Common Compliance Terms

Abuse is defined as, provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the Medicaid/Medicare 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 costs to the Medicaid/Medicare program.

Breach A breach of protected health information (“PHI”) is defined as the acquisition, access, use, or disclosure of unsecured PHI, in a manner not permitted by HIPAA, which poses a significant risk of financial, reputational, or other harm to the affected individual

CFR is short for Code of Federal Regulations

Code of Conduct (Standards of Conduct) a set of conventional principles and expectations that are considered binding on any person who is a member of a particular group

Compliance (plan) is a set of procedures designed to ensure that a health care entity complies with laws and regulations governing its activities. It also serves as a mechanism to detect and prevent improper behavior in the workplace

Delegated Vendor/Subcontractor/FDR Entity is an external organization that performs a function(s) that is otherwise the responsibility of CareSource per CMS, State Medicaid oversight agencies, NCQA/URAC accrediting agencies, and/or CareSource business rules.

Delegation is the assignment to a Vendor/Subcontractor/FDR entity, by written contract, of a function(s) that is otherwise the responsibility of CareSource under its contract with CMS, State Medicaid oversight agencies, NCQA/URAC accrediting agency, and/or CareSource business rules.

First Tier, Downstream or Related Entity (FDR):

  • First Tier Entity is any party that enters into a written arrangement, acceptable to CMS, with an MAO or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program. (42 C.F.R. §423.501).
  • Downstream Entity is any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit or Part D benefit, below the level of arrangement between an MAO or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services (42 C.F.R. §423.501).
  • Related Entity is any entity that is related to an MAO or Part D sponsor by common ownership or control and:
    • Performs some sort of the MAO or Part D plan sponsor’s management functions under contract or delegation;
    • Furnishes services to Medicare enrollees under an oral or written agreement; or
    • Leases real property or sells materials to the MAO or Part D plan sponsor at a cost of more than $2,500 during a contract period (42 C.F.R. §423.501).
    • Leases real property or sells materials to the MAO or Part D plan sponsor at a cost of more than $2,500 during a contract period (42 C.F.R. §423.501).

Fraud is defined as an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

FWA is short for fraud, waste, and abuse

Health Information Technology for Economic and Clinical Health (HITECH) Act is law enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology.

HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information

Improper Payment is any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative or other legally applicable requirements. This includes any payment to an ineligible recipient, any payment for an ineligible good or service, any duplicate payment, any payment for a good or service not received (except for such payments where authorized by law), and any payment that does not account for credit for applicable discounts. – Improper Payments Elimination and Recovery Act (IPERA).

Kickbacks are defined as knowingly and willingly accepting or offering remuneration of any sort and in any manner intended to influence the referral of Medicare and Medicaid services.

Medicare Advantage Organization (MAO) is a type of Medicare health plan offered by a private company that contracts with Medicare to provide all Part A and B benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.

Offshore Subcontractor is when you use an individual or entity outside of the United States to fulfill requirements of your contract. This includes all first-tier, downstream and/or related entities. Offshore refers to any country that is not within the United States or one of the United States territories. Subcontractors that are considered offshore can be either American-owned companies with certain portions of their operations performed outside the United States or foreign-owned companies with their operations performed outside of the United States. Offshore subcontractors provide services that are performed by workers located in offshore countries, regardless of whether the works are employees of American or foreign companies.

Physician Self-Referral is making referrals for certain designated health services payable to Medicare to an entity with which the physician (or an immediate family member) has a financial relationship (ownership, investment, or compensation).

Protected Health Information (PHI) is all “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. “Individually identifiable health information” is information, including demographic data, that relates to the member’s past, present or future physical or mental health or condition, the provision of health care to the member, or the past, present, or future payment for the provision of health care to the member, and that identifies the member or for which there is a reasonable basis to believe it can be used to identify the member.

Security encompasses all of the administrative, physical, and technical safeguards in an information system

Subcontractor is a person or entity which a first-tier or downstream entity contracts to fulfill or help fulfill requirements in a Medicare Advantage contract.

Waste involves taxpayers not receiving reasonable value for money in connection with any government funded activities due to an inappropriate act or omission by a person with control over or access to government resources (e.g., executive, judicial or legislative branch employees, grantees or other recipients). Waste goes beyond fraud and abuse, and most waste does not involve a violation of law. Waste relates primarily to mismanagement, inappropriate.