Chapter 1: Reimbursement, HIPAA, and Compliance
According to the filing guidelines, providers must file claims for their Medicare patients within ________ months of the date of service.
12
For co-surgeons, Medicare pays the lesser of the actual charge or ________% of the global fee, dividing the payment equally between the two surgeons.
125
The Medicare program was established in what year?
1965
Medicare publishes the Medicare fee schedule and usually pays what percentage of the amounts indicated for services?
80%
Hospital insurance is Medicare Part _____
A
Preferred Provider Organization (PPO)
A group of providers who form a network to provide services to enrollees at a discounted rate.
Medicare Fee Schedule (MFS)
A list of allowable charges for Medicare services.
What services do Medicare Part A, B, and D pay?
A: Hospital B: Physician D: Prescription Drugs
The most major change to the health care industry as a result of HIPAA was a result of what portion of the act?
Administrative Simplification
Medicare Administrative Contractor (MAC)
An entity that manages the process claims for CMS.
Federal Register
An official publication of all government "Rules and Regulations" and "Proposed Rules."
Supplemental Medical Insurance is Medicare Part _______
B
Individuals covered under Medicare are termed _____________
Beneficiaries
To what government organization did the Secretary of the Department of Health and Human Services delegate the responsibility for administering the Medicare program?
Centers for Medicare and Medicaid Services (CMS)
There are three items that Medicare beneficiaries are responsible for paying before Medicare will begin yo pay for services. What are these three items?
Deductions, premiums, and co-insurance
What is the issuing office?
Department of Health and Human Services
The transfer of electronic documentation is accomplished through the use of ____________________ Interchange technology
Electronic Data
The Medicare Economic Index is published in what publication?
Federal Register
What is the Action?
Final rule
This term is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes knowing that deception could result in some unauthorized benefit.
Fraud
Within an HMO, there is usually an individual who as been assigned to monitor the services provided to the patient both inside and outside the facility. This person is known as the......
Gate Keeper (Primary Physician)
HIPPA stands for ______________________________________________
Health Insurance Portability and Accountability Act
In this model of HMO, the HMO contracts with the physician to provide the service at a set fee. This organization are known as ___________________________ Associations.
Individual Practice
Specific regulations for Medicare are contained in the _____________________ Manual
Internet Only
According to the "For Further Information Contact" section, who is the person you would contact for issues related to CMS appeals policies?
Joella Roland
Comments are effective on what date?
March 20, 2017
The _______________ _________________ ___________________ do the paperwork for Medicare and are usually insurance companies that have bid for a contract with CMS to handle the Medicare program or a specific area.
Medicare Administrative Contractors (MACs)
Medicare Part C is also known as ________________
Medicare Advantage
The number that is assigned to all providers as a result of HIPAA: ___________________ Identifications
National Provider
Quality Improvement Organization (QIO)
National network of consumers, physicians, hospitals, and other caregivers, who work to refine care delivery systems at the state level, striving to improve quality, timing, and cost of care for Medicare Patients.
What editions of the Federal Register would the outpatient facilities be interested in?
November and December
Which edition of the Federal Register is of special interest to hospital facilities?
November or December
In 1989, a major change took place in Medicare with the enactment of
OBRA
Which edition of the Federal Register is of special interest to outpatient facilities?
October
This organization develops a work plan to identify areas of the Medicare program that will be monitored.
Office of the Inspector General (OIG)
Who is responsible for developing an annual work plan to identify fraud?
Office of the Inspector General (OIG)
Under what act was a major change in Medicare in 1989 made possible?
Omnibus Budget Reconciliation Act
In the RBRVS system, payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into what three components?
Physician work, practice expense, and malpractice
What does the abbreviation PACE stand for?
Program for All-Inclusive Care of the Elderly
An all-inclusive care program for the elderly that provides a comprehensive package of services that permits the client to continue to live at home is known as a _________________________ for ___________-_____________________ Care for the Elderly (PACE).
Program, All-Inclusive
The Privacy Rule standards address the use and disclosure of individuals' health information called.....
Protected health information
The three components of work. overhead (practice expense), and malpractice are part of an RVU. What do the initials RVU stand for?
Relative Value Unit
What does RBRVS stand for?
Resource-Based Relative Value Scale
What government organization handles the funds for the Medicare program?
Social Security Administration
In this model of HMO, the HMO directly employs the physicians, __________ model?
Staff
The physician responsible for controlling and managing health care of a HMO enrollee is the.....
The gatekeeper (Primary Physician)
The major third-party payer in the United States is the _______________
The government
What two groups of persons were added to those eligible for Medicare benefits after the initial establishment of the Medicare program?
Those eligible for Social Security disability, and those in end stage renal disease.
1. Automatic coverage under Social Security is... a) Part A (b. Part B (c. Part C or (d. Part D
a) Part A
3. Hospice care coverage is... a) Part A (b. Part B (c. Part C or (d. Part D
a) Part A
7. Codes assigned for payment using diagnoses; CPT; and HCPCS is... a) Part A (b. Part B (c. Part C or (d. Part D
a) Part A, b) Part B, c) Part C
5. Physician visit coverage is... a) Part A (b. Part B (c. Part C or (d. Part D
b) Part B
2. Optional coverage under Social Security is... a) Part A (b. Part B (c. Part C or (d. Part D
b) Part B, c) Part C, and d) Part D
6. Beneficiary pays premium for coverage is... a) Part A (b. Part B (c. Part C or (d. Part D
b) Part B, c) Part C, d) Part D
Susan recently graduated as a medical coder and has been employed at Island Clinic for three months. While coding last Monday, she encountered a superbill for a Medicare patient for $62, but there was no supporting documentation in the patient's medical record. Susan questioned the physician and he said he just forgot to do the paperwork and asked her to send the claim to Medicare with a promise to complete the paperwork later. Susan should do which of the following: a) Complete the claim and send it in, and write a reminder to the physician to complete the documentation. b) Wait until the physician completes the documentation. c) Inform the physician that she cannot submit a claim without appropriate documentation in the medical record.
c) Inform the physician that she cannot submit a claim without appropriate documentation in the medical record.
The purpose of managed health care is to provide ______________ services and theoretically to _____________ the health care services provided to the enrollee.
cost-effective, improve
4. Prescription drug coverage is... a) Part A (b. Part B (c. Part C or (d. Part D
d) Part D
The _____________ charge historically was specific for each physician, but in 1993, the charge for a service was the same for all physicians, within a locality, regardless of the specialty.
limiting
CMS's mission is to....
serve Medicare and Medicaid beneficiaries
Under the Relative Value Unit system, ________ values are assigned to each service and are determined on the basis of the resources necessary to the physician's performance of the service.
unit