A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

aberrancy - medical services that deviate from what is considered normal or typical when compared to the national average

ABN - advance beneficiary notice

abuse - actions that directly or indirectly, result in unnecessary costs to the Medicare or Medicaid programs, improper payment, or payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Some inappropriate practices may initially be considered abusive, but later evolve into fraud. See also fraud.

Act - usually refers to the Social Security Act

adjudication - process of determining whether a Medicare claim is paid

adjustment - additional payment or correction of records on a previously processed claim

administrative law judge (ALJ) - hears appeals of denied claims, as well as appeals from proposed OIG exclusions

admission - entry to a hospital or other healthcare institution as an inpatient

advance beneficiary notice (ABN) - written notification to a patient, before a service is rendered, that payment may be denied or reduced, because the service may not be covered as medically reasonable and necessary

advance registered nurse practitioner (ARNP) - nurse with two or more years of advanced training who has passed a special exam

ALJ - administrative law judge

AMA - American Medical Association

ambulatory surgical center (ASC) - facility that operates exclusively for the purpose of providing outpatient surgery services to patients

ancillary services - professional services by a hospital or other inpatient health program, other than room, board, and surgery (e.g., laboratory, X-ray, drugs)

appeal - request for reconsideration should you disagree with any decision made about a claim or overpayment processed by Medicare. This request is made to your Medicare contractor

appellant - an individual who appeals a claim decision

approved charge - amount Medicare pays a physician based on the Medicare fee schedule or its transition rules; physicians may bill beneficiaries for an additional amount, subject to the limiting charge.

ASC - ambulatory surgical center

assignment - provider agrees to accept Medicare approved charges as payment in full and beneficiary agrees to have Medicareês share of cost of service paid directly to the provider

audit - process to ensure that Medicare reimburses providers based only on costs associated with patient care 

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B

balance billing, excess charge - difference between billed amount and amount approved by Medicare

Balanced Budget Act of 1997 (BBA) - law that changes sections of the Social Security Act, including several anti-fraud and abuse provisions and improvements to protect program integrity

BBA - Balanced Budget Act of 1997

BCBSA - Blue Cross Blue Shield Association

beneficiary - person eligible to receive Medicare or Medicaid payment and/or services

beneficiary impersonation - use of lost, stolen, or otherwise obtained Medicare identification to unlawfully procure Medicare benefits

benefit period - the measure of a Medicare beneficiaryês use of hospital and skilled nursing facility services

billing service - company that furnishes billing, collection, and/or claim filing services for physicians and/or suppliers, for a fee

Blue Cross Blue Shield Association (BCBSA) - nonprofit corporation representing the Blue Cross and Blue Shield plans on a national level as a coordinating agency in marketing, government relations, and other system wide initiatives; owns the Blue Cross Blue Shield mark and sets approval standards

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C

Carrier Advisory Committee (CAC) - a formal mechanism for physicians to be informed of and participate in the development of a Local Medical Review Process in an advisory capacity. This group also discusses ways to improve administrative policies that are within carrier discretion.

CAH - Critical Access Hospital

calendar year (CY) - January 1 through December 31

capitation rate - fixed amount CMS pays to a managed care plan selected by an enrolled Medicare beneficiary

carrier - CMS contractor that determines reasonable charges, accuracy, and coverage for Medicare Part B services and processes Part B claims and payments

case management - arrangement of services needed to give proper healthcare to a beneficiary; tracking of beneficiaryês use of facilities and resources

Centers for Medicare & Medicaid Services (CMS) - federal agency, part of DHHS; administers and oversees the Medicare Program and a portion of the state Medicaid program. Responsibilities include managing contractor claims payment, fiscal audit and/or overpayment prevention and recovery, and developing and monitoring payment safeguards necessary to detect and respond to payment errors or abusive patterns of service delivery.

CFR - Code of Federal Regulations

CHAMPUS (TRICARE) - TRICARE, the new Department of Defense (DOD) triple-option healthcare program, brings together the healthcare delivery systems of each of the military services, as well as CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), the health program administered by the DOD to provide medical care to the dependents of active duty personnel and to retired members of the uniformed military services

claim - request for payment of Medicare benefits or services rendered by a provider or received by a beneficiary

clearinghouse - an organization, usually national, that, for a fee, receives and sorts provider claims and forwards them to the correct Medicare contractor or commercial insurer.

CLIA - Clinical Laboratory Improvement Amendments

Clinical Laboratory Improvement Amendments (CLIA) - 1988 legislation that set quality and performance standards for all laboratory testing. CLIA standards are national and are not Medicare-exclusive. CLIA applies to all providers rendering clinical laboratory and certain other diagnostic services, whether or not claims are filed to Medicare.

CMHC - community mental health center

CNS - clinical nurse specialist

CO - CMS central office in Baltimore, Maryland

COBRA - Consolidated Omnibus Budget Reconciliation Act

coinsurance, copayment - amount that Medicare will not pay; the beneficiary or the beneficiaryês supplemental insurance company is responsible for paying coinsurance to the physician

community mental health center (CMHC) - facility that provides outpatient mental health services to individuals residing within a specific geographic area.

concurrent care - certain E/M services that are rendered by more than one physician with the same or similar specialty on the same date of service

consultation - examination by an additional physician or specialist, at the request of a referring physician, the patient, or the patientês family

contractor - state or private health insurer that processes Medicare claims and makes payments to providers of services and to beneficiaries. See also carrier, durable medical equipment regional contractor (DMERC), and intermediary

copayment, see coinsurance

covered services - reasonable and medically necessary services, rendered to Medicare or Medicaid patients, and reimbursable to the provider

CPT - Current Procedural Terminology

Critical Access Hospital (CAH) - established as part of the BBA Medicare Rural Hospital Flexibility program to replace the Essential Access Community and Rural Primary Care Hospital programs

crossover claims ® Medicare claims that are also covered by other insurance (e.g., Medigap, private insurance)

Current Procedural Terminology (CPT) - system of uniform medical procedure codes to identify specific healthcare services performed; developed by the AMA and used by most insurers and providers for billing purposes

CY - calendar year

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D

date of service - date a service was actually performed

deductible - amount a beneficiary must pay before Medicare begins to pay for covered services and supplies

DHHS - U.S. Department of Health and Human Services; administers many of the federal ?social? programs dealing with the health and welfare of the citizens of the United States; parent of the Centers for Medicare & Medicaid Services (CMS)

diagnosis - identification of the patientês condition, cause, or disease

diagnosis related group (DRG) - system that groups patients according to principal diagnosis, presence of a surgical procedure, age, presence or absence of significant complications, etc.

diagnostic examination - procedures used to discover the nature and underlying cause of an illness

DME - durable medical equipment

DMERC - durable medical equipment regional contractor

documentation guidelines (DG) ® criteria used when preparing or reviewing documentation for an Evaluation and Management service

D.O. - doctor of osteopathy

DOD - U.S. Department of Defense

DOJ - U.S. Department of Justice

DRG - diagnosis related group

duplicate claims - billing for the same service more than once; Medicare may remove from the electronic billing network physicians who repeatedly submit duplicate claims

durable medical equipment (DME) - reusable medical equipment ordered by a doctor for use in a beneficiaryês home (e.g., walker, wheelchair, hospital bed)

durable medical equipment regional contractor (DMERC) - CMS contractor that provides Medicare claims processing and payment for DME, prosthetics, orthotics, and supplies

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E

EFT - Electronic Funds Transfer

EIN - Employer Identification Number

electronic funds transfer (EFT) - electronic transfer of Medicare payments directly to a providerês financial institution.

electronic media claims (EMC) - transmission of claims via modem to the contractor, eliminating mailroom processing and manual data entry; payment is released when CMS time requirements are satisfied, resulting in a faster cash flow turnaround for providers

Electronic Remittance Notice (ERN) - electronic summarized statement for providers, including payment information for one or more beneficiaries; equivalent to the Medicare Remittance Notice (MRN); see also Medicare Remittance Notice, Medicare Summary Notice, and Explanation of Medicare Benefits

eligible - qualified to receive benefits

eligibility date - starting date that benefits are available

E/M - evaluation and management services

EMC - electronic media claims

emergency - a situation in which a patient requires immediate medical intervention as a result of severe, life-threatening, or potentially disabling conditions

end-stage renal disease (ESRD) - kidney failure that is severe enough to require lifetime dialysis or a kidney transplant; ESRD patients are eligible for Social Security payments if found to be disabled

enrollment - the means by which a person establishes membership in a program or group

entitlement - state of meeting all of the requirements for a particular Medicare benefit; the date of entitlement begins at age 65 for most beneficiaries

ESRD - end stage renal disease

excess charge, see balance billing

exclusion - situation or condition where coverage is disallowed by a subscriberês contract; DHHS/OIG penalty imposed on a provider, prohibiting the individual from billing Medicare or other government programs

exclusion list, sanctioned provider list - OIG list of providers, individuals, and entities that are excluded from Medicare reimbursement; includes identifying information about the sanctioned party, specialty, notice date, sanction period, and sections of the Social Security Act used in arriving at the determination to impose a sanction. The OIG sanctioned provider list is available on the Internet. Go to: http://exclusions.oig.hhs.gov/cgi-bin/oig_counter.pl and click on ?Search.? Debarment, exclusion, and suspension lists for all federal agencies are available on the Internet at http://epls.arnet.gov, under ?EPLS Reports Menu.?

experimental, investigative - any treatment, procedure, equipment, drug, drug usage, device, or supply not generally recognized as accepted medical practice; includes services or supplies requiring federal or other government approval not granted at the time services were rendered

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F

False Claims Act - federal legislation that prohibits knowingly filing a false or fraudulent claim to the government for payment, knowingly using a false record or statement to obtain payment on a false or fraudulent claim paid by the government, and conspiring to defraud the government by getting a false or fraudulent claim allowed or paid

Federal Employees Health Benefits (FEHB) program - the largest private employer-sponsored healthcare program in the country, with about 300 participating health insurance plans and over 8.7 million federal employees, retirees, and dependents

fee-for-service - payment system where providers are paid a specific amount for each service rendered

fee schedule, Medicare fee schedule (MFS) - complete list of medical procedure codes and the maximum dollar amounts Medicare will pay providers for each service rendered for a beneficiary. MFS is based on the calculation of several components, including relative value unit (RVU). RVU is based on three factors: work, overhead, and malpractice.

FI - fiscal intermediary

fiscal intermediary (FI), see intermediary

fiscal year (FY) - October 1 through September 30, for Medicare Parts A and B

MR - Medical review

Medical review (MR) - medical review process used by contractors; includes analysis of claims data to focus medical review efforts in the most significant areas of over-utilization, abusive billing, and inappropriate care

fraud - knowing and willful execution, or attempt at execution, of a scheme or artifice to defraud any healthcare benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any money or property owned by, or under the custody or control of, any healthcare benefit program. See also abuse, hotline

FY - fiscal year

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G

gaps, Medicare gaps - costs or services that are not covered under the Medicare plan

global fee - combined technical (equipment) and professional (physician) charges or payment

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H

HCFA - Health Care Financing Administration. See CMS.

HCPCS - Healthcare Common Procedure Coding System

Health Care Financing Administration (HCFA) - federal agency, part of DHHS; administers and oversees the Medicare Program and a portion of the state Medicaid program. Responsibilities include managing contractor claims payment, fiscal audit and/or overpayment prevention and recovery, and developing and monitoring payment safeguards necessary to detect and respond to payment errors or abusive patterns of service delivery. (Name was changed to: Centers for Medicare & Medicaid Services.)

Healthcare Common Procedure Coding System (HCPCS) - uniform method for providers and suppliers to report professional services, procedures, and supplies. HCPCS includes CPT codes (Level I), national alphanumeric codes (Level II), and local codes (Level III) assigned and maintained by local Medicare contractors.

Health Insurance Claim Number (HIC/HICN) - unique alphanumeric Medicare entitlement number assigned to a Medicare beneficiary; appears on the Medicare card

Health Insurance Portability and Accountability Act of 1996 (HIPAA) - one provision imposes significant changes to fraud and abuse controls; another provision protects health insurance coverage for workers and their families when they change or lose their jobs, including those with pre-existing medical conditions

health maintenance organization (HMO) - organizations that combine the functions of insurers and providers of care, giving most necessary medical care for a prepaid fee and placing an emphasis on prevention and careful assessment of medical necessity

health professional shortage area (HPSA) - medically under-served area of a state where physicians receive a ten percent bonus payment for all professional physician services (i.e., services subject to the Medicare physician fee schedule)

Hearing Officer hearing - independent determination related to claims where a party has appealed a review decision within six months of the date of notice of the decision; hearing is rendered by a hearing officer assigned by the contractor; amount in controversy must be at least $100, which can include more than one claim

HHA - home health agency

HI - Medicare Part A; see Hospital Insurance

HICN - health insurance claim number

HIPAA - Health Insurance Portability and Accountability Act of 1996

HMO - health maintenance organization

home health agency (HHA) - public or private organization that specializes in giving in-home skilled nursing and other therapeutic services, such as physical therapy

homebound - normally unable to leave home; leaving home takes considerable and taxing effort; patient may leave home for medical treatment or short, infrequent absences for nonmedical reasons, like a trip to the barber

home healthcare - part-time healthcare services provided in the home for the treatment of an illness or injury. Medicare pays for home care only if the type of care needed is skilled and required on an intermittent basis and is intended to help people recover or improve from an illness, not to provide unskilled services over a long period of time.

hospice - facility providing pain relief, symptom management, and supportive services to terminally ill people and their families; eligible beneficiary must have a life expectancy of six months or less

hospital - institution with organized medical staff, with permanent facilities that include inpatient beds, and with medical services, including physician services and continuous nursing services, to provide diagnosis and treatment for patients with a variety of medical conditions, both surgical and nonsurgical

hospital based physician - A doctor of medicine or osteopathy, salaried or unsalaried, under contract or arrangement to provide services in a hospital setting, who renders treatment or services in the hospital environment

hospital, special - institution with organized medical staff, with permanent facilities that include inpatient beds, and with medical services, including physician services and continuous nursing services, to provide definitive diagnosis and treatment for patients with specific needs, including obstetrics, tuberculosis, psychiatry, physical medicine, rehabilitation, and similar specialized treatment

Hospital Insurance (HI) - Part A of Title XVIII of the Social Security Act, which provides insurance for hospital, skilled nursing facility, home healthcare, and hospice costs to workers and beneficiaries insured under Social Security, certain dependents, and certain disabled Social Security beneficiaries; see also Medical Insurance

hotline - providers and the public are encouraged to ask questions about fraud and abuse of DHHS programs and grants or to report suspected fraudulent or abusive activities; contact the local Medicare contractor or call the national DHHS/OIG hotline directly at: 1-800-HHS-TIPS

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I

ICD-9-CM - International Classification of Diseases, 9th Revision - Clinical Modification; a national coding method to enable providers to effectively document the medical condition, symptom, or complaint that is the basis for rendering a specific service; the coding system consists of three- to five-character numeric or alphanumeric codes for reporting purposes

?incident to? services - services rendered by employees of physicians or physician-directed clinics, when the services provided are integral, though incidental, to the physicianês professional service

inpatient - beneficiary who has been admitted at least overnight to a hospital or other health facility for the purpose of receiving a diagnosis, treatment, or other health service

interactive telecommunication systems - multimedia communications equipment that permits real-time consultation among a consultant, referring practitioner, and beneficiary

intermediary, fiscal intermediary (FI) - CMS contractor that determines reasonable charges, accuracy, and coverage for Medicare Part A services and processes Part A claims and payments

inquiry - written request for information, usually pertaining to claim status or general information, such as deductible or entitlement

IPL - independent physiological laboratory

investigative, see experimental

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J

judicial review - part of the Medicare appeal process; if at least $1,000 remains in controversy following the ALJês decision, judicial review before a federal district court judge can be considered

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K

kickback - situation in which a laboratory or other business agrees to pay a physician for every patient referred for a specific study or other service; prohibited by federal law

L

LCSW - licensed clinical social worker

licensed physician - physician who is authorized to perform services within limitations imposed by the state on the scope of practice; issuance by a state of a license to practice medicine constitutes legal authorization; see also physician

lifetime reserve days - the nonrenewable, one-time bank of 60 days that a Medicare patient is given to use when the covered days of a spell of illness are exhausted

limiting charge - maximum amount that a nonparticipating physician may legally charge a Medicare beneficiary for services billed on nonassigned claims

LMRP - local medical review policy

local medical review policy (LMRP) - formal document, developed through a specifically defined process; provides criteria for claim and review payment decisions ensuring that suitability of the carrierês medical policies, medical care, and review guidelines are consistent with standards of medical practice

long-term care - custodial care given at home or in a nursing home for people with chronic disabilities and lengthy illnesses; not covered by Medicare

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M

managed care, see Medicare + Choice

M.D. - medical doctor

Medicaid - joint federal and state program, established by Title XIX of the Social Security Act; helps with medical costs for some people of all ages who have low incomes and limited resources; programs vary from state to state

Medical Insurance, Supplementary Medical Insurance (SMI) - Part B of Title XVIII of the Social Security Act, which provides insurance for doctorsê services, outpatient hospital care, and various services, such as ambulance and laboratory services, DME, and physical/occupational therapists, to workers and beneficiaries insured under Social Security, certain dependents, and certain disabled Social Security beneficiaries; see also Hospital Insurance

medically necessary services - services Medicare determines to be consistent with symptoms or diagnosis and treatment of the beneficiaryês condition, disease, ailment, or injury; appropriate with regard to standards of good medical practice; provided not primarily for the convenience of the insured, the hospital, or the physician; and the most appropriate level of service that can be safely provided

Medicare - federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with end stage renal disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD)

Medicare certified provider - physician, other individual, or entity meeting certain quality standards that provides outpatient self-management training services and other Medicare covered items and services

Medicare mill - provider group that aggressively seeks out Medicare patients

Medicare + Choice - Part C of the Medicare Program; set of heath care options created by BBA; ?managed care? plan; includes HMO, POS, PSO, PPO, MSA, RFP, private fee-for-service plan

Medicare Part A, see Hospital Insurance

Medicare Part B, see Medical Insurance

Medicare Part C, see Medicare + Choice

Medicare Remittance Notice (MRN) - paper summarized statement for providers, including payment information for one or more beneficiaries; equivalent to the Electronic Remittance Notice (ERN); formerly called Provider Claim Summary (PCS). See also Electronic Remittance Notice, Medicare Summary Notice, and Explanation of Medicare Benefits

Medicare Secondary Payer (MSP) - the statutory requirement that, under certain circumstances, private or other government insurance programs available to beneficiaries be exhausted before Medicare must pay

Medicare Summary Notice (MSN) - statement sent to a Medicare beneficiary that indicates how Medicare processed the claim; see also Electronic Remittance Notice, Medicare Remittance Notice, and Explanation of Medicare Benefits

Medicare Trust Funds - U.S. Department of Treasury accounts established by the Social Security Act for the receipt of revenues, maintenance of reserves, and disbursement of payments for Medicare Programs

Medigap - Medicare supplemental health insurance policies sold by private insurance companies and designed to supplement, or fill ?gaps? in, Medicare coverage; such policies usually, but not always, feature coverage of copayments and deductibles

MEDPARD Directory - state/county directory of physicians participating in the Medicare Program

modifier - two-character code appended to a CPT code; indicates that a service or procedure has been changed by some specific situation, but not changed in definition or code

MRN - Medicare Remittance Notice

MSA - Medicare medical savings account

MSN - Medicare Summary Notice

MSP - Medicare Secondary Payer

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N

nonassigned claim - claim potentially payable directly to the Medicare beneficiary

nonparticipating physician - physician who does not sign a participation agreement and who is not obligated to accept assignment on Medicare claims; may accept assignment of Medicare claims on a case-by-case basis

nonphysician practitioner - healthcare provider who meets state licensing requirements to provide specific medical services. Medicare allows payment for services furnished by nonphysician practitioners, including but not limited to advance registered nurse practitioners (ARNP), clinical nurse specialists (CNS), licensed clinical social workers (LCSW), physician assistants (PA), nurse midwives, physical therapists, and audiologists.

normal/reasonable - applying normal collection processes to Medicare as well as non-Medicare patients.

NP - nurse practitioner

nursing home - place that gives nursing care, help with healing after an injury or hospital stay, or custodial care

O

OBRA - Omnibus Budget Reconciliation Act

occupational therapy - services given to help a beneficiary return to his or her usual activities (such as bathing, preparing meals, and housekeeping) after an illness, either on an inpatient or outpatient basis

OCR - optical character recognition

Office of the Inspector General (OIG) - an organizational component of the Office of the Secretary, DHHS; responsible for conducting and supervising audits, investigations, and inspections relating to the programs and operations of DHHS, including Medicare and Medicaid. OIG provides leadership and coordination, recommends policies and corrective actions, prevents and detects fraud and abuse in DHHS programs and operations, and is responsible for all DHHS criminal investigations, including Medicare fraud, whether committed by contractors, grantees, beneficiaries, or providers of service.

OIG - Office of the Inspector General

open enrollment period - the one opportunity each year when physicians may change participation status for the following calendar year, usually in November.

optical character recognition (OCR) - an automated scanning process similar to scanners that read price labels in grocery stores; some contractors use OCR to scan claims information for further processing

ORT - Operation Restore Trust; federal/state partnership to fight Medicare and Medicaid fraud, waste, and abuse

outlier days - days for which extra payment is made under PPS for long stay cases

outpatient - patient who receives care at a hospital or other health facility without being admitted to the facility; outpatient care also refers to care given in organized programs, such as outpatient clinics

overpayment - amount of money received by a party that exceeds the correct payment; an overpayment occurs when Medicare has paid a physician or entity more than the amount owed

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P

PA - physician assistant

Pap smear, Papanicolaou test - used for early detection of cancer and precancerous cellular changes

Part A, see Hospital Insurance

Part B, see Medical Insurance

Part C, see Medicare + Choice

participation program - Medicare Program in which a physician voluntarily enters into an agreement to accept assignment for all services provided to Medicare patients

participating physician - physician who signs a participation agreement to accept assignment on all claims submitted to Medicare

patient - person under treatment or care, by a physician or surgeon, or in a hospital

payment floor - time frame established for contractor payment of Medicare Part B claims

peer review - evaluation of a healthcare practitionerês professional services by other practitioners of the same profession.

Peer Review Organization (PRO) - organization contracting with CMS to review medical necessity and quality of care provided to Medicare beneficiaries

physical therapy - treatment of injury and disease by mechanical means, e.g., heat, light, exercise, and massage

physician - doctor of medicine or osteopathy; doctor of dental surgery or dental medicine; chiropractor; doctor of podiatry or surgical chiropody; or doctor of optometry, legally authorized to practice by a state in which he or she performs this function

physician assistant (PA) - person with two or more years of advanced training who has passed a special exam

physician associate (PA) group — partnership, association, or corporation composed of two or more physicians and/or nonphysician practitioners who wish to bill Medicare as a unit

PIN - see provider identification number

place of service (POS) - where a service is performed, such as a hospital (inpatient or outpatient), doctorês office, or skilled nursing facility

plan of care - a doctorês written plan stating the kind(s) of service(s) and care a beneficiary needs for his or her health problem

POS - place of service; point of service (Medicare + Choice option)

postoperative visit - visit related to recovery of the surgery, during the postoperative period of the surgery

PPO - preferred provider organization

PPS - prospective payment system

preferred provider organization (PPO) - managed care plan in which the patient uses providers and services that belong to a network

premium - the amount a beneficiary regularly pays to Medicare, an insurance company, or a healthcare plan, for healthcare coverage

preventive care - services to keep a beneficiary healthy or to prevent illness, such as Pap smears, mammograms, prostate and colorectal cancer screenings, and influenza and pneumonia vaccinations

primary payer - insurer (private or governmental) that pays first on a claim for medical care

procedure - an established series of steps used to eliminate a health problem or to learn more about it, such as surgery, tests, and inserting an intravenous line

procedure code - see Current Procedural Terminology (CPT)

professional component - diagnostic test situation where the physician interprets but does not perform the test

prognosis - prediction of a probable course of a disease and the chances of recovery

prosecute - submit a charging document to a court; seek a grand jury indictment against person(s) accused of committing criminal offenses

prospective payment system (PPS) - mandated by the Balanced Budget Act of 1997 (BBA); changes Medicare payments from cost-based to prospective, based on national average capital costs per case. PPS helps Medicare control its spending by encouraging providers to furnish care that is efficient, appropriate, and typical of practice expenses for providers. Patients and resource needs are statistically grouped, and the system is adjusted for patient characteristics that affect the cost of providing care. A unit of service is then established, with a fixed, predetermined amount for payment.

provider - doctor, healthcare professional, hospital, or healthcare facility approved to furnish care to Medicare beneficiaries and to receive payment from Medicare

provider identification number (PIN) - unique individual provider number issued to a provider by the local Medicare contractor, allowing the physician or patient to receive reimbursement for claims filed to the contractor

PSA - screening prostate specific antigen blood test, detects marker for adenocarcinoma of the prostate

PSO - provider sponsored organization

purchased diagnostic test - test, such as an EKG, X-ray, or ultrasound, purchased from an outside supplier; the physician does not personally perform or supervise the test; see also professional component and technical component

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Q

quality assurance - process of looking at how well a medical service is provided; may include formally reviewing healthcare given, locating and correcting the problem, and checking to see if the changes worked

query - request transmitted to SSA for information on a beneficiary

qui tam - the ?Whistle Blower,? or ?qui tam? provision, allows any person having knowledge of a false claim against the government to bring an action against the suspected wrongdoer on behalf of the United States Government. A person who files a qui tam suit on behalf of the government is known as a ?relator? and may share a percentage of the recovery realized from a successful action.

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R

referral - specialty, inpatient, outpatient, or laboratory services that are ordered or arranged, but not furnished directly; approval from a beneficiaryês primary or other physician to see a specialist or get certain services

remittance notice, see Medicare Remittance Notice (MRN)

review of systems (ROS) - inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced

regional home health intermediary (RHHI) - organization that contracts with Medicare to pay home health bills and to audit home health physicians

regional office (RO) - one of several CMS offices around the country that provide policy guidance and other liaison services to Medicare contractors. The CMS central office (CO) in Baltimore, Maryland, provides operational direction and policy guidance for nationwide Medicare/Medicaid administration. ROs are in Atlanta, Boston, Chicago, Dallas, Denver, Kansas City, New York, Philadelphia, San Francisco, and Seattle.

relator - see qui tam

reopening - reevaluation of a claim determination; not an appeal right but a discretionary action in response to the identification of an error, fraud, or the submission of new material and information not available at the time of the previous adjudication

reserve days - see lifetime reserve days

resident - for Medicare purposes, a physician who is participating in an approved postgraduate training program or one who is not in an approved program but who is authorized to practice only in a hospital setting

restitution - court-ordered giving or returning of funds

review - request for additional consideration of a previously processed service

RFP - religious fraternal benefit society plan

RHHI - regional home health intermediary

RO - regional office (CMS)

RPCH - Rural Primary Care Hospitals; see Critical Access Hospital (CAH)

RRB - Railroad Retirement Board

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S

sanction - see exclusion

sanctioned provider list - see exclusion list

screening test - examination for early detection of a specific disease; Medicare pays for specific routine screenings, such as Pap smears, mammograms, prostate cancer screenings, and colorectal cancer screenings

skilled nursing care - provided or supervised by licensed nurses under general direction of a physician

skilled nursing facility (SNF) - institution or distinct part of an institution having a transfer agreement with one or more hospitals; primarily engaged in providing inpatient skilled nursing care or rehabilitation services

SMI - Supplementary Medical Insurance; Medicare Part B; see Medical Insurance

Social Security Administration (SSA) - federal agency that administers various programs funded under the Social Security Act; determines eligibility for Medicare benefits

SSN - Social Security Number

standing order - prescription written in advance by a responsible, identifiable physician to cover certain common treatment situations

subrogation - insurerês right to recovery of money paid when another party is found to be legally responsible for payment of expenses

supplier - entity that provides medical items or equipment, such as a wheelchair or portable X-ray

supplemental insurance - policy purchased by a beneficiary to help pay charges, such as deductibles, coinsurance, and excluded services, that Medicare does not pay

surrogate UPIN - used if no UPIN has been assigned to the ordering/referring physician; temporary, except those of retired physicians; may be used only until an individual UPIN is assigned

swing-bed hospital - rural hospital with fewer than 50 beds that can "swing" beds between hospital and SNF levels of care and that may be reimbursed under Medicare for furnishing post-hospital extended care services to Medicare beneficiaries

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T

technical component - diagnostic test situation where the physician performs the test but does not interpret the results

TIN - Tax Identification Number (e.g., SSN or EIN)

Title XVIII of the Social Security Act - statutory authority for the Medicare Program

Title XIX of the Social Security Act - statutory authority for the Medicaid program

treatment - action taken to help with a health problem

TRICARE - see CHAMPUS

U

Unique Physician/Practitioner Identification Number (UPIN) - six-character alphanumeric code, assigned by CMS to each Medicare provider and used to identify a referring physician

United States, U.S. - For Medicare coverage purposes, the term United States means the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. For purposes of services furnished on a ship, it includes the territorial waters adjoining the land areas of the United States.

unprocessable claim - Medicare process for notifying a physician that his or her claim cannot be processed, due to specific incomplete or incorrect information; until the errors are corrected and the claim resubmitted, the claim cannot be paid, and the physician may not charge the beneficiary for the service

UPIN - Unique Physician/Practitioner Identification Number

utilization review - review that determines the medical necessity of services furnished or ordered by a physician or other provider

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V

VA - U.S. Department of Veterans Affairs; formerly Veterans Administration

vendor - provides hardware, software, and/or ongoing support services for a fixed purchase price or a lease-to-own option for providers to file electronically to Medicare

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W

waived test certificate - issued to a provider who, with minimal supervision, performs simple tests posing little or no risk to the patient if performed incorrectly

waiver of liability - provision designed to protect a beneficiary from liability under certain conditions when services he or she received are found to be not reasonable and necessary

WC - Workers Compensation

Whistle Blower law, see qui tam

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