become systemic or reported externally.

A formal framework of policies, leadership oversight, training, monitoring, and enforcement designed to prevent, detect, and correct violations of law and payer requirements.

The foundational compliance program components: written standards, designated leadership, training and education, communication lines, internal monitoring and auditing, enforcement and discipline, and prompt corrective action.

The individual charged with day-to-day operation of the compliance program, including policy development, training, investigation oversight, and reporting to senior leadership and the board.

A cross-functional group of leaders that advises the compliance officer, reviews risk areas, and helps coordinate compliance initiatives across clinical, billing, and operational departments.

Federal health and safety requirements that providers must meet to participate in Medicare and Medicaid; noncompliance can result in denial of payment or termination from the programs.

A CMS decision that establishes whether a particular item or service is covered nationally under Medicare, sometimes with conditions on diagnosis, frequency, or setting.

A coverage policy issued by a Medicare Administrative Contractor that specifies when an item or service is reasonable and necessary within its jurisdiction, often including documentation requirements.

A regional contractor that processes Medicare claims, issues local coverage policies, conducts audits, and serves as the first point of contact for coverage and payment questions.

The determination that a service is reasonable and necessary for the diagnosis or treatment of illness or injury, consistent with accepted standards of care and payer coverage criteria.

A written notice given to a Medicare beneficiary before a service that may not be covered, explaining the likely denial and obtaining the patient's agreement to pay if payment is refused.

A contractor that reviews Medicare claims to identify and recover improper payments, including overpayments and underpayments, and refers findings for provider education and appeals.

Billing a service at a higher level or with a more complex code than the documentation supports, which can constitute a false claim if done knowingly.

Billing separately for components of a service that should be reported under a single comprehensive code, resulting in improper duplicate or excessive payment.

A Medicare billing arrangement allowing services furnished by auxiliary personnel to be billed under a supervising physician's number when specific supervision, employment, and documentation conditions are met.

A two-character code appended to a procedure code to convey additional information, such as laterality, distinct service, or reduced service, that affects payment and claim accuracy.

Any ownership, investment, or compensation arrangement between a physician or immediate family member and an entity furnishing designated health services, which triggers Stark analysis.

Legal safeguards prohibiting an employer from discharging, demoting, or otherwise discriminating against an employee who reports suspected fraud or participates in an investigation.

An individual who reports suspected illegal or unethical conduct within an organization, often through internal hotlines or external channels such as the OIG or a qui tam lawsuit.