AMG-SIU - The Total Health Care Fraud, Waste and Abuse Solution

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Glossary

AMG-SIU has compiled a few definitions to explain some of the terms found on this website.

Abuse:

A range of the following improper behaviors or billing practices including, but not limited to:

Billing for a non-covered service;
Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered); or
Inappropriately allocating costs on a cost report

Source: CMS

Artificial Intelligence:

Computer programs that can solve problems creatively.

AMG-SIU uses a form of artificial intelligence in its ACE forensic editing system.

Compliance Plan:

The plan describing the implementation or systematic process to ensure an organization is performing in accordance to government laws, regulations and policies.

Particular to AMG-SIU, a compliance plan is the fraud, waste and abuse portion of a compliance plan that outlines the procedures and process of detecting fraud, waste and abuse. Each plan is created by AMG-SIU’s legal department to ensure the compliance plan addresses the plans policies and all applicable federal and state laws, regulations and policies including government programs.

Errors:

Errors include billing and information submitted incorrectly that result in an over or underpayment. Errors also include data entry errors by MCOs causing an alteration in the payment of the claim.

Forensic Editing:

The process of editing a medical claim for validity using all known scientific, logical and legal parameters.

Fraud:

The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s). Source: CMS

HIPAA:

The Health Insurance Portability and Accountability Act, HIPAA, was passed in 1996 which is also sometimes called the "Kassebaum-Kennedy" law. This law expands your health care coverage if you have lost your job, or if you move from one job to another, HIPAA protects you and your family if you have: pre-existing medical conditions, and/or problems getting health coverage, and you think it is based on past or present health. HIPAA also:

Limits how companies can use your pre-existing medical conditions to keep you from getting health insurance coverage;
Usually gives you credit for health coverage you have had in the past;
May give you special help with group health coverage when you lose coverage or have a new dependent; and
Generally, guarantees your right to renew your health coverage. HIPAA does not replace the states' roles as primary regulators of insurance.

Source: CMS

Medicaid:

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. Source: CMS

Medicare:

The 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). Source: CMS

Provider:

Any organization, institution, or individual that provides health care services to beneficiaries.

Currently, AMG-SIU reviews medical claims data from a wide range of provider types including, but not limited to:

Ambulatory surgical centers
Ancillary providers
Behavioral health providers
DME
Dental
In-patient hospital
Laboratory
Out-patient hospital
Physicians
Prescriptions
Rural health clinics
Vision

Waste:

Waste is defined as billing and information submitted for items or services where there was no intent to deceive or misrepresent, but the outcome resulted in an overpayment of funds.

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