Plain-English definitions for the acronyms and regulations that govern home health compliance. Bookmark this page and share it with your team.
The federal watchdog agency within the U.S. Department of Health and Human Services (HHS). The OIG investigates fraud, waste, and abuse in federal healthcare programs and maintains the LEIE, the primary database of excluded healthcare providers. Agencies billing Medicare or Medicaid are required to screen staff against OIG records.
How ClientCare automates OIG screeningA financial penalty imposed by the OIG for violations of federal healthcare program rules. As of 2024, the penalty for employing or contracting with an excluded individual is $22,427 per item or service billed. CMPs are in addition to any repayment of claims and can include treble damages (three times the amount billed).
The federal standards that healthcare providers must meet to participate in and receive payment from Medicare. For home health agencies, CoPs cover patient rights, care planning, quality assessment, and compliance programs. Failure to meet CoPs can result in termination from the Medicare program.
The federal database maintained by the OIG containing the names of individuals and entities excluded from participating in Medicare, Medicaid, and other federal healthcare programs. Employing or contracting with someone on the LEIE exposes your agency to Civil Monetary Penalties of up to $22,427 per item or service billed.
A government-wide debarment and exclusion database maintained by the General Services Administration (GSA). SAM.gov covers all federal programs, not just healthcare. Compliance-conscious agencies check both the LEIE and SAM.gov to ensure staff are not excluded from any federal program.
A multi-state sanctions and exclusions database that aggregates disciplinary actions from state licensing boards, federal agencies, and other regulatory bodies. FACIS casts a wider net than the LEIE alone, catching state-level sanctions that may not appear in the federal database.
A person or entity that has been barred from participating in any federal healthcare program, including Medicare and Medicaid. Exclusion can result from criminal convictions, license revocations, or other violations. Any items or services furnished by an excluded individual cannot be reimbursed by federal programs.
An exclusion that the OIG may impose at its discretion for certain offenses, such as license revocation, failure to provide claims data, or fraud in a non-healthcare program. Permissive exclusions typically last a minimum of one to three years, depending on the offense. The OIG weighs aggravating and mitigating factors when deciding whether to exclude.
An exclusion that the OIG is required by law to impose for certain serious offenses, including felony convictions related to healthcare fraud, patient abuse or neglect, and controlled substance offenses. Mandatory exclusions last a minimum of five years and cannot be waived. These are the most common entries on the LEIE.
The HIPAA-standard electronic transaction for checking patient insurance eligibility. A 270 is the inquiry sent to a payer asking whether a patient is covered; a 271 is the response containing coverage status, effective dates, and benefit details. ClientCare uses 270/271 transactions to detect coverage lapses before you bill.
See eligibility monitoring plansThe HIPAA-standard electronic transaction for checking the status of a submitted claim. A 276 is the inquiry and a 277 is the response. These transactions let agencies track claims in real time instead of waiting weeks for paper remittance notices or portal updates.
The annual process in which state Medicaid agencies verify that enrolled beneficiaries still meet eligibility requirements. During redetermination periods, patients can lose coverage if they fail to respond to paperwork or no longer qualify. Home health agencies that do not monitor redetermination status risk billing for patients who have been disenrolled.
Automated coverage monitoringA Medicaid program that allows states to provide home- and community-based care as an alternative to institutional settings like nursing homes. HCBS waivers fund personal care, home health aides, and other services that keep patients in their homes. Agencies providing HCBS services must comply with all Medicaid exclusion screening requirements.
A unique 10-digit identification number assigned to healthcare providers by CMS. Every provider who bills Medicare or Medicaid must have an NPI. It is used in electronic transactions, claims submissions, and provider enrollment. Type 1 NPIs are for individual providers; Type 2 NPIs are for organizations.
The CMS database that manages provider enrollment in Medicare. PECOS contains information about every provider and supplier approved to bill Medicare, including ownership details and practice locations. Agencies must maintain active PECOS enrollment to receive Medicare reimbursement.