Compliance/Other Key Definitions
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Glossary of Terms: Compliance / Other Key Definitions ComplianceConsolidated Omnibus Budget Reconciliation Act (COBRA):
Health benefit provisions passed by Congress in 1986 amending the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act to provide continuation of group health coverage that otherwise might be terminated.
Division of Insurance (DOI):
The primary mission of the Division of Insurance is to monitor the solvency of its licensees in order to promote a healthy, responsive and willing marketplace for consumers who purchase insurance products.
Employee Retirement Income Security Act (ERISA):
A federal law that exempts self-insured health plans from state laws governing health insurance, including contribution to risk pools, prohibitions against disease discrimination and other state health reforms.
False Claims Act:
A federal law that imposes liability for treble damages and fines of $5,000 to $10,000 for knowingly submitting to the federal government a false or fraudulent claim for payment.
Federal Register:
An official publication of the federal government that provides final and proposed regulations of federal legislation.
www.gpoaccess.gov/fr/index.html Health Insurance Portability and Accountability Act (HIPAA):
Federal legislation, enacted in 1996, mandating regulations governing privacy, security and administrative simplification standards for health care information. HIPAA governs how health care organizations handle all facets of information management, including patient records.
Office of Inspector General (OIG):
The enforcement arm within the U.S. Department of Health and Human Services that oversees investigations of alleged violations of Medicare and Medicaid laws and rules. (Most federal agencies have their own OIG.) www.hhs.gov
Other Key DefinitionsAgency for Healthcare Research and Quality (AHRQ):
A federal agency within the Public Health Service responsible for research on quality, appropriateness and cost of health care. AHRQ also centralizes access to state inpatient data. www.ahrq.gov
American Hospital Association (AHA):
A national association that represents allopathic and osteopathic hospitals in the U.S. AHA is based in Washington, D.C., with operational offices in Chicago. www.aha.org
Disproportionate Share Hospital (DSH):
A hospital that provides care to a high number of patients who cannot afford to pay and/or do not have insurance.
Durable Medical Equipment (DME):
Equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use at home, such as hospital beds, wheelchairs and oxygen equipment. Replacement parts and accessories for implantable hearing solutions are considered prosthetics and are included as DME.
Electronic Health Record (EHR):
A patient’s computerized health information as recorded and maintained by a provider system. An EHR is distinguished from a physician health record (PHR) by control: an EHR is controlled by the provider’s system while a PHR is owned and controlled by the patient.
Group Purchasing Organization (GPO):
A group purchasing organization (GPO) is an entity that helps healthcare providers – such as hospitals, nursing homes and home health agencies – realize savings and efficiencies by aggregating purchasing volume and using that leverage to negotiate discounts with manufacturers, distributors and other vendors.
Independent Practice Association (IPA):
A health care delivery model in which an association of independent physicians contracts with health maintenance organizations and preferred provider organizations for physicians' services. The IPA physicians practice in their own offices and continue to see fee-forservice patients.
Management Service Organization (MSO):
A legal entity that provides practice management, and administrative and support services to individual physicians or group practices. An MSO may be a direct subsidiary of a hospital, a joint venture with physicians, a physician-owned organization or an investor-owned expertise.
Medical Consumer Price Index:
An inflationary statistic that measures the cost of all purchased health care services.
Out-of-pocket Maximums:
Dollar amounts set by MCOs that limit the amount a member has to pay out of his/her own pocket for particular healthcare services during a particular time period.
Physician-Hospital Organization (PHO):
A legal entity formed and owned by one or more hospitals and physician groups in order to obtain payer contracts and to further mutual interests; one type of integrated delivery system.
Premium:
A prepaid payment or series of payments made to a health plan by purchasers and often plan members, for medical benefits.
FAQs
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What is the Medicare Recovery Audit Program (RAC)?
A:
The responsibility of the RAC is to detect and correct improper Medicare payments from providers. The RAC will attempt to collect payment from providers who are identified through an auditing process. Improper payments and coding errors can result in a significant overpayment demand.
Q:
What is HIPAA?
A:
HIPAA, which stands for the Health Insurance Portability and Accountability Act, establishes national requirements for the electronic use, disclosure, storage and transmission of patient’s protected health information (PHI). HIPAA identifies how PHI may be used and disclosed by health care providers or covered entities, as defined in the law, and requires that certain security measures be utilized in maintaining and transmitting PHI electronically.
Q:
When is an implantable hearing device considered durable medical equipment (DME) and why?
A:
Although implantable hearing devices are initially introduced to the patient in a surgical setting, these devices have a number of external components as well. Like any electronic device, these external components are subject to breakage, malfunction, or loss and eventually need replacement or upgrade. As components of prosthetic devices, these items are often reimbursed as DME, such as Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule.
Q:
Are parts and accessories for cochlear implants (CI) and Baha® considered durable medical equipment (DME)?
A:
CI and Baha parts and accessories are often considered DME for the purposes of determining insurance benefits and reimbursement. However, each payer has a distinct definition of what is considered DME, so you should check with your payer to ensure benefit categories, payment levels, and participation requirements.
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Disclaimer: The information provided in this reimbursement site is provided as a set of guidelines only to address the unique nature of implantable hearing solutions technology and is not intended as legal advice. There is no guarantee that following these guidelines will result in any form of coverage or reimbursement from any insurance company or federal health care program payer. The information presented herein is subject to change at any time and may become outdated. This information cannot and does not contemplate all situations that the health care professional/provider may encounter. To be sure that you have the most current and applicable information available for your unique circumstances, please consult your own coding advisors, and payers to verify that the information provided herein is applicable to your needs. Seek your own legal advice regarding your reimbursement needs and the proper implementation of these guidelines. All products should be used according to their labeling. In all cases, services billed must be medically necessary, actually performed, and appropriately documented in the medical record.
Last update: 09/30/10
