Certified Compliance Technician (CCT) Exam Study Outline 2018

Certified Compliance Technician (CCT) Exam Study Outline 2018 December 2017 11240 Waples Mill Road, Suite 200, Fairfax, VA 22030 Phone: 703-281-4043 Fax: 703-359-7562 www.aaham.org

Copyright 2017 American Association of Healthcare Administrative Management (AAHAM) All Rights Reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage or retrieval system, without written permission from the AAHAM National Office in Fairfax, VA.

Acknowledgments This study outline is the work of the following committed and creative group of individuals: AAHAM CCT Committee Officer: Lori Sickelbaugh, CRCE-I, National First Vice President Committee Chair: Doris Dickey, CRCE-I, Illinois Chapter Committee Members: Heather Bode, CRCS-I, North/South Dakota Rushmore Chapter Sandra Peffer, CRCS-I, Ohio Western Reserve Chapter Colleen Wentz, CRCS-I, CCT, CRCP-I, CRCP-P, CRIP, Washington Inland Empire Chapter Instructional Designer Debra Halsey, Halsey & Co., Phoenix, AZ

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Contents Contents 1 Introduction Overview of this Outline... 1-1 Knowledge and Skill Requirements for Certification... 1-1 Glossary... 1-1 An Alternative to this Outline... 1-2 AAHAM Certification Programs... 1-2 Overview of CCT Exam... 1-3 Eligibility... 1-3 Applications, Fee and Deadlines... 1-4 Applications... 1-4 Fee... 1-4 Deadlines... 1-4 Exam Format and Grading... 1-4 Suggested Preparation... 1-5 Re-certification... 1-6 2 Study Outline Knowledge and Skill Requirements... 2-1 Glossary... 3-1 AAHAM i

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Introduction 1 Introduction Overview of this Outline The American Association of Healthcare Administrative Management (AAHAM) offers this Certified Compliance Technician (CCT) Exam Study Outline - 2018 to help you prepare for the CCT examination. Knowledge and Skill Requirements for Certification This outline lists the knowledge and skill requirements for certification. TIP: Pay careful attention to the wording of the requirements, as it indicates specifically what you must be able to do in order to achieve certification. For example, you ll need to be able simply to List the two types of reporting systems for adverse events, while you ll need to be able to both List and describe the seven elements of an effective compliance plan. The word describe indicates you ll need to be able to do more than just state the seven elements; you ll need to know a little about each element. Glossary There is an extensive glossary at the back of this outline. TIP: It will be extremely helpful when taking the exam if you are very familiar with the terms and definitions in the glossary. AAHAM (Rev. 12/01/2017) 1-1

Introduction An Alternative to this Outline Should you want a more comprehensive and robust study aid, consider purchasing the AAHAM Certified Compliance Technician (CCT) Exam Study Manual - 2018. Like this outline, the study manual lists the specific skill and knowledge requirements you must meet to achieve certification. However, the study manual also includes extensive information you can review to prepare for the exam. In addition, the study manual has Knowledge Checks where you can test your ability to apply what you have learned, with answer keys so you can assess your progress. To purchase the Certified Compliance Technician (CCT) Exam Study Manual - 2018, please visit our website at http://www.aaham.org/certification.aspx. AAHAM Certification Programs Healthcare revenue cycle professionals across the nation and around the globe are looking for an edge a way to work smarter, build a career, stay informed, and make the right contacts; an AAHAM certification helps you achieve all of these goals. AAHAM is the premier association of healthcare revenue cycle professionals. AAHAM members have committed to the highest standards of professionalism, integrity, and competence. They are dedicated to the exchange of knowledge about changes in technology and concepts in the delivery of healthcare. AAHAM certification is an investment in your personal growth and your professional future, regardless of where you are in your career. Available AAHAM certifications include: Certified Revenue Cycle Executive (CRCE) - for all senior/executive leaders and directors in the healthcare revenue cycle, to assist in critical thinking, communication, and strategic management skills Certified Revenue Cycle Professional (CRCP) - for all managers and supervisors in the healthcare revenue cycle, to help in effectively managing key aspects of the revenue cycle Certified Revenue Cycle Specialist (CRCS) - for frontline revenue cycle staff with responsibilities in the revenue cycle with a focus on specific knowledge required in registration, billing, and credit, and collections 1-2 AAHAM (Rev. 12/01/2017)

Introduction Certified Revenue Integrity Professional (CRIP) - for anyone in the revenue cycle industry to help ensure that facilities effectively manage their chargemaster, and bill and document appropriately for all services rendered to a patient Certified Compliance Technician (CCT) - for all revenue cycle staff who must meet employers' annual compliance training requirements In addition to bolstering your resume, earning an AAHAM certification is an essential, proactive step in maximizing your knowledge, income potential, and networking opportunities in the healthcare revenue cycle industry. In particular, many AAHAM members use the CRCS, CRCP, and CRCE certifications as a career ladder to help achieve their professional goals. Overview of CCT Exam Introduced in 2004, the CCT exam tests compliance staff proficiency and provides a resource for healthcare managers to ensure staffing competence. Successful completion will establish individuals as being proficient and competent in compliance and regulatory issues. Further, the designation, sponsored by AAHAM, will provide recognition from your peers and healthcare executives nationally. In many instances, certification can help you get the job or promotion you really want. Eligibility Any person involved in the healthcare field is eligible for the CCT exam. Membership in AAHAM is not a requirement, although it is encouraged. One year of experience in a clinical or hospital setting is recommended. AAHAM (Rev. 12/01/2017) 1-3

Introduction Applications, Fee and Deadlines Applications There are two ways to apply for an exam: Online go to www.aaham.org; use the online application link on the technical certification page; and pay with a credit card (amount described under Fees below). Mail in obtain an application from www.aaham.org, Certification tab. Complete and mail the application with a check or money order (amount described under Fees below), payable to AAHAM, to: National AAHAM 11240 Waples Mill Rd., Ste. 200 Fairfax, VA 22030 If you have any further questions or would like to request a copy of the certification brochure, contact the AAHAM national office at 703-281-4043, ext. 211 or send an e-mail to julia@aaham.org. Fee The exam fee is $100. Deadlines The application and fee must be received by: December 15 for the March exam April 15 for the July exam August 15 for the November exam Exam Format and Grading The examination includes 80 multiple-choice questions. A grading report will appear after you submit your results at the completion of your exam. If a printer is available, you may print your scores. These scores will also be sent to you via e-mail to the e-mail address you provide on your application. You must attain a score of at least 70% in order to successfully pass the exam. 1-4 AAHAM (Rev. 12/01/2017)

Introduction Certificates are mailed directly to the examinees, with the address that was listed on their exam application. Examinees receive their certificate by the end of the month following the exam period. Suggested Preparation Independent research and hands-on experience will be necessary in order to successfully complete the exam. Be sure to allow enough time for all the preparation you want to do. Finding a study-buddy can be very helpful; try to pair up with another person in your chapter and take the exam together. Many chapters offer coaching sessions to help members prepare. We want you to succeed; therefore, we urge you to attend these sessions. The Chapter Technical Certification Chair determines the exact dates, times, and locations of exams. You should hear from your Chapter Certification Chair by the 7th of your examination month via phone, e- mail, or letter, using the information you provided on your application. If you do not hear from your Chapter Certification Chair by the 7th of that month, contact him or her directly. (There is a directory of Chapter Certification Chairs in the certification section of the AAHAM website, www.aaham.org.) TIP: Examinations are offered three times per year based on proctor availability, during March, July, and November. For further details, see the home page of www.aaham.org and view the Calendar of Events area. The day of the exam, you will need current photo identification. You will also need your AAHAM exam confirmation that contains your Test Taker Authorization Code, which you will receive via e-mail approximately one to two weeks before your exam date. You will be unable to take the exam without your Test Taker Authorization Code. WARNING: You will not be able to use study guides, written and/or electronic notes, or verbal and/or signaled help during the exam. Examinees who witness this conduct are required to report it to the examination proctor. AAHAM (Rev. 12/01/2017) 1-5

Introduction Plan your arrival approximately 15 minutes prior to the examination. This allows you ample time should delays or problems present themselves. Failure to arrive on time will negate sitting for the exam and result in forfeiture of the application. There are no refunds or postponements, and exam fees are non-transferable. The exam is taken online in the physical presence of a proctor. You will have 80 minutes to complete the exam. Re-certification There are two options to retain CCT certification: 1. Retake and pass the entire exam every three years. 2. Join as a national member and earn continuing education units (CEUs). In order to qualify for recertification, you must: Be a national member in good standing. You must join as a national AAHAM member within the calendar year you become certified. Earn 20 hours of CEUs within the three calendar years following certification. Ten of the CEUs must result from attendance at AAHAM-related educational programs. Dual certified individuals must adhere to these same requirements. 1-6 AAHAM (Rev. 12/01/2017)

Study Outline 2 Study Outline Knowledge and Skill Requirements In order to achieve certification, you should be able to: 1. Describe the role of the Office of Inspector General (OIG) in the implementation of compliance. Explain how the OIG protects the integrity of the federal Department of Health and Human Services. List and describe the seven elements of an effective compliance plan. List benefits of an effective compliance plan. Describe the evaluation and certification/accreditation process. List and describe the four components the OIG uses to plan and carry out audits, evaluations, investigations, and legal activities. List potential enforcement actions for noncompliance. List OIG recommendations for compliance in individual and small group physician practices. 2. Describe fraud and abuse prevention efforts. Define fraud and abuse. List types of individuals who can be considered violators of fraud. List types of CMS contractors that support the efforts to prevent, detect, and investigate fraud and abuse. Describe elements of the Anti-Kickback Statute. List items and activities that can be considered kickbacks. Explain the purpose and impact of the Safe Harbor regulations. Describe elements of the False Claims Act. Explain the Physician Self-Referral Law (Stark Law). Describe elements of Operation Restore Trust (ORT). Describe elements of Medicaid Fraud Control Units (MFCUs). AAHAM (Rev. 12/01/2017) 2-1

Study Outline 3. Describe the purpose and benefits of self-disclosure/self-reporting. Explain typical terms and protocol of a Corporate Integrity Agreement. Describe obligations established by the Patient Protection and Affordable Care Act (PPACA). 4. Describe the use of Fraud Alerts. Explain when Fraud Alerts are issued and reviewed, and the level of detail included. List and describe the four types of Fraud Alerts. Explain when a CMS Central Office Alert is prepared. 5. Describe elements of the Health Insurance Portability and Accountability Act (HIPAA). Describe the purpose of HIPAA. Explain the intent of the Health Care Fraud and Abuse Control (HCFAC) program. Describe the four HIPAA Administrative Simplification Provisions. List standard transaction formats mandated by HIPAA. Describe the purpose of the Privacy Rule and requirements for a Privacy Practices Notice. Describe the three categories of security standards. 6. Describe National Provider Identifier (NPI) Requirements. 7. Describe the purpose and key requirements of each of the following regulations related to credit and collections: Truth in Lending Act (Title I of the Consumer Credit Protection Act, also known as Regulation Z) Fair Credit Billing Act Fair Credit Reporting Act Fair Debt Collection Practices Act 8. Describe the purpose, key amendment, general provisions, and potential penalties of the Telephone Consumer Protection Act of 1991 (TCPA). 2-2 AAHAM (Rev. 12/01/2017)

Study Outline 9. Describe the objective and general provisions of the Clinical Laboratory Improvement Amendments (CLIA). Describe the enrollment process. Describe surveyor criteria. Name the types of certificates awarded. Explain when a Certificate of Waiver can be awarded. List the six CMS-approved CLIA accreditation organizations. Describe criteria for exemption from CLIA requirements. 10. Describe the purpose and impact of the Civil Monetary Penalties (CMP) provision of the Social Security Act. List potential fines and prison terms for various types of Privacy Rule violations. List administrative sanctions for inappropriate and/or fraudulent behavior on the part of a provider in addition to CMPs. Explain how settlements can resolve CMP cases. 11. Explain the integration of civil rights protection in healthcare. 12. Describe the purpose, enforcement, obligations, and potential penalties related to the Emergency Medical Treatment and Active Labor Act (EMTALA). 13. Describe the Comprehensive Error Rate Testing (CERT) program. Describe the purpose of the CERT program. List requirements and recommendations for submitting accurate and acceptable claims. Explain the purpose of monitoring in conjunction with review and analysis provided by HPMP Quality Improvement Organization Support Centers (QIOSCs). Describe the timeframe for fulfilling mandatory review requirements. 14. Describe the Health Care Quality Improvement Program (HCQIP). 15. List agencies that produce annual reports reviewing and analyzing Medicare payments. 16. List ways that CMS attempts to reduce the percentage of Medicare dollars paid. AAHAM (Rev. 12/01/2017) 2-3

Study Outline 17. Describe the ICD-10 code set. Describe the two types of ICD-10 implementations: ICD-10-CM and ICD-10-PCS. Explain the purpose of the 5010 transaction. List benefits of ICD-10. 18. Describe the six aims outlined by the Institute of Medicine (IOM) for improving today s healthcare system. 19. Explain the purpose and process of reporting adverse events. List the two types of reporting systems for adverse events. Describe advantages and disadvantages of mandatory reporting systems. Describe the MedWatch reporting system for physicians. 20. Explain the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act. List the purpose, benefits, and functions of electronic health records/electronic medical records. 21. Describe the Medicare Secondary Payer (MSP) provisions, including situations when Medicare is the secondary payer. 22. Describe the Recovery Audit Program. Explain the Recovery Audit Program goal and mission, and describe the results of the demonstration project. Identify Recovery Audit Contractors (RACs) and their regions. Describe the purpose of the RAC Data Warehouse. List three categories of improper payments. Identify services excluded from an Improper Payment Notification. Describe the RAC review processes and denials. List in order the five levels in the appeal process and key requirements for each level. 23. Describe the goals, responsibilities, and priorities of Zone Program Integrity Contractors (ZPICs). Identify examples of fraud complaints. 2-4 AAHAM (Rev. 12/01/2017)

Study Outline 24. Describe the Medicaid Integrity Program: Explain CMS s broad responsibilities under the program. Explain the role of Medicaid Integrity Contractors (MICs). Define the objective and three types of MIC audits. 25. Define common acronyms and terms. AAHAM (Rev. 12/01/2017) 2-5

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Glossary Glossary 5010 transaction the transaction developed to accommodate the ICD-10 coding instructions AABB American Association of Blood Banks; one of six CMS-approved accreditation organizations Abuse improperly, and often unknowingly, violating regulations ALJ hearing the third level of Medicare appeal; the amount in controversy threshold for 2012 is $130 American Association of Blood Banks AABB; one of six CMS-approved accreditation organizations American Osteopathic Association AOA; one of six CMS-approved accreditation organizations American Society of Histocompatibility and Immunogenetics ASHI; one of six CMS-approved accreditation organizations Anti-Kickback Statute the Act that makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration for referrals of items or services reimbursable by a federal healthcare program AOA American Osteopathic Association; one of six CMS-approved accreditation organizations Appeals Council Review the fourth level of appeal, which can be requested if the provider is not satisfied with the Administrative Law Judge s decision ASCA Administrative Simplification Compliance Act ASHI American Society of Histocompatibility and Immunogenetics; one of six CMS-approved accreditation organizations automated review a RAC review using various types of analytics to identify improper payments; usually done without a human review of the medical records AAHAM (Rev. 12/01/2017) 3-1

Glossary CAN-SPAM Act Controlling the Assault of Non-Solicited Pornography and Marketing Act CAP College of American Pathologists; one of six CMS-approved accreditation organizations CERT Comprehensive Error Rate Testing program instituted by CMS to monitor and calculate the accuracy and error rates for all MACs and to monitor the accuracy of Medicare payments to FIs, carriers, and DMERCs Certificate for Provider Performed Microscopy the CLIA certificate issued to a laboratory in which a physician, mid-level practitioner, or dentist performs specific microscopy procedures during the course of a patient s visit Certificate of Accreditation COA; the CLIA certificate issued to a laboratory on the basis of the laboratory s accreditation by an accreditation organization approved by CMS Certificate of Compliance COC; the CLIA certificate issued to a laboratory once the State Department of Health conducts an on-site survey (inspection) and determines that the laboratory is compliant with all applicable CLIA requirements Certificate of Registration the CLIA certificate issued to allow a laboratory to conduct nonwaived testing until the laboratory is surveyed to determine its compliance with the CLIA regulations Certificate of Waiver COW; the CLIA certificate issued to a laboratory that performs only waived tests ( simple laboratory examinations and procedures that have an insignificant risk of an erroneous result ) CIA Corporate Integrity Agreement (the agreement that spells out integrity measures required of a provider that has engaged in serious misconduct but is being allowed to continue participating in the healthcare programs) or Central Intelligence Agency CLIA Clinical Laboratory Improvement Amendment; the amendments that established quality standards for all laboratory testing CMP Civil Monetary Penalties CMS Centers for Medicare and Medicaid Services CMS Central Office Alert one of the five types of Fraud Alerts; prepared by a ZPIC if a scheme is about to be publicized on a national level, the case involves patient abuse or a large dollar amount, or the issue involves politically sensitive testimony 3-2 AAHAM (Rev. 12/01/2017)

Glossary COA Certificate of Accreditation; the CLIA certificate issued to a laboratory on the basis of the laboratory s accreditation by an accreditation organization approved by CMS COC Certificate of Compliance; the CLIA certificate issued to a laboratory once the State Department of Health conducts an on-site survey (inspection) and determines that the laboratory is compliant with all applicable CLIA requirements COLA Commission on Office Laboratory Accreditation; one of six CMSapproved accreditation organizations College of American Pathologists CAP; one of six CMS-approved accreditation organizations Commission on Office Laboratory Accreditation COLA; one of six CMS-approved accreditation organizations complex review a RAC review involving review of the medical record documentation; used where there is a high probability that the service is not covered or where no Medicare policy, Medicare article, or Medicaresanctioned coding guideline exists Comprehensive Error Rate Testing CERT; a program instituted by CMS to monitor and calculate the accuracy and error rates for all MACs and to monitor the accuracy of Medicare payments to FIs, carriers, and DMERCs COP Medicare Conditions of Participation Corporate Integrity Agreement the agreement that spells out integrity measures required of a provider that has engaged in serious misconduct but is being allowed to continue participating in the healthcare programs COW Certificate of Waiver; the CLIA certificate issued to a laboratory that performs only waived tests ( simple laboratory examinations and procedures that have an insignificant risk of an erroneous result ) CPG Compliance Program Guidance CPT Current Procedural Terminology demand letter document describing the rationale for a RAC determination and providing information in case an appeal is warranted DNC do-not-call DOJ Department of Justice AAHAM (Rev. 12/01/2017) 3-3

Glossary EHR electronic health record EMC emergency medical condition Emergency Medical Treatment and Active Labor Act EMTALA; the Act that requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition; also known as the Federal Anti-Dumping Statute EMR electronic medical record EMTALA Emergency Medical Treatment and Active Labor Act EPHI electronic protected health information Fair Credit Billing Act an amendment to the Truth in Lending Act that protects consumers from inaccurate or unfair practices by issuers of open-ended credit Fair Credit Reporting Act Title VI of the Consumer Credit Protection Act that defines what information from consumer reports can be used, by whom, and when Fair Debt Collection Practices Act Title VIII of the Consumer Credit Protection Act that protects consumers from abusive, deceptive, and unfair collection practices False Claims Act the Act that helps recover billions of dollars stolen through fraud while also protecting whistleblowers from retaliation FDA Food and Drug Administration Federal Anti-Dumping Statute another name for EMTALA Fraud willingly and knowingly violating regulations full denial a RAC denial that occurs when the RAC determines that the service was not reasonable or necessary or that the service billed to CMS was not rendered GAO General Accounting Office; one of two government entities that produces reports every year that review and analyze aspects of Medicare payments GME Graduate Medical Education 3-4 AAHAM (Rev. 12/01/2017)

Glossary HCFAC Health Care Fraud and Abuse Control program established by HIPAA to combat waste, fraud, and abuse in the Medicare and Medicaid programs HCQIP Health Care Quality Improvement Program; a program that supports the mission of CMS to assure healthcare security for beneficiaries Health Care Fraud and Abuse Control HCFAC; a program established by HIPAA to combat waste, fraud, and abuse in the Medicare and Medicaid programs Health Care Quality Improvement Program HCQIP; a program that supports the mission of CMS to assure healthcare security for beneficiaries Health Information Technology for Economic and Clinical Health HITECH; an Act intended to accelerate the adoption of EHRs/EMRs among providers Health Insurance Portability and Accountability Act HIPAA; an Act passed in 1996 to improve portability and continuity of health insurance coverage; to combat waste, fraud, and abuse in health insurance and healthcare delivery; to promote the use of medical savings accounts; to improve access to long-term care services and coverage; to simplify the administration of health insurance, etc. HHS Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act HITECH Health Information Technology for Economic and Clinical Health Act; an Act intended to accelerate the adoption of EHRs/EMRs among providers hospital an institution primarily engaged in providing inpatient diagnostic and therapeutic services, outpatient, or rehabilitation services Hospital Payment Monitoring Program HPMP; a program responsible for monitoring payments to inpatient acute care hospitals HPMP Hospital Payment Monitoring Program; a program responsible for monitoring payments to inpatient acute care hospitals ICD International Classification of Diseases IME Indirect Medical Education IOM Institute of Medicine AAHAM (Rev. 12/01/2017) 3-5

Glossary JCAHO Joint Commission on Accreditation of Healthcare Organizations; former name for The Joint Commission (TJC) Joint Commission on Accreditation of Healthcare Organizations JCAHO; former name for The Joint Commission (TJC) Judicial Review the fifth level of appeal, which can be done if the denial issue is still in controversy following the Appeals Council s decision MAC Medicare Administrative Contractor Medicaid Fraud Control Unit federal- and state-funded law enforcement entities that investigate and prosecute provider fraud and violations of state law pertaining to fraud in the Medicaid program; they also review complaints of resident abuse or neglect in nursing homes and other health care facilities Medicaid Integrity Contractor private company that conducts auditrelated activities under a contract with CMS Medicare Drug Integrity Contractor MEDIC; a type of contractor that supports CMS efforts to prevent, detect, and investigate fraud and abuse Medicare Secondary Payer MSP; provisions to protect the Medicare Trust Fund by ensuring that Medicare does not pay for services and items that certain other health insurance or coverage is primarily responsible for paying MedWatch an FDA reporting system that encourages physicians and facilities to report voluntarily serious adverse events that occur as a result of drug reactions MIC Medicaid Integrity Contractor NMFA National Medicare Fraud Alert National Medicare Fraud Alert one of the five types of Fraud Alerts; the most commonly issued type that focuses on a particular scheme or scam and serves as a fraud detection lead NPI National Provider Identifier OAS Office of Audit Services; the OIG component that conducts financial and performance audits of departmental programs, operations, grantees, and contractors 3-6 AAHAM (Rev. 12/01/2017)

Glossary OCIG Office of Counsel to the Inspector General; the OIG component that provides legal advice and representation to the OIG on matters relating to Medicare, Medicaid, and other HHS programs and operations OCR Office for Civil Rights; the entity that is responsible for enforcing the HIPAA Privacy Rule OEI Office of Evaluation and Inspections; the OIG component that conducts national evaluations to provide Congress, HHS, and the public with timely, useful, and reliable information on significant issues Office for Civil Rights OCR; the entity that is responsible for enforcing the HIPAA Privacy Rule Office of Audit Services OAS; the OIG component that conducts financial and performance audits of departmental programs, operations, grantees, and contractors Office of Counsel to the Inspector General OCIG; the OIG component that provides legal advice and representation to the OIG on matters relating to Medicare, Medicaid, and other HHS programs and operations Office of Evaluation and Inspections OEI; the OIG component that conducts national evaluations to provide Congress, HHS, and the public with timely, useful, and reliable information on significant issues Office of Inspector General OIG; primary enforcement arm of the HHS, created to protect the integrity of HHS programs and operations and the well-being of federal healthcare program beneficiaries Office of Investigations OI; the OIG component that conducts and coordinates investigations of fraud and misconduct related to the Department s programs, operations, and beneficiaries OI Office of Investigations; the OIG component that conducts and coordinates investigations of fraud and misconduct related to the Department s programs, operations, and beneficiaries OIG Office of Inspector General; part of the HHS and the principle driver in the implementation of compliance Operation Restore Trust ORT; a pilot, voluntary disclosure program of potential violations as a way to fight fraud and abuse in the Medicare and Medicaid programs AAHAM (Rev. 12/01/2017) 3-7

Glossary partial denial a RAC denial that occurs when the RAC determines that the service was not reasonable or necessary but that a lower level service would be, or when the service was upcoded or an incorrect code was submitted which yielded a higher reimbursement of the service Patient Protection and Affordable Care Act PPACA; a law that established an obligation under the False Claims Act to report and return identified Medicare or Medicaid payments within 60 days after the date on which the overpayment was identified PCCM Primary Care Case Management PHI protected health information PHSA Public Health Service Act; the Act that provides for exemption of CLIA requirements in states with requirements that are equal to or more stringent than CLIA s Physician Self-Referral Law a law that prohibits a physician from making certain referrals to an entity in which the physician (or a member of his or her immediate family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies; also known as the Stark Law PPM Provider Performed Microscopy Program Safeguard Contractor and Zone Program Integrity Contractor BI Unit Alert one of the five types of Fraud Alerts Provider Self-Disclosure Protocol a publication by the OIG to promote voluntary disclosure of potential violations providers Medicare-participating entities Public Health Service Act PHSA; the Act that provides for exemption of CLIA requirements in states with requirements that are equal to or more stringent than CLIA s QIOSC Quality Improvement Organization Support Centers qui tam provisions in the False Claims Act that protect whistleblowers from retaliation and allow them to sue, on behalf of the government, in order to recover the stolen funds RAC Recovery Audit Contractor 3-8 AAHAM (Rev. 12/01/2017)

Glossary RAC Data Warehouse an important tool for measuring the performance of the Recovery Auditors; source of data so providers can gain knowledge about the recovery program and so that compliance officers will know what healthcare areas the facilities should review; allows CMS to generate reports to show the types of claims that the RACs are reviewing, as well as which healthcare issue is increasing in the number of corrected claims reconsideration the second level of appeal, which is requested if the provider is dissatisfied with the redetermination results Recovery Audit Contractor recipient of a contract to help guard the operations of the Medicare Trust Fund Recovery Audit Program a program created by Congress to identify improper Medicare payments and to help fight fraud, waste, and abuse in the government program redetermination the first level of appeal, in which a claim is reviewed by Medicare Area Contractor personnel different from the personnel who made the initial denial determination remuneration anything of value Restricted Medicare Fraud Alert one of the five types of Fraud Alerts RMFA Restricted Medicare Fraud Alert Safe Harbor regulations developed to identify specific payment and business practices that, while potentially prohibited by the Anti- Kickback Statute, would not be prosecuted SDP Self-Disclosure Protocol semi-automated review one of the three processes followed by Recovery Auditors to identify improper payments; the review is determined by data mining but records may be sent to justify the charges Stark Law another name for the Physician Self-Referral Law State Survey Agency the entity that evaluates and certifies hospitals for compliance with Medicare requirements Telephone Consumer Protection Act of 1991 TCPA; a law that amended the Communications Act of 1934 and restricts telephone solicitations (in other words, telemarketing) and the use of automated telephone equipment AAHAM (Rev. 12/01/2017) 3-9

Glossary The Joint Commission TJC; one of six CMS-approved accreditation organizations TJC The Joint Commission; one of six CMS-approved accreditation organizations Truth in Lending Act Title I of the Consumer Credit Protection Act also known as Regulation Z; deals with the disclosure of information before credit is extended Waiver Alerts one of the five types of Fraud Alerts Zone Program Integrity Contractors (ZPIC) contractors used by CMS to identify problem areas, investigate potential fraud, and develop fraud cases for referrals to law enforcement 3-10 AAHAM (Rev. 12/01/2017)