* Fraud Schemes and Red Flags in Healthcare

**Ability to Pay (ATP) determination #

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A process used by healthcare providers to determine if a patient has the financi… #

This information is used to make decisions about providing care, setting payment terms, and pursuing collections.

**Accredited Healthcare Organization (AHO) #

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An organization that has been accredited by a recognized accreditation body, suc… #

Accreditation indicates that the organization has met certain standards for quality and safety.

**Admitting privileges #

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The right of a healthcare provider to admit patients to a particular hospital or… #

The right of a healthcare provider to admit patients to a particular hospital or healthcare facility.

**Advance Beneficiary Notice of Noncoverage (ABN) #

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A document that a healthcare provider must give to a Medicare beneficiary when t… #

The ABN explains why the service or item may not be covered and gives the beneficiary the option to receive the service or item and pay for it themselves.

**Affordable Care Act (ACA) #

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A federal law passed in 2010 that made significant changes to the healthcare sys… #

The ACA expanded access to health insurance, created new regulations for healthcare providers and insurance companies, and established new programs to improve the quality and efficiency of healthcare.

**Anti #

Kickback Statute (AKS):**

A federal law that prohibits the exchange of anything of value in return for ref… #

The AKS is intended to prevent healthcare providers from offering or accepting bribes, kickbacks, or other forms of remuneration in exchange for patient referrals.

**Assignment of benefits #

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A process in which a healthcare provider assigns their right to receive payment… #

This means that the payer will pay the provider directly for the service or item, rather than the patient paying the provider and then seeking reimbursement from the payer.

**Billing and Coding Compliance #

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The process of ensuring that healthcare providers follow all applicable laws, re… #

This includes using the correct codes to describe the services and items provided, accurately documenting the services and items, and following all rules related to billing and payment.

**Bundled payment #

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A payment model in which a healthcare provider is paid a single amount for all t… #

This model is intended to encourage providers to coordinate care and reduce unnecessary services and costs.

**Centers for Medicare & Medicaid Services (CMS) #

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The federal agency that administers the Medicare and Medicaid programs #

CMS sets rules and policies for these programs, pays healthcare providers and suppliers, and works to improve the quality and efficiency of healthcare.

**Certified Professional Coder (CPC) #

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A professional designation given to individuals who have demonstrated proficienc… #

CPCs must pass a certification exam and meet continuing education requirements to maintain their certification.

**Charge description master (CDM) #

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A comprehensive list of all the services and items that a healthcare provider ca… #

The CDM is used to generate bills and is an important tool for managing revenue and ensuring compliance with billing regulations.

**Claim #

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A request for payment that a healthcare provider submits to a third #

party payer, such as an insurance company or government agency. The claim includes information about the services or items provided, the patient, and the provider, as well as the codes and charges for the services or items.

**Clinical Laboratory Improvement Amendments (CLIA) #

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Federal regulations that govern laboratory testing in the United States #

CLIA establishes standards for laboratory personnel, equipment, and testing procedures, and requires laboratories to be certified by CMS.

**Compliance program #

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A set of policies, procedures, and practices that a healthcare organization impl… #

A compliance program typically includes training and education for employees, internal audits and monitoring, and a process for reporting and investigating compliance issues.

**Continuous Positive Airway Pressure (CPAP) #

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A treatment for obstructive sleep apnea that involves using a machine to deliver… #

A treatment for obstructive sleep apnea that involves using a machine to deliver a steady flow of air through a mask to keep the airway open during sleep.

**Cost reporting #

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The process of submitting financial information to CMS for the purpose of determ… #

Cost reporting includes providing detailed information about the costs of providing care, as well as information about the provider's services, facilities, and patients.

**Credentialing #

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The process of verifying the qualifications, training, and licensure of healthca… #

Credentialing is typically done by healthcare organizations, insurance companies, and other entities that hire or contract with providers.

**Current Procedural Terminology (CPT) #

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A coding system used by healthcare providers to describe the services and proced… #

CPT codes are used for billing and are updated annually by the American Medical Association.

**Durable Medical Equipment (DME) #

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Medical equipment that is intended for use in the home, is reusable, and has a u… #

DME includes items such as wheelchairs, oxygen equipment, and hospital beds.

**Electronic Health Record (EHR) #

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A digital version of a patient's medical record that can be accessed, shared, an… #

EHRs are intended to improve the quality and efficiency of care by providing providers with timely and accurate information about their patients.

**Encounter #

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A healthcare provider's interaction with a patient, whether in person or through… #

Encounters include office visits, hospital stays, and other services and procedures.

**Federal healthcare program #

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Any program administered by the federal government that provides healthcare serv… #

Any program administered by the federal government that provides healthcare services or coverage, including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the Veterans Health Administration.

**Fee schedule #

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A list of fees that a third #

party payer, such as an insurance company or government agency, has established for specific healthcare services and items. Fee schedules are used to determine the amount that a provider will be paid for a service or item.

**Fee #

for-service (FFS):**

A payment model in which healthcare providers are paid for each service or item… #

FFS is the traditional payment model for healthcare in the United States.

**Fraud #

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The intentional deception or misrepresentation of facts for the purpose of obtai… #

Fraud can take many forms, including billing for services not provided, misrepresenting the diagnosis or severity of a patient's condition, and paying or receiving kickbacks.

**Healthcare Common Procedure Coding System (HCPCS) #

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A coding system used by healthcare providers to describe the services and items… #

HCPCS codes are used for billing and are updated annually by CMS.

**Health Insurance Portability and Accountability Act (HIPAA) #

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A federal law passed in 1996 that established standards for the privacy and secu… #

HIPAA requires healthcare providers and other entities that handle PHI to implement safeguards to protect the confidentiality, integrity, and availability of the information.

**Home Health Agency (HHA) #

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An organization that provides healthcare services to patients in their own homes #

HHAs are regulated by CMS and must meet certain standards for quality and safety.

**Identity theft #

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The unauthorized use of another person's personal information, such as their nam… #

Identity theft can occur in healthcare when someone uses another person's information to obtain healthcare services or insurance coverage.

**Inpatient Prospective Payment System (IPPS) #

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A payment system used by Medicare to pay hospitals for inpatient stays #

The IPPS sets a fixed rate for each diagnosis-related group (DRG) based on the patient's condition and the services provided during the stay.

**Kickback #

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The offering, soliciting, or receiving of anything of value in exchange for refe… #

Kickbacks are illegal under the AKS and can result in criminal and civil penalties.

**Medicaid #

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A joint federal #

state program that provides healthcare coverage to low-income individuals and families. Medicaid is administered by the states and is funded jointly by the states and the federal government.

**Medical necessity #

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The requirement that healthcare services and items be necessary for the diagnosi… #

Medical necessity is a