Abuse
An action that results in unnecessary costs to a federal healthcare program, directly or indirectly.
Anti-kickback
Knowingly and willfully offering or accepting rewards or remuneration for services that are billable to a federal healthcare plan.
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Benefiiciary
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CPB Exam
Abuse - Answer An action that results in unnecessary costs to a federal healthcare
program, directly or indirectly.
Anti-kickback - Answer Knowingly and willfully offering or accepting rewards or
remuneration for services that are billable to a federal healthcare plan.
Benefiiciary - Answer An individual that is eligible for Medicare or Medicaid benefits
based on the CMS guidelines.
Conditions of Participation (CoP) - Answer Conditions that healthcare organizations
must meet in order to participate with the plan or program.
Covered Entity - Answer Clearinghouse and providers who electronically transmit any
health information in connection with transactions for which HHS has adopted
standards.
Criminal Healthcare Fraud Act - Answer Scheme to willingly defraud any healthcare
benefit program.
False Claims Act - Answer Federal statute setting criminal and civil penalties for falsely
billing the government; over representing the amount of a delivered product, or under
stating an obligation to the government.
Fraud - Answer Making false statements or misrepresenting facts to obtain an
undeserved benefit or payment from a federal HC program.
HIPAA-Health Insurance Portability and Accountability Act of 1996 - Answer Federal law
in which the primary goal is to make it easier for people to keep insurance, protect the
confidentiality and security of HC info and help control administration costs.
PPO-Preferred Provider Organization - Answer Managed care organization of Drs,
hospitals and other providers who agree with insurer to provide HC at reduced rates to
their clients.
PHI-Protected Health informaion - Answer Individually identifiable health information,
reasonably used to identify an individual.
Qui Tam Action - Answer A lawsuit brought by a private citizen against a person or
company who is believed to have violated the law in the performance contact with the
government of in violation of government regulation.
Stark Law - Answer A federal law that places limitations of certain physician referrals.
, Truth in Lending Act - Answer An act which requires lenders to inform borrowers of all
direct, indirect and true costs of credit.
ACO-Accountable Care Organizations - Answer HC organization characterized by a
payment and care delivery model rust seeks to tie provider reimbursements to quality
metrics and reductions in the total cost of care for an assigned population of patients.
Capitation - Answer Fixed payment remitted at regular intervals to a medical provider by
a managed care organization for an enrolled patient.
Carve-out - Answer Service not covered in an insurance contract, usually reimbursed
according to a different arrangement or rate formula.
CDHP-Consumer Driven Health Plans - Answer Third tier insurance plans giving
members more control over their heath budgets.
CSC-Customized Sub-capitation - Answer Managed care plan in which HC expenses
are funded by insurance coverage, individual selects one of each type of provider to
create customized premium.
DEERS-Defense Enrollment Eligibility Reporting System - Answer Database of all
uniformed service members, their spouses and family members and others who are
eligible for Tricare.
Employer's Liability Insurance - Answer Protects an employer from damages from a
lawsuit resulting from an injury due to the employer's negligence.
EPO- Exclusive Provider Organization - Answer Organization that has entered into
contracts with medical care providers or groups of medical care providers to provide HC
services to members.
FSA-Flexible Spending Account - Answer Tax advantaged HC account an individual
contributes money into that is used to pay for certain out of pocket HC costs.
Gatekeeper - Answer Physician, usually PCP, who is responsible for determining a
patient's primary services and coordinating care for patient.
GPWW-Group Practice Without Walls - Answer Medical practice formed to share
economic risk, expenses and marketing effort.
HMO-Health Maintenance Organization - Answer Organization that provides
comprehensive HC with limited referral to outside specialists that is financed by fixed
periodic payments determined in advance.
HSA-Health Savings Account - Answer Savings account used in conjunction with a high
deductible policy that allows users to save money tax free for medical expenses.
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