CPMA Medical Auditor key terms

A federal statute that imposes civil liability, including treble damages, on anyone who knowingly presents or causes to be presented a false claim for payment to a government health care program.

A provision of the False Claims Act that lets a private individual sue on behalf of the government for fraud and receive a share of any recovery; such suits are often filed by employees.

A criminal statute that prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce referrals for items or services paid by federal health care programs.

A law barring physicians from referring Medicare patients for designated health services to an entity in which the physician or an immediate family member has a financial relationship, unless a regulatory exception applies. Intent is not required.

Providing free or discounted items or services to a federal health care beneficiary that are likely to influence the beneficiary's choice of provider, unless the arrangement fits a safe harbor or exception.

A binding agreement between an organization settling a federal health care case and the OIG that requires compliance program elements such as auditing, monitoring, training, and periodic reporting for a stated term.

The List of Excluded Individuals and Entities maintained by the OIG; employers must screen staff and vendors because billing for services furnished by an excluded person may create liability.

An organization's ongoing structure for preventing and detecting legal and policy violations; the OIG model lists seven elements including written standards, a compliance officer, training, monitoring and auditing, and corrective action.

A systematic, documented review that compares actual records or practices with defined standards, such as regulations, payer policies, or coding rules, and reports the differences found.

Ongoing, routine surveillance of operations, metrics, and reports intended to catch problems early; it is generally broader, more frequent, and less formal than an audit.

An initial review of current performance used to measure where an organization stands, identify error patterns, and set targets for later audits and education.

A small number of records reviewed first to estimate whether an error problem exists and to decide whether a larger or statistically valid sample is needed.

Selecting records by a random, probability-based method so that the results reflect the population and can be projected with a stated confidence level and precision.

Using the error rate measured in a valid random sample to estimate the total number or dollar amount of errors in the full population of claims or records.

A structured process of identifying potential compliance failures and rating their likelihood and impact, used to decide which areas and codes to audit first.

The judgment that a service is reasonable and needed to diagnose or treat a patient's condition and meets the payer's coverage criteria; services without it can be denied or recouped.

A Medicare policy that states whether a specific item or service is covered nationally and under what conditions, often including documentation requirements.

A coverage policy issued by a Medicare Administrative Contractor for its own jurisdiction that lists covered indications and the documentation needed to support them.

The specific code chosen for a visit or outpatient encounter based on the documented history, examination, and medical decision making, or for some services, total time.

The complexity of a provider's thinking during an encounter, scored by the number and type of problems addressed, the amount of data reviewed, and the risk of complications.

A two-digit modifier added to an evaluation and management code to show that a significant, separately identifiable service was provided on the same day as a procedure.

A modifier used to show that a procedure was distinct and separate from another service performed on the same day, so the bundling edit should not apply.

Reporting components of a single procedure as separate codes, or overriding bundling edits without support, which raises payment above what the documentation justifies.

Copying documentation from a prior encounter or another patient into a record; it suggests the service was not individually documented and is a frequent audit red flag.

A written request to the provider for clarification of unclear or incomplete documentation needed for accurate code assignment, worded neutrally so it does not suggest the answer.

A correction or addition made to a record after the original note was signed; it must be dated, timed, signed, and explain why it is being added.

The process of recording the services, supplies, and drugs actually provided so they can be translated into billable codes and submitted on a claim.

The organization's master list of billable items with their codes, descriptions, and prices, which must be reviewed and updated when codes or payment rules change.

A claim that contains all required data elements and passes basic edits, allowing the payer to process it without requesting additional information.

Tracking, appealing, and analyzing claims that payers reject or deny in order to recover payment and to correct the underlying causes of the denials.

A report that groups unpaid claims by how long they have been outstanding, helping managers spot slow payment, missed appeals, and collection problems.

The average relative weight of a hospital's diagnosis-related group assignments, which reflects how resource-intensive its patient population is and affects payment.

A form a provider gives a Medicare beneficiary before a service that may be denied as not medically necessary, so the beneficiary can agree to pay if Medicare does not.

The formal written product of an audit that describes objectives, scope, methods, findings, and recommendations, and is issued to the audited area and leadership.

A conclusion that a documented condition differs from an applicable criterion, supported by evidence and usually stated with the cause, effect, and recommendation.

A written plan listing the specific steps, responsible persons, and deadlines for fixing the deficiencies identified in an audit, plus how completion will be verified.

A meeting at the end of fieldwork where auditors review preliminary findings with the audited area, confirm facts, and discuss recommendations before the report is finalized.

The records an auditor keeps of the evidence reviewed, the tests performed, and the conclusions reached, which support the report and allow quality review.

A method of tracing a problem back to the process or system failures that produced it, rather than blaming individuals, so corrective actions actually prevent recurrence.