ATI HEALTHCARE FRAUD, WASTE, AND ABUSE PREVENTION WITH 100% CORRECT ANSWERS

abuse misuse of healthcare funds, products and services Anititrust Laws laws that prevent the formation of monopolies appeal To ask a higher court to review the decision and determine if justice was done balance billing collecting the difference between a provider's usual fee and a payer's lower allowed charge Centers for Medicare and Medicaid Services (CMS) a federal agency within the U.S. Department of Health and Human Services that is responsible for Medicare and Medicaid, among many other responsibilities. claim A request for payment of the benefits provided by an insurance contract. complaint a formal notice that a lawsuit is being brought Concealment A means of hiding counterfeit fake; false Covered Entity A health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health information in electronic form in connection with a transaction doctor shopping practice of requesting care from multiple providers, often simultaneously, without coordinating care or informing the providers of the multiple caregivers drug formulary a list of provider-preferred generic and brand-name drugs covered under various insurance plans Durable Medical Equipment (DME) Any medical device, equipment, or instrument used in the care of a patient. fraud wrongful or criminal deception intended to result in financial or personal gain Health Insurance Portability and Accountability Act (HIPAA) public law regulates disclosure of individulas health information allows to qualify for health insurance when employers changed Informatics use information and technology to communicate, manage knowledge, mitigate error, and support decision making kickback the return of a portion of the money received in a sale or contract, often secretly or illegally, in exchange for favors Medicare Drug Integrity Contractors (MEDIC) Program network of individuals who identify medicare underpayments and overpayments Upcoding A fraudulent practice in which provider services are billed for higher procedural codes than were actually performed, resulting in a higher payment. Unbundling codes refers to separating the components of a procedure and reporting them as billable codes with charges to increase reimbursement rates vendor A business from which merchandise is purchased or supplies or other assets are bought waste Material which is eliminated or discarded as no longer useful or required. whistle-blowing The disclosure of information by a company insider that exposes illegal or unethical behavior by others within the organization Whistle Blower Protection Act (1989) Created the Office of Special Counsel to investigate complaints from bureaucrats that were punished after reporting to Congress about waste, fraud, or abuse in their agencies