Glossary of Health Care Fraud
Terminology Comprehensive
Questions (Frequently Tested) and
Complete Solutions Graded A+
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Abuse (Genally, in health care) - Answer: Incidents or practices of
providers, physicians, or suppliers, or services and equipment which are
inconsistent with accepted sound medical, business or fiscal practices
,Abuse (Medicaid RAC Program, Title 42 CFR 455.2) - Answer: Abuse
means provider practices that are inconsistent with sound fiscal,
business, or medical practices, and result in an unnecessary cost to the
Medicaid program, or in reimbursement for services that are not
medically necessary or that fail to meet professionally recognized
standards for health care.
It also includes recipient practices that result in unnecessary cost to the
Medicaid program.
Abuse (CMS Glossary) - Answer: A range of the following improper
behaviors or billing practices including, but not limited to:
* Billing for a non-covered service;
* Misusing codes on the claim (i.e., the way the service is coded on the
claim does
not comply with national or local coding guidelines or is not billed as
rendered); or
* Inappropriately allocating costs on a cost report.
Abuse (Medicare.gov) - Answer: Abuse occurs when doctors or
suppliers do not follow good medical practices that can result in
unnecesary costs to Medicare. These practicies may result in
,unnecessary costs to the Medicare Program, improper payment, or
services that are not medically necessary
Abuse (Medicare Part C & D Compliance): Abuse includes actions that
may, directly or indirectly, result in: - Answer: *Unnecessary costs to
the Medicare Progam
*Improper payment
*Payment for services that fail to meet professionally recognized
standards of care
*Services that provider has not knowingly and/or intentionally
misrepresented facts to obtain payment.
Abuse cannot be differentiated categorically from fraud, because the
distinction between "fraud" and "abuse" depends on specific facts and
circumstances, intent and prior knowledge, and available evidence,
among other factors.
ACA - Answer: Affordable Care Act
Accountable Care Organization. (ACO) - Answer: A health care
organiztion that is formed by a group of health care providers
(physicians, hospitals and other providers), with the goal of providing
coordinated and integrated care.
, It is characterized by a payment and care delivery model that seeks to
tie provider reimbursements to quality of care metrics and reductions
in the total cost of care for an assigned population of patients.
Thus the ACO is "accountable" to the patients and the 3rd-party payer
for the quality, appropriateness and efficiency of the health care
provided. An ACO may employ a range of payment models
Active Case - Answer: An investigation that is assigned to an SIU staff
member who is responsible for its follow-up, tracking and completion.
Actuarial justification - Answer: The demonstration by an insurer that
the premiums collected are reasonable, given the benefits provided
under the plan or that the distribution of premiums among
policyholders are proportional to the distribution of their expected
costs, subject to limitations of state and federal law.
The Affordable Care Act requires insurers to publically disclose the
actuarial justifications behind unreasonable premium increases.
Advanceable Tax Credit - Answer: The Affordable Care Act provides
insurance premium subsidies to certain low- and middle-income people
(individuals with income up to 400% of the poverty line and single
Terminology Comprehensive
Questions (Frequently Tested) and
Complete Solutions Graded A+
Professional Academic Assistance Services
Services Offered
• Proctored Exam Assistance
• Online Class Management (Full Course Support)
• Exam Preparation & Study Materials
• Assignments and Coursework Support
• Essay and Research Paper Writing
• Discussion Posts & Responses
• Editing and Proofreading
• Confidential Academic Consultation
Contact Information
Email:
WhatsApp link: https://wa.me/254704846336
Fast Response | Confidential | Reliable Academic Support
Helping Students Achieve Academic Excellence
Abuse (Genally, in health care) - Answer: Incidents or practices of
providers, physicians, or suppliers, or services and equipment which are
inconsistent with accepted sound medical, business or fiscal practices
,Abuse (Medicaid RAC Program, Title 42 CFR 455.2) - Answer: Abuse
means provider practices that are inconsistent with sound fiscal,
business, or medical practices, and result in an unnecessary cost to the
Medicaid program, or in reimbursement for services that are not
medically necessary or that fail to meet professionally recognized
standards for health care.
It also includes recipient practices that result in unnecessary cost to the
Medicaid program.
Abuse (CMS Glossary) - Answer: A range of the following improper
behaviors or billing practices including, but not limited to:
* Billing for a non-covered service;
* Misusing codes on the claim (i.e., the way the service is coded on the
claim does
not comply with national or local coding guidelines or is not billed as
rendered); or
* Inappropriately allocating costs on a cost report.
Abuse (Medicare.gov) - Answer: Abuse occurs when doctors or
suppliers do not follow good medical practices that can result in
unnecesary costs to Medicare. These practicies may result in
,unnecessary costs to the Medicare Program, improper payment, or
services that are not medically necessary
Abuse (Medicare Part C & D Compliance): Abuse includes actions that
may, directly or indirectly, result in: - Answer: *Unnecessary costs to
the Medicare Progam
*Improper payment
*Payment for services that fail to meet professionally recognized
standards of care
*Services that provider has not knowingly and/or intentionally
misrepresented facts to obtain payment.
Abuse cannot be differentiated categorically from fraud, because the
distinction between "fraud" and "abuse" depends on specific facts and
circumstances, intent and prior knowledge, and available evidence,
among other factors.
ACA - Answer: Affordable Care Act
Accountable Care Organization. (ACO) - Answer: A health care
organiztion that is formed by a group of health care providers
(physicians, hospitals and other providers), with the goal of providing
coordinated and integrated care.
, It is characterized by a payment and care delivery model that seeks to
tie provider reimbursements to quality of care metrics and reductions
in the total cost of care for an assigned population of patients.
Thus the ACO is "accountable" to the patients and the 3rd-party payer
for the quality, appropriateness and efficiency of the health care
provided. An ACO may employ a range of payment models
Active Case - Answer: An investigation that is assigned to an SIU staff
member who is responsible for its follow-up, tracking and completion.
Actuarial justification - Answer: The demonstration by an insurer that
the premiums collected are reasonable, given the benefits provided
under the plan or that the distribution of premiums among
policyholders are proportional to the distribution of their expected
costs, subject to limitations of state and federal law.
The Affordable Care Act requires insurers to publically disclose the
actuarial justifications behind unreasonable premium increases.
Advanceable Tax Credit - Answer: The Affordable Care Act provides
insurance premium subsidies to certain low- and middle-income people
(individuals with income up to 400% of the poverty line and single
