AAPC CPB - Chapter 1 Terminology Exam 2023

Abuse - Answer- An action that results in unnecessary costs to a federal healthcare program, either 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 Beneficiary - Answer- An individual that is eligible for Medicare or Medicaid benefits based on CMS guidelines Conditions of Participation (CoP) - Answer- Conditions that healthcare organization must meet in order to participate with the plan or program Covered Entity - Answer- According to HIPAA, defined as health plans, healthcare clearinghouses, and healthcare 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 healthcare program Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Answer- Federal law in which the primary goal is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information, and help the healthcare industry control administrative costs Preferred Provider Organization (PPO) - Answer- Managed care organization of medical doctors, hospitals, and other healthcare providers who have agreed with an in surer or a third-party administrator to provide healthcare at reduced rates to the insurer's or administrator's clients Protected Health Information (PHI) - Answer- Individually identifiable health information that includes many common identifiers, such as demographic data, name, address, birth date, and social security number. It also includes information that relates to an individual's past, present, or future physical or mental health or condition; the provision of healthcare to the individual; or, the past, present, or future payment for the provision of healthcare to the individual, which reasonably may be 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 of a contract with the government or in violation of a government regulation, when there is a statute which provides for a penalty for such violations Stark Law - Answer- A federal law that places limitations of certain physician referrals Truth in Lending Act - Answer- Designed to assure that every customer who needs consumer credit is given meaningful information co