Coding and Reimbursement
Which is the term for the reason for a denied or rejected claim as reported on the remittance advice or explanation of benefits?
CARC
Which is the financial record source document used by health care providers and other personnel in a hospital outpatient setting to select codes for treated diagnoses and services rendered to the patient during the current visit?
chargemaster
Which is a review for medical necessity of tests and procedures ordered during an inpatient hospitalization?
concurrent review
An integrated delivery system (IDS) is an organization of __________ that offer joint health care services to subscribers.
affiliated providers' sites
Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.
establishes a utilization management program and performs external utilization review services
Which of the following is an example of fraud?
falsifying certificates of medical necessity plans of treatment
Which is submitted to the payer requesting reimbursement?
health insurance claim
A lifetime maximum amount is the maximum benefits payable to a __________.
health plan participant
Clinical Laboratory Improvement Act (CLIA) legislation established __________ for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed.
quality standards
Which defines a profession, delineates qualifications and responsibilities, and clarifies supervision requirements?
scope of practice
Dr. Jones is a nonparticipating provider (nonPAR) for the ABC Health Insurance Plan. Anne Smith is treated by Dr. Jones in the office, for which a $100 fee is charged. Given the information in the table located below, calculate the nonPAR provider write-off amount. nonPAR provider fee $100 nonPAR allowable charge $90 Patient copayment $18 Insurance payment $72 nonPAR provider write-off amount _________
$0
To create flexibility in managed care plans, some HMOs, and preferred provider organizations have implemented a(n) __________, under which patients have the freedom to use the managed care panel of providers or to self-refer to out of- network providers.
point-of-service plan
Which may specifically result in the early detection of health problems, allowing less drastic and less expensive treatment options?
preventative examination
Which is Latin for "let the master answer," which means that the employer is liable for the actions and omissions of employees as performed and committed within the scope of their employment?
respondeat superior
Health care services provided to subscribers by physicians employed by the HMO are associated with a __________. Premiums and other revenue are paid to the HMO, and usually, all ambulatory services are provided within HMO corporate buildings.
staff model HMO
The Patient Protection and Affordable Care Act (PPACA) of 2010 includes a health care reform measure that requires implementation of the hospital __________ program to promote better clinical outcomes and patient experiences of care.
value-based purchasing
Which unique identifier is assigned to third-party payers and has 10 numeric positions, including a check digit as the tenth position?
HPID
Which program provides consumers with quality of care information so they can make more informed decisions about health care options?
Hospital Inpatient Quality Reporting (Hospital IQR)
Data analytics are tools and systems that are used to __________ clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.
evaluate
The Patient Protection and Affordable Care Act (PPACA) was signed into federal law on March 23, 2010, and resulted in the creation of a Health Insurance Marketplace to:
allow Americans to purchase health coverage that fits their budget and meets their needs.
The National Committee for Quality Assurance (NCQA) reviews managed care plans and develops report cards to __________.
allow health care consumers to make informed decisions when selecting a plan
Which is the amount for which the patient is financially responsible before an insurance policy provides payment?
deductible
The proposed standard for an electronic signature is __________, which applies a mathematical function to the electronic document.
digital
Which is associated with contracted health care services that are delivered to subscribers by individual physicians in the community?
direct contract model HMO
The Preferred Provider Health Care Act of 1985 __________ restrictions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO.
eased
Encoding or __________ a computer file makes it safe for electronic transmission so that unauthorized parties cannot read it.
encrypting
A managed care organization (MCO) is responsible for the health of a group of __________.
enrollees
Managed health care was developed as a way to provide affordable, comprehensive, prepaid health care services to__________.
enrollees
One result of the Patient Protection and Affordable Care Act (PPACA) was the establishment of state health insurance __________ that Americans will use to purchase health coverage that fits their budget and meets their needs.
exchanges or marketplaces
Many states have enacted legislation requiring a(n) __________ to review health care provided by managed care organizations.
external quality review organizationPhysician incentives include payments made directly or indirectly to health care providers to __________ so as to save money for the managed care plan. Managed care plans that contract with Medicare or Medicaid must disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.
A competitive medical plan (CMP) is an HMO that meets __________ eligibility requirements for a Medicare risk contract, but is not licensed as a __________ qualified plan.
federal; federally
Which consumer-directed health plan provides tax-exempt accounts offered by employers to any number of employees, which individuals use to pay health care bills? The employees contribute funds through a salary reduction agreement and withdraw funds to pay medical bills. Funds are exempt from both income tax and Social Security tax (and employers may also contribute). By law, employees forfeit unspent funds at the end of the year.
flexible spending account
Which type of health insurance coverage has costs that are typically less per person and provides broader coverage?
group health insurance
Which type of health insurance coverage is subsidized by employers and other organizations?
group health insurance
Which consumer-directed health plan allows participants to enroll in a relatively inexpensive high-deductible insurance plan and open tax-deductible savings account to cover current and future medical expenses? Money deposited (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax-free. Money can be withdrawn for purposes other than health care expenses after payment of income tax plus a 15 percent penalty. Unused balances "roll over" from year to year, and if an employee changes jobs, he or she can continue to use the fund to pay for qualified health care expenses.
health savings account
The National Correct Coding Initiative (NCCI) was created to promote national correct coding methodologies and to eliminate __________ coding.
improper
A remittance advice submitted to the provider electronically is called an electronic remittance advice (ERA), and __________.
it contains identical information to the information on a paper-based remittance advice
Which documents health care services provided to a patient and includes patient demographic (or identification) data, documentation to support diagnoses and justify treatment provided, and the results of treatment provided?
patient record
Any information communicated by the __________ is considered privileged communication, and HIPAA provisions address the privacy and security of protected health information.
patient to a health care provider
When a health insurance plan's prior approval requirements are not met by providers
payment of the claim is denied
Which party signs a contract with a health insurance company and thus, owns the health insurance policy?
policyholder
Conduct or qualities that characterize a professional person are called __________.
professionalism
Medicare administrative contractors are organizations that contract with the Centers for Medicare and Medicaid Services to process fee-for-service healthcare claims and perform __________ for both Medicare Part A and Part B.
program integrity tasks
Laws that are implemented as guidelines written by administrative agencies, such as CMS, are called __________.
regulations
Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider's office has received a(n) __________ from the primary payer.
remittance advice
The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) utilizes information from a __________to classify patients into distinct groups based on clinical characteristics and expected resource needs.
resource utilization group
Which involves the safekeeping of patient information by controlling access to records, protecting patient information from alteration/destruction/tampering/loss, and providing employee training in HIPAA requirements, which includes the consequences of improper disclosure of patient information?
security
Large employers who assume the financial risk for providing health care benefits to employees do not pay a fixed premium to a health insurance payer but establish a trust fund (of employer and employee contributions) out of which claims are paid. This concept is called __________.
self-insurance
Physician incentives include payments made directly or indirectly to health care providers to __________ so as to save money for the managed care plan. Managed care plans that contract with Medicare or Medicaid must disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.
encourage them to reduce or limit patient services
Revenue cycle monitoring involves assessing the revenue cycle to ensure __________ stability using standards of measurement (e.g., cash flow).
financial viability
An appeal is documented as a(n) __________ why a claim should be reconsidered for payment.
letter signed by the provider explaining
Which does a provider usually employ to perform administrative and clinical tasks, which help keep the office or clinic running smoothly?
medical assistant
Which includes the identification of disease and the provision of care and treatment to persons who are sick, injured, or concerned about their health status?
medical care
Which is another name for a health insurance specialist?
reimbursement specialist
Prior to scheduling elective surgery, managed care plans often require a __________ during which another physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery
second surgical report
Record retention is the __________ of documentation for an established period of time, usually mandated by federal and/or state law.
storage
The primary care provider (PCP) is responsible for __________.
supervising and coordinating health care services for enrollees
Covered entities are required to use mandated national standards when conducting any of the defined transactions covered under HIPAA. Which is an example of a covered entity?
ERISA-covered health benefit plans
Dr. Smith is a participating provider (PAR) for the ABC Health Insurance Plan. Mary Talley is treated by Dr. Smith in the office, for which a $100 fee is charged. Given the information in the table located below, calculate the PAR provider write-off amount. PAR provider fee $100 PAR allowable charge $80 Patient copayment $20 Insurance payment $60 PAR provider write-off amount ______
$20
Third-party recovery standards for investigation of liability coverage and the process for filing a lien in a potential liability case vary on a federal and state basis. A lien is defined as __________.
Securing a debtor's property as security or payment for a debt
Which is part of an effective coding compliance program because it helps ensure accurate and thorough patient record documentation?
CDI
Which is the former name for TRICARE Standard?
CHAMPUS
Which insurance claim is submitted to receive reimbursement under Medicare Part B?
CMS-1500
Which insurance claim is submitted to receive reimbursement under Medicare Part C?
CMS-1500 or UB-04
Provider services for inpatient care are billed on a fee-for-service basis, and service results in a unique and separate charge designated by a __________ or HCPCS level II service/procedure code.
CPT
Private fee-for-service (PFFS) plans are offered by private insurance companies in some regions of the country, and Medicare pays a pre-established amount of money each month to the insurance company, which decides how much it will pay for services. Such plans reimburse providers on a fee-for-service basis and are authorized to charge enrollees up to __________ percent of the plan's payment schedule.
115
ICD-10-CM diagnosis codes are entered in Block 21 of the CMS-1500 claim. A maximum of __________ ICD-10-CM codes may be entered on a single claim
12
The Balanced Budget Act of 1997 allows certain health care providers to withdraw from Medicare and enter into private contracts with their Medicare patients, which requires "opting out" of Medicare for at least __________ years for all covered items and services furnished to Medicare beneficiaries.
2
When outpatient preadmission services are provided by a hospital on the day of or during the three days prior to a patient's inpatient admission and the inpatient principal diagnosis code exactly matches that for preadmission services, the IPPS __________ rule applies.
3-day payment window
A Medicare benefit period begins with the first day of hospitalization and ends when the patient has been out of the hospital for __________ consecutive days.
60
Medicare lifetime reserve days, which total __________ days, are used once during a patient's lifetime and are usually reserved for use during the patient's final, terminal hospital stay.
60
An initial enrollment period (IEP) that provides an opportunity for the individual to enroll in Medicare Part A and/or Part B is for a period of __________ months.
7
The Office of Workers' Compensation Programs (OWCP) administers programs that provide wage-replacement benefits, medical treatment, vocational rehabilitation, and other benefits to federal workers (or eligible dependents) who are injured at work or acquire an occupational disease. In which federal department is the OWCP located?
Department of labor
Which is filed with the workers' compensation board to document any significant change in the worker's medical or disability status?
Detailed narrative progress/supplemental report
The U.S. Labor Department's Mine Safety and Health Administration (MSHA) helps reduce deaths, injuries, and illnesses in U.S. mines through a variety of activities and programs. Which is an example of such an activity or program?
Develops and enforces safety and health rules that apply to all U.S. mines
Which type of insurance is defined as reimbursement for income lost as a result of a temporary or permanent illness or injury?
Disability
Which consists of routine pediatric checkups provided to all children enrolled in Medicaid, including dental, hearing, vision, and other screening services to detect potential problems?
Early and periodic screening, diagnostic, and treatment
When selecting a clearinghouse, providers may also want to determine whether it is accredited by the __________.
Electronic Healthcare Network Accreditation Commission
To qualify for workers' compensation benefits, an employee must be injured while working within the scope of the job description, be injured while performing a service required by the employer, or develop a disorder that can be directly linked to employment, such as asbestosis or mercury poisoning. The worker does not have to be physically on company property to qualify for workers' compensation. Which is an example of an on-the-job injury that would qualify the employee for workers' compensation benefits?
Employee is injured when picking up reports for the office at the local hospital.
The BlueCross BlueShield Federal Employee Program (FEP) is a(n) __________ health benefits program established by an Act of Congress in 1959.
Employer-sponsored
A(n) __________ claim has a payment correction, resulting in additional payment(s) to the provider.
Adjusted
Survivor benefits claims provide death benefits to eligible dependents. These benefit amounts are calculated according to the employee's earning capacity __________.
At the time of the illness or injury
Workers' compensation insurance provides weekly cash payments and reimburses health care costs for covered employees who develop a work-related illness or sustain an injury while on the job. It also provides payments to qualified dependents of a worker who dies from a compensable illness or injury. Each state establishes a workers' compensation __________, which is responsible for administering workers' compensation laws and handling appeals for denied claims or cases in which a worker feels compensation was too low.
Board
The Away From Home Care Program(R) allows participating BCBS plan members who are temporarily residing outside of their home HMO service area for at least 90 days to temporarily enroll with a local __________.
Health maintenance organization
Which is associated with "last resort" health insurance for individuals who cannot obtain coverage due to a serious medical condition?
High-risk pool
Diagnosis pointer letters A-L are preprinted in Block 21 of the CMS-1500 claim to allow for entry of __________ codes and they are reported in Block 24E.
ICD-10-CM
The medical emergency care rider covers __________ treatment sought and received for sudden, severe, and unexpected conditions that if not treated would place the patient's health in permanent jeopardy or cause permanent impairment or dysfunction of an organ or body part.
Immediate
Which established the CERT, FATHOM, HPMP, PEPPER, and PERM programs?
Improper Payments Information Act of 2002
Vocational rehabilitation claims cover expenses for vocational retraining for both temporary and permanent disability cases. Vocational rehabilitation retrains an ill or injured employee so he or she can return to the workforce. The employee __________ of resuming the position held prior to the illness or injury.
May be incapable
The State Children's Health Insurance Program (SCHIP) was implemented in accordance with the Balanced Budget Act (BBA) to allow states to create or expand existing insurance programs, providing more federal funds to states for the purpose of expanding __________ eligibility to include a greater number of currently uninsured children.
Medicaid
A Medicare-Medicaid (Medi-Medi) crossover plan provides both Medicare and Medicaid coverage to __________ beneficiaries with low incomes.
Medicare
Which is a type of HMO that works in much the same way and has some of the same rules as a Medicare Advantage Plan, except that the individual receives health care from a non-network provider, and the original Medicare plan covers the services? The individual pays Medicare Part A and Part B coinsurance and deductibles.
Medicare cost plan
Which program includes managed care and private fee-for-service plans that provide contracted care to Medicare
Medicare part c
BCBS corporations offer several federally designed and regulated Medicare supplemental plans that augment the Medicare program by paying for Medicare deductibles and copayments. These plans are usually identified by the word __________ on the patient's plan ID card.
Medigap
Which is the name of the entire health care system of the U.S. uniformed services and includes military treatment facilities as well as various programs in the civilian healthcare market, such as TRICARE?
Military Health Services System
Health Affairs (HA) refers to the Office of the Assistant Secretary of Defense for Health Affairs, which is responsible for __________.
Military readiness and peacetime health care
A mother/baby claim is submitted for services provided to a baby under the __________ Medicaid identification number.
Mother's
Which was developed by the Centers for Medicare and Medicaid Services to assign the unique health care provider and health plan identifiers and to serve as a database from which to extract data?
NPPES
Any provider who accepts a Medicaid patient must accept the Medicaid-determined payment as __________.
Payment in full
First Report of Injury forms are completed by the __________ when treatment for a work-related illness or injury is sought.
Physician or other health care provider
Who is required to personally sign the original and all photocopies of reports submitted to the workers' compensation board?
Physician or other health care provider
The forerunner of what is known today as the BlueCross plan began in 1929 when Baylor University Hospital in Dallas, Texas, approached teachers in the Dallas school district with a plan that would guarantee up to 21 days of hospitalization per year for subscribers and each of their dependents, in exchange for a $6 annual premium. This was considered a __________ plan.
Prepaid
Which is responsible for the surveillance of fraud and abuse activities worldwide involving purchased care for beneficiaries in the Military Health Care System?
Program integrity office
The BCBS outpatient pretreatment authorization plan (OPAP) requires preauthorization of outpatient physical, occupational, and speech therapy services. Other terms for OPAP include precertification and __________ authorization.
Prospective
Which is the special group that requires states to pay Medicare premiums, deductibles, and coinsurance amounts for individuals whose income is at or below 100 percent of the federal poverty level and whose resources are at or below twice the standard allowed under SSI?
Qualified medicare beneficiaries
Which is the special group that requires states to pay Medicare Part A premiums for certain disabled individuals who lose Medicare coverage because of work?
Qualified working disabled individuals
Which is the special group that requires states to pay Medicare Part B premiums for individuals with incomes between 120 and 175 percent of the federal poverty level?
Qualify individuals
The TRICARE Management Activity (TMA) coordinates and administers the TRICARE program and is accountable for __________ health care provided to members of the uniformed services and their families.
Quality
Mary Smith is working full time and enrolled in Medicare Part A at age 65. She decided not to enroll in Medicare Part B at that time because her employer group health insurance coverage reimburses for physician and other outpatient encounters. Mary is eligible to enroll in Medicare Part B anytime during a(n) __________ enrollment period, which is a set time when individuals can sign up for Medicare Part B if they did not enroll when they applied for Medicare Part A.
Special
TRICARE __________ are uniformed service personnel who are either active duty, retired, or deceased.
Sponsors
The Occupational Safety and Health Act of 1970 created the Occupational Safety and Health Administration (OSHA) to protect employees against injuries from occupational hazards in the workplace. OSHA and its state partners (of approximately 2,100 inspectors) establish protective __________, which are enforced. OSHA also reaches out to employers and employees by providing technical assistance and consultation programs.
Standards
In 1965 Congress passed Title 19 of the Social Security Act, establishing a federally mandated, __________- administered medical assistance program for individuals with incomes below the federal poverty level.
State
The portion of the Medicaid program paid by the federal government is called the Federal Medical Assistance Percentage (FMAP) and is determined annually for each state using a formula that compares __________ average per capita income level with the national average.
State
Which refers to the contractual right of a third-party payer to recover health care expenses from a liable party?
Subrogation
Which is the TRICARE managed care option similar to a civilian health maintenance organization?
TRICARE Prime
Which is the current program that makes cash assistance available, for a limited time, for children deprived of support because of a parent's absence, death, incapacity, or unemployment?
Temporary Assistance for Needy Families
Hospital inpatient charges are reported on the __________ claim.
UB-04
Which insurance claim is submitted to receive reimbursement under Medicare Part A?
UB-04
Which term is used to describe the Army, Navy, Air Force, Marines, and Coast Guard, Public Health Service Commissioned Corps, and the National Oceanic and Atmospheric Administration (NOAA) Commissioned Corps?
Uniformed services
BlueShield plans were created as the result of a resolution passed by the House of Delegates at an American Medical Association meeting in 1938. This resolution supported the concept of __________ health insurance that would encourage physicians to cooperate with prepaid health care plans.
Voluntary
Postoperative complications requiring a return to the operating room for surgery related to the original procedure are billed as an additional procedure, and the additional procedure is linked to __________.
a new diagnosis that describes the complication
An ambulatory surgical center (ASC) is a state-licensed, Medicare-certified supplier (not provider) of surgical health care services that must __________ on Medicare claims.
accept assignment
Which best assists providers in the overall collection of appropriate reimbursement for services rendered?
accounts receivable management
When a workers' compensation claim is denied, the employee (or eligible dependents) can appeal the denial to the state workers' compensation board and undergo a process called __________, which is a judicial dispute resolution process in which an appeals board makes a final determination.
adjudication
Coding compliance programs include written policies and procedures, routine coding audits and monitoring, compliance-based education and training, and education and training programs. As a minimum, how often should written policies and procedures be updated?
annually
Which is a helpful practice that allows the coding manager to establish criteria for coding assessment purposes?
benchmarking
Which is a facility's measure of the types of patients treated and reflects patient utilization of varying levels of health care resources?
case mix
Which involves comparing the claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures performed or services provided are covered benefits?
claim adjudication
Electronic claims are submitted directly to the payer after being checked for accuracy by billing software or a health care clearinghouse, which results in a __________ claim that contains all required data elements needed to process and pay the claim.
clean
Local coverage determinations specify under which __________ a service is covered and coded correctly.
clinical circumstances
Medicare reimburses laboratory services according to a(n) __________, which is based on the submitted charge, national limitation amount, or local fee schedule amount, whichever is lowest.
clinical laboratory fee schedule
Which is the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits?
deductible
The MUE project was implemented by CMS as part of the NCCI to improve the accuracy of Medicare payments by __________.
detecting and denying unlikely Medicare claims on a prepayment basis
Which occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department
direct admission
DRG reimbursement rates are recalculated according to a(n) __________ adjustment, which results in increased Medicare payments for hospitals that treat a high percentage of low-income patients.
disproportionate share hospital
When a person uses a title such as Sr., Jr., II, or III, __________.
do not enter it on the claim unless printed on the patient's insurance ID card
HIPAA regulations require all payers to accept __________ attachments.
electronic
Voluntary compliance program guidance documents were developed by the Department of HHS OIG for the healthcare industry to __________ the development and use of internal controls to __________ adherence to applicable regulations, statutes, and program requirements.
encourage; monitor
The code reported in Block 21A of the CMS-1500 claim is the major reason the patient was treated by the health careprovider. It is called the __________ diagnosis.
first-listed
When reporting procedures and services on the CMS-1500, list one procedure per line, starting with line one of Block 24. To report more than six procedures or services for the same date of service, __________.
generate a new claim to enter more procedures/services
Coding compliance is the conformity to established coding __________.
guidelines and regulations
Which determines whether provided services are appropriate for patient's current or proposed level of care?
intensity of service (IS)
Block 33 of the CMS-1500 claim requires entry of the name, address, and telephone number of the billing entity, which is the __________.
legal business name of the practice
Medical malpractice insurance is which type of insurance?
liability
Which were incorporated into the National Correct Coding Initiative to compare units of service (UOS) with CPT and HCPCS level II codes reported on claims for the purpose of indicating the maximum number of UOS allowable by the same provider for the same beneficiary on the same date of service under most circumstances?
medically unlikely edits
CMS develops national coverage determinations on an ongoing basis, and __________ create(s) edits for NCD rules, which are local coverage determinations.
medicare administrative contractors
Which reimburses providers according to predetermined rates assigned to services and is revised by CMS each year?
medicare physical fee schedule
When a child lives with both parents, and each parent subscribes to a different health insurance plan, the primary and secondary policies are determined by applying the birthday rule. The individual who holds the primary policy for dependent children is the spouse whose birth __________.
month and day occur earlier in the calendar year
A child is listed as a dependent on both his father's and his mother's group insurance policies. The father's birth date is March 20, 1977, and the mother's birth date is March 6, 1979. Which policy is primary? Answer by entering either mother or father.
mother
Surgeon's charges for inpatient and outpatient surgery are billed according to a global fee, which means that __________ cover(s) presurgical evaluation and management, initial and subsequent hospital visits, surgical procedure, the discharge visit, and uncomplicated postoperative follow-up care in the surgeon's office.
one charge
Health insurance plans may include a(n) __________ provision, which means that when the patient has reached that limit for the year, appropriate patient reimbursement to the provider is determined.
out-of-pocket payment
Hospitals that treat unusually costly cases receive increased __________ payments that are designed to protect hospitals from large financial losses due to unusually expensive cases.
outlier
The MMA of 2003 mandated implementation of a(n) __________ payment amount as a substitute for the Ambulatory Surgical Center (ASC) standard overhead amount for surgical procedures performed at an ASC.
outpatient prospective payment system
The CMS-1500 paper claim was designed to accommodate optical scanning of __________ claims.
paper
Which is a computerized permanent record of all financial transactions between the patient and the practice?
patient account record
The federal government administers several health care programs, some of which require services to be reimbursed according to predetermined reimbursement methodologies, which are established as __________.
payment systems
Medicare will award an assigned claim conditional primary payer status and process the claim when a __________.
plan considered primary to Medicare issues a denial of payment that is under appeal
The inpatient prospective payment system (IPPS) resulted in Medicare reimbursing hospitals for inpatient hospital services according to a __________ rate for each discharge
predetermined
The optical scanning process uses a device that converts __________ characters into text that can be viewed by an optical character reader (OCR).
printed
An advance beneficiary notice of noncoverage (ABN) is a written document provided to a Medicare beneficiary by a supplier, physician, or provider, and the ABN must be presented to the patient __________.
prior to providing the service or treatment
Which program helps individuals whose assets are not low enough to qualify them for Medicaid by requiring states to pay their Medicare Part A and B premiums, deductibles, and coinsurance amounts?
qualified Medicare beneficiary program
Which program helps individuals who received Social Security and Medicare because of disability, but who lost their Social Security benefits and free Medicare Part A because they returned to work and their earnings exceed the limit allowed, by requiring states to pay their Medicare Part A premiums?
qualified disabled working individual
A Medicare medical necessity denial is a denial of otherwise covered services that were found to be not __________.
reasonable and necessary
The CMS Quarterly Provider Update (QPU) is an online CMS publication that contains information about __________ currently under development or completed/canceled and new/revised manual instructions.
regulations and major policies
Which are preprinted on a facility's chargemaster to indicate the location or type of service provided to an inpatient?
revenue codes
When entering codes for diagnoses on a CMS-1500 claim, qualified diagnosis codes (e.g., possible, probable) are never reported. Instead, codes for the patient's __________ are entered.
signs or symptoms
Which is a centralized health care system adopted by some Western nations (e.g., Canada, Great Britain) and funded
single-payer plan
When completing the CMS-1500, enter a __________ for the dollar sign or decimal in all charges or totals and parentheses surrounding the area code in a telephone number.
space
Which is a licensed physician in good standing who, according to state regulations, engages in the direct management of nonphysician practitioners whose duties are encompassed by that physician's scope of practice?
supervising physician
Which rule applies when patients are discharged from the hospital directly to a postacute provider?
transfer rule
Encoding or __________ a computer file makes it safe for electronic transmission so that unauthorized parties cannot read it.
transmittals
Which adjusts payments to account for geographic variations in hospitals' labor costs?
wage index
Each home health resource group (HHRG) has an associated __________ that increases or decreases Medicare's payment for an episode of home health care.
weight value
Effective July 31, 2001, the Energy Employees Occupational Illness Compensation Program (EEOICP) started providing benefits to eligible employees and former employees of the Department of Energy, its contractors and subcontractors, or to certain survivors of such individuals, and to certain beneficiaries of the Radiation Exposure Compensation Act. Which is responsible for adjudicating and administering claims filed by employees, former employees, or certain qualified survivors?
Office of Workers' Compensation Programs (OWCP)
When the same payer issues the primary, secondary, or supplemental policies, the correct procedure for submitting the claim would be to submit __________.
One claim for all policies
Which increased resources available to CMS to combat abuse, fraud, and waste in the Medicaid program, creating the Medicare Improvement Program (MIP)?
Deficit Reduction Act of 2005
Which includes health maintenance organizations and preferred provider organizations?
Managed care
Where is the first-listed diagnosis reported on the CMS-1500 claim?
Block 21A
Which type of health insurance covers the medical expenses of individuals (e.g., private health insurance) and groups (e.g., employer group health insurance)?
Commercial
The Medicare Catastrophic Coverage Act of 1988 implemented Spousal Impoverishment Protection Legislation in 1989 to prevent married couples from being required to spend down income and other liquid assets (cash and property) before one of the partners could be declared eligible for Medicaid coverage for nursing facility care. The spouse residing at home is called the __________ spouse.
Community
The base period of a disability policy usually covers 12 months and is divided into four __________ quarters.
Consecutive
When a patient seeks health care under the TRICARE program, sponsor information is verified in the __________ computer system, which contains up-to-date workforce personnel information.
DEERS
Group health insurance is available through employers and other organizations, and allvor part of the premium costs are paid by employers. Employer-based group health insurance __________.
Covers all employees, regardless of health status, and cannot be canceled if anemployee becomes ill
Which is the sequence of activities that can normally be expected to result in the most cost-effective clinical course of treatment?
Critical pathway
Which describes annual income guidelines established by the federal government?
Federal poverty level
By 1932 some plans modified the prepaid plan concept and organized community-wide programs that allowed the subscriber to be hospitalized in one of several member hospitals in accordance with signed contracts to provide services __________.
For negotiated special rates
Individuals who wait until they turn 65 to apply for Medicare will cause a delay in the start of Part B coverage, because they will have to wait until the next __________ enrollment period, which is held January 1 through March 31 of each year, with Part B coverage starting on July 1 of that year.
General
BCBS has a mandatory second surgical opinion (SSO) requirement necessary when a patient is considering elective, nonemergency surgical care. The initial surgical recommendation must be made by a physician qualified to perform the anticipated surgery. If a second surgical opinion is not obtained prior to surgery, the patient's out-of-pocket expenses may be __________.
Increased
Which is traditional fee-for-service health insurance that covers a portion of services, such as inpatient hospitalizations or physician office visits, with the patient paying the remaining costs?
Indemnity insurance
The Longshore and Harbor Workers' Compensation Program, administered by the U.S. Department of Labor, provides medical benefits, compensation for lost wages, and rehabilitation services to longshoremen, harbor workers, and other maritime workers who are __________.
Injured from or suffer diseases during employment
Commanders of selected military treatment facilities are called __________ for TRICARE regions.
Lead agents
Temporary disability claims cover health care treatment for illness and injuries as well as payment for __________.
Lost wages
Which allows providers to electronically access the state's eligibility file to verify Medicaid eligibility?
MEVS
Which was adopted by Medicare in 2008 to improve recognition of severity of illness and resource consumption and reduce cost variation among DRGs?
MS-DRGs
BCBS fee-for-service __________ coverage includes additional benefits, such as office visits, physical and occupational therapy, and mental health encounters.
Major medical
Participating providers contract to participate in a BCBS plan's preferred provider network (PPN), which is a program that requires providers to adhere to __________ care provisions.
Managed
The CHAMPUS Reform Initiative (CRI) demonstration project offered military families a choice of how their health care benefits could be used. The DoD noted its successful operation and high levels of patient satisfaction, and determined that its concepts should be expanded to a __________ program.
Nationwide uniform
Which is issued by a military treatment facility that cannot provide needed care to TRICARE Standard beneficiaries and means the beneficiary can seek care from a civilian provider and reimbursement will be approved?
Nonavailability statement
TRICARE __________ are available 24/7 for advice and assistance with treatment alternatives and to discuss whether a sponsor should see a provider based on a discussion of symptoms, and they will also discuss preventive care and ways to improve a family's health.
Nursing advisors
Programs of All-inclusive Care for the Elderly (PACE) use a capitated payment system to provide a comprehensive package of community-based services as an alternative to institutional care for persons age 55 or older who require a(n) __________ level of care.
Nursing facility
Some BCBS contracts also include one or more riders, which are special clauses that stipulate additional coverage __________ the standard contract.
Over and above
Which is a combination Medicare and Medicaid option that combines medical, social, and long-term care services for frail people who live and receive health care in the community?
PACE
A simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass __________ programs offered by public health clinics and other entities that bill Medicare payers.
PPV and influenza virus vaccination
The Coal Mine Workers' Compensation Program provides medical treatment and other benefits for __________ conditions related to former employment in the nation's coal mines
Respiratory
Nonprofit corporations are charitable, educational, civic, or humanitarian organizations whose profits are __________.
Returned to the nonprofit corporation
If a patient is covered by two different policies, the usual procedure for submitting a claim would be __________.
To submit to the primary payer first, followed by submitting to the secondary after primary payment is received
Health information technicians __________.
manage medical records
Diagnoses must be entered in the patient's record to validate __________ of procedures or services billed.
medical necessity
A quality assurance program includes activities that __________ the quality of care provided in a health care setting.
assess
Which is the format of the EIN?
00-0000000
Triple option plans are intended to prevent the problem of covering members who are sicker than the general population, which is called __________ selection.
adverse
Accreditation organization standards are recognized by CMS through a process called deeming, which requires that standards meet or exceed __________ requirements.
Conditions of Participation and Conditions for Coverage
Which is the physician self-referral law that protects patients and federal health care programs from fraud and abuse by curtailing the corrupting influence of money on health care decisions?
Federal Anti-Kickback Law
Which requires Medicare administrative contractors to attempt the collection of overpayments received by a provider or beneficiary?
Federal Claims Collects Act
Which legislation provides civilian employees of the federal government with medical care, survivors' benefits, and compensation for lost wages?
Federal Employees' Compensation Act
Which is a legal newspaper published every business day by the National Archives and Records Administration (NARA), and is available in paper form, on microfiche, and online?
Federal Register
Which authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program?
MIP
Which established the Hospital IQR, RAC, and ZPIC programs?
Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003
The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the __________ and created standards to assess managed care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators.
National Committee for Quality Assurance (NCQA)
Which consists of audits implemented by DHHS that examines the billing practices of physicians at teaching hospitals with the focus on compliance with the Medicare rule affecting payment for physician services provided by residents and whether the level of the physician service was coded and billed properly?
PATH
Which program was implemented to find and correct improper Medicare payments paid to health care providers participating in fee-for-service Medicare?
Recovery Audit Contractor (RAC)
Which prohibits physicians from referring Medicare patients to clinical laboratory services in which the physicians or their family members have a financial ownership/investment interest and/or compensation arrangement?
Stark I
Which is a series of fixed-length records used to bill institutional services, such as services performed in hospitals?
UB-04 flat file
Which are the amounts owed to a business for services or goods provided?
accounts receivable
Resource allocation monitoring uses data __________ to measure whether a health care provider or organization achieves operational goals and objectives within the confines of the distribution of financial resources.
analytics
Which of the following is an example of abuse?
billing noncovered services/procedures as covered services/procedures
Which guarantees repayment for financial losses resulting from an employee's act or failure to act?
bonding insurance
Which restricts patient information access to those with proper authorization and maintains the security of patient information?
confidentiality
The primary purpose of the patient record is to provide for __________ of care, which involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment.
continuity
Which is a legal action that can be used to recover a debt and is usually the last resort for a medical practice?
litigation
Chargemaster __________ is the process of updating and revising key elements of the chargemaster to ensure accurate reimbursement.
maintenance
Which involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity of performing that procedure or service?
medical necessity
The Medicare Integrity Program includes medical review, which is defined by CMS as a review of claims to determine whether services provided are __________, as well as to follow up on the effectiveness of previous corrective actions.
medically reasonable and necessary
The Amendment to the HMO Act of 1973 allowed federally qualified HMOs to permit members to __________.
occasionally use non-HMO physicians and be partially reimbursed
Which claims are organized by month and insurance company after submission to the payer, but for which processing is not complete?
open claims
Many physician practices contract out or __________ the delinquent accounts to a full-service collections agency that utilizes collection tactics, including written contacts and multiple calls from professional collectors.
outsource
Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work-related. Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contacting the provider, who is liable for the __________ because of the provider's failure to disclose that the injury was work-related.
overpayment
During completion of a student internship, the facility will likely require students to sign a nondisclosure agreement to protect ____________.
patient confidentiality
A claims examiner is employed by a
third-party payer to review claims.
Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization, are called __________ services.
unauthorized
Which is the practice of submitting multiple CPT codes when just one code should have been submitted?
unbundling
Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment), some hospitals engage in a practice called __________, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the purpose of illegally increasing reimbursement.
upcoding
Which is a method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care or after care has been provided?
utilization management