CPCO Compliance Officer key terms

A federal statute that imposes civil liability on any person who knowingly submits, or causes to be submitted, a false or fraudulent claim for government payment. Penalties include treble damages and per-claim fines.

A criminal law prohibiting the knowing and willful offer, payment, solicitation, or receipt of anything of value to induce or reward referrals of items or services reimbursed by federal healthcare programs. Violations can lead to imprisonment and exclusion.

A strict-liability civil statute barring physicians from referring patients for designated health services to entities with which the physician, or an immediate family member, has a financial relationship, unless a regulatory exception applies. No intent to induce is required.

A regulatory provision that describes arrangements the government will not treat as violating the Anti-Kickback Statute. Meeting every element of a safe harbor provides protection from prosecution for that arrangement.

A private individual who files suit on behalf of the government under the False Claims Act alleging fraud. The relator may receive a share of recovered funds and is protected from retaliation by the employer.

A false statement or record used to conceal, avoid, or decrease an obligation to pay money to the government, such as failing to return an identified overpayment. Liability arises even though no claim was submitted.

A statute authorizing civil money penalties and program exclusion for conduct such as presenting claims the provider knows are false, offering inducements to beneficiaries, and violating the Anti-Kickback Statute. Penalties accrue per item or service.

The process of checking employees, contractors, and vendors against the OIG List of Excluded Individuals/Entities and the SAM database before hiring and monthly thereafter. Billing for services furnished by an excluded person can trigger liability.

The federal agency within the Department of Health and Human Services that investigates healthcare fraud and abuse, issues advisory opinions, publishes work plans, and administers the exclusion authority for federal healthcare programs.

A settlement document between a provider and the OIG that requires the provider to maintain a compliance program, submit to independent reviews, and report violations for a defined period, often in exchange for avoiding exclusion.

A structured set of policies, procedures, training, monitoring, and enforcement mechanisms an organization adopts to prevent, detect, and correct violations of law and payer requirements. Federal guidance identifies seven core elements.

The individual responsible for overseeing an organization's compliance program, including policy development, training, auditing, investigation of concerns, and reporting to senior leadership and the board.

A cross-functional group, typically including clinical, billing, legal, and operational leaders, that advises the compliance officer, reviews audit findings, and helps prioritize corrective actions across the organization.

Legal and organizational safeguards that prohibit retaliation against employees who report suspected fraud or compliance concerns in good faith, including reinstatement and back pay remedies under federal statutes.

Intentional deception or misrepresentation that an individual or entity knows could result in an unauthorized benefit to themselves or another person within a healthcare program. It requires knowing or willful conduct.

Waste is the overuse of services or resources that produces no benefit, while abuse is conduct that directly or indirectly causes unnecessary cost or improper payment without meeting the intent threshold for fraud.

A payment a provider receives to which it is not entitled after considering applicable requirements. The provider must report and return the overpayment within 60 days of identification and explain the reason.

The determination that a service or item is reasonable and necessary for the diagnosis or treatment of illness or injury and meets accepted standards of care. Documentation must support this determination for payment.

The clinical evidence in the medical record that substantiates the service rendered, its medical necessity, the level of care, and the codes billed. Insufficient support is a leading cause of recoupment.

A written schedule that defines the audit's scope, objectives, sampling methodology, timeline, responsible staff, and reporting format. It ensures audits are systematic, defensible, and repeatable.

The statistical or non-statistical approach used to select records for review, such as random, stratified, or targeted sampling. The method determines whether findings can be extrapolated to the full population.

A statistical technique that projects the error rate found in a sample onto the entire population of claims, allowing a payer to calculate an overpayment amount for claims not individually reviewed.

A written notice from a payer or recovery auditor stating that a payment was improper, identifying the claims and amount, and specifying the response and appeal deadlines available to the provider.

A Medicare-contracted entity that reviews claims to identify improper payments, including overpayments and underpayments, and returns recovered funds to the Medicare Trust Funds. Providers may appeal RAC determinations.

A Medicare program that samples claims to measure the rate of improper payments made to providers and suppliers, categorizing errors by type and publishing national and contractor-specific error rates.

A payment that should not have been made or was made in an incorrect amount under statutory, contractual, or administrative requirements. Causes include insufficient documentation, coding errors, and lack of medical necessity.

A planned, independent review of coding, billing, or clinical documentation conducted by or for the organization to verify compliance and identify corrective action before external scrutiny occurs.

A documented set of steps, owners, and deadlines created to fix the root cause of an audit finding, including education, system changes, and follow-up monitoring to confirm the problem is resolved.

A structured method for determining the underlying reason a compliance or coding error occurred, rather than only describing the symptom, so that corrective action addresses the source of the problem.

A standardized code set maintained by the American Medical Association that describes medical, surgical, and diagnostic services. CPT codes are used for physician and outpatient facility billing.

A code set with two levels: Level I is CPT, and Level II contains alphanumeric codes for products, supplies, and services not described by CPT, such as drugs, durable medical equipment, and ambulance services.

The diagnosis and procedure code set used to report patient conditions and inpatient procedures. Accurate ICD-10 coding supports medical necessity, risk adjustment, and public health reporting.

The selection of a CPT code for a patient encounter based on documented elements such as history, examination, and medical decision making, or time. Level selection drives reimbursement and audit risk.

A two-character code appended to a procedure code to indicate a circumstance that changed the service, such as a distinct site, bilateral procedure, or reduced service. Modifiers affect payment and bundling.

A CMS program that publishes edit pairs identifying code combinations generally not payable together because they represent overlapping or bundled services. Associated modifiers may allow separate payment when justified.

Billing separately for components of a service that are properly reported under a single comprehensive code. It can be a coding error or intentional fraud and is a frequent target of payer audits.

Assigning a code that represents a higher level of service or greater complexity than the documentation supports, resulting in increased payment. It is a common audit finding and can constitute fraud.

A national policy issued by CMS stating whether and under what conditions Medicare covers a particular item or service. Local coverage determinations may supplement NCDs within a contractor's jurisdiction.

A coverage policy issued by a Medicare Administrative Contractor that specifies the conditions under which an item or service is considered reasonable and necessary within its jurisdiction, including covered diagnoses.

The process of determining which of two or more health plans pays first when a patient is covered by multiple payers, preventing duplicate payment and establishing the correct primary and secondary billing sequence.

A statement sent to the patient or policyholder summarizing services billed, amounts allowed, amounts paid by the plan, and patient responsibility. It is not a bill but supports billing transparency.

An electronic or paper document from a payer to a provider explaining payment, adjustment, or denial of submitted claims, including reason codes that drive posting and follow-up work.

A payer's decision not to pay a claim, in whole or in part, because of reasons such as missing information, eligibility issues, coding errors, or lack of medical necessity. Denials must be tracked and appealed timely.

The formal, time-limited procedure by which a provider challenges a denial or overpayment determination, moving through successive review levels such as redetermination, reconsideration, and administrative law judge hearing.

The deadline set by a payer or regulation by which a claim must be submitted or an appeal filed to be considered for payment. Missing the deadline generally forfeits reimbursement rights.

A private entity contracted by CMS to process Medicare claims, make coverage determinations, conduct medical review, and handle first-level appeals within an assigned geographic jurisdiction.

A written notice given to a Medicare beneficiary before a service that may not be covered, stating the likelihood of denial and the estimated cost, so the patient can accept financial responsibility.

The internal list of prices a hospital assigns to every item and service it provides. It feeds claims and must be maintained consistently, as it affects payment calculations and transparency requirements.

A published list of payment amounts a payer will allow for specific services, often adjusted by geographic factors. Reimbursement is generally the lesser of the billed charge or the fee schedule amount.