CPCO Compliance Officer 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, compliance officer and committee, training, communication lines, monitoring and auditing, enforcement and discipline, and response and prevention. These form the foundation of an effective compliance program.

False Claims Act

Federal law imposing liability for knowingly submitting false or fraudulent claims to government programs. Penalties include treble damages and per-claim fines adjusted for inflation.

Anti-Kickback Statute

Prohibits offering, paying, soliciting, or receiving remuneration to induce referrals for items or services covered by federal healthcare programs. Safe harbors protect certain arrangements.

Stark Law

Prohibits physician referrals for designated health services to entities with which the physician or immediate family has a financial relationship, unless an exception applies.

HIPAA Privacy Rule

Sets national standards for protecting individually identifiable health information. It governs use and disclosure of protected health information by covered entities and business associates.

OIG Compliance Guidance

Voluntary guidance published by the Office of Inspector General for various healthcare sectors. It outlines steps to develop and implement an effective compliance program.

EMTALA

Federal law requiring hospitals to provide a medical screening examination and stabilizing treatment for emergency conditions regardless of the patient's ability to pay.

Compliance committee

A group responsible for overseeing the compliance program, including reviewing audit results, recommending corrective actions, and ensuring program effectiveness.

Audit sampling

Selecting a subset of claims or records for review to estimate error rates. Sample size and confidence level must be determined before the audit to allow valid extrapolation.

Error rate calculation

Number of claims with errors divided by total claims audited, multiplied by 100 to express as a percentage. It measures coding or billing accuracy.

OIG Work Plan

Annual publication listing audit and enforcement priorities of the Office of Inspector General. It guides compliance auditing and risk assessment.

Root cause analysis

A systematic process to identify underlying causes of coding or billing errors. Corrective action plans should address each identified cause to prevent recurrence.

Baseline audit

An initial audit conducted to establish the current error rate and identify areas for improvement. It serves as a benchmark for future audits.

RAT-STATS

Statistical software developed by the Office of Inspector General for random sampling and extrapolation in healthcare audits. It helps calculate sample sizes and error rates.

Corrective action plan

A documented plan outlining steps to address audit findings, including responsible parties, timelines, and expected outcomes. It is essential for compliance program effectiveness.

Audit scope

Defines the boundaries of an audit, including time period, provider types, claim types, and objectives. A clear scope ensures focused and efficient auditing.

ICD-10-CM

International Classification of Diseases, 10th Revision, Clinical Modification. Used to code diagnoses for outpatient and inpatient services in the United States.

CPT codes

Current Procedural Terminology codes maintained by the American Medical Association. Used to report medical, surgical, and diagnostic services and procedures.

HCPCS Level II

Healthcare Common Procedure Coding System codes used for supplies, drugs, and services not represented in CPT. Maintained by CMS.

E/M coding

Evaluation and Management coding for patient visits. Level selection is based on medical decision making or time, per current CPT guidelines.

Modifier -25

Indicates a significant, separately identifiable evaluation and management service by the same physician on the same day as a procedure or other service.

NCCI edits

National Correct Coding Initiative edits prevent improper payment when services are billed together. They include column one/column two edits and medically unlikely edits.

ICD-10-PCS

International Classification of Diseases, 10th Revision, Procedure Coding System. Used to code inpatient procedures in the United States.

Coding audit

A review of medical records and assigned codes to ensure accuracy and compliance with coding guidelines. It identifies educational needs and potential fraud.

CMS-1500 form

The standard claim form used for billing outpatient services to Medicare and other insurers. It contains patient, provider, and service information.

UB-04 form

The standard claim form used for billing institutional services, such as hospital inpatient and outpatient claims. It includes revenue codes and condition codes.

Clean claim rate

The percentage of claims accepted on first submission without errors. It is a key performance indicator of revenue cycle efficiency.

A/R days

Accounts receivable days measures the average time to collect payment. Calculated as (total A/R divided by total charges) multiplied by days in period.

Explanation of Benefits

A document from the insurer explaining payments, adjustments, and denials for a claim. It should be reconciled with the original claim.

Medicare Physician Fee Schedule

The payment system for physician services under Medicare. It uses relative value units and a conversion factor to determine payment.

OPPS

Outpatient Prospective Payment System. Medicare payment system for hospital outpatient services using Ambulatory Payment Classifications (APCs).

Coordination of benefits

The process of determining the primary and secondary payer when a patient has multiple insurance coverage. It prevents duplicate payment.