AN ORGANIZION THAT IS A Private-Public Partnership Against Health Care Fraud
What is the NHCAA
100
TIN, CPT, DX, Date of Service, customer information and generally housed in a warehouse
What are data elements
100
overutilization of services, or other practices that, directly or indirectly, result in unnecessary
What is WASTE
100
Billing for a higher‐level treatment than was actually provided.
What is UPCODING
100
Includes source, allegation, plan, has due dates and outcomes and proposed completion dates
What is an Investigative Action Plan
200
The year the NHCAA was formed with the collaboration of Travelers, MetLife and Aetna
What is 1985
200
This is an ongoing function and changes over time as the investigator, reviewer, etc find patterns
What is data analysis
200
includes actions that may, directly or indirectly, result in: unnecessary costs, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary.
What is ABUSE
200
Billing separately for services that are already included in the primary procedure.
What is UNBUNDLING
200
Medical records, license check, data review, internal sources for information, working with law enforcement, state agencies, policy, etc.
What is the Collection of Evidence or Research and Review
300
YEARLY GATHERING OF SIU, FBI AND LAW ENFORCEMENT TO DISCUSS TRENDS AND ATTEND WORKSHOPS
What are components to being a successful investigator and/or lead
300
is knowingly and willfully executing, or attempting to execute, a scheme
What is FRAUD
300
Physicians not providing enough care or delaying needed
care.
What is UNDER UTILIZATION
300
Refer case to law enforcement agencies (DOI, FBI, DOJ, etc.)
Establish an overpayment and send letter to (SOI)
Enter a settlement agreement with the SOI
Engage in civil litigation
Place a flag with a specific protocol
Implement an edit
What is RESOLUTION STRATEGIES
400
A state agency that governs providers and/or hospitals as well as private payors
What is the Dept of Insurance (DOI)
400
when a provider pays the fine and costs to avoid a lenghtly investigation and possible indictment
What is a SETTLEMENT
400
Federal healthcare system
What is CMS (Medicare)
400
Use of medical benefits by an unauthorized individual.
What is MEDICAL IDENTITY THEFT
400
Establish damage theory
Determine and implement a definitive resolution strategy
What is ONE OF THE IMPORTANT ROLES OF AN INVESTIGATOR and/or WA LEAD
500
Issues a certification that the HCP or Facility can practice in their state
What is the Stated Medical Licensing Boards
500
It can hit all payors, all clients, all customers due to a breakdown in the claim systems and costs millions
What is a scheme
500
EHFCN
What is European Healthcare Fraud and Corruption Network
500
illegal for individuals or entities to knowingly or
willfully offer, pay, solicit, or receive remuneration in order to induce or reward business
What is THE ANTI-KICKBACK STATUTE
500
An Investigator or WA Lead can not do this but law enforcement can