Reimbursement - Final Exam Review
help a manager determine a staff's level of coding compliance
Internal and external benchmarking can ...
experimental or investigational diagnostic and therapeutic procedures; medically unnecessary diagnostic or therapeutic procedures; cosmetic procedures, except when related to accidents, disease, or congenital defects, and source-of-injury treatments
List at least 3 typical exclusions found in insurance plan riders:
Improper Payments Information Act of 2002
PERM and CERT were created under which act and its amendments?
RACs are reimbursed on a contingency-based system
RACs are different from other improper payment review contractors because ...
True
T/F: Copayments are cost-sharing provisions of policies that require insureds to pay a flat fee to healthcare service providers and suppliers.
True
T/F: In terms of healthcare insurance coverage, both children and spouses may be considered dependents.
False -
T/F: Individual (private) healthcare insurance is the most common means of coverage for the non-elderly in the United States.
False -
T/F: Out-of-pocket costs for subscribers and patients are decreasing.
False -
T/F: The CERT program was established to correct improper payments.
False -
T/F: The ICD is maintained by the AMA.
True
T/F: The National Health Service (Beveridge) model is different from the Social Insurance (Bismark) model because the Beveridge model is financed by general revenue funds from fiscal taxes, whereas the Bismark model is financed by workers' and employers' compulsory payroll contributions into sickness funds.
False -
T/F: The actual charge is the same as the allowable charge.
False -
T/F: The federal role in the healthcare sector is limited to paying providers for the healthcare costs of senior citizens.
False -
T/F: The patient and the guarantor are always the same person.
False -
T/F: When people purchase healthcare insurance for themselves and their dependents, they are purchasing single coverage.
HIPAA of 1996
The code sets to be used for healthcare services reporting by both public and private insurers were designated by what legislation?
ICD-10-CM
The coding system that is used primarily for reporting diagnoses for hospital inpatients is known as ...
category
The first three characters in an ICD-10-CM diagnosis code represent its ...
abuse, the submission of unintentional inaccurate charges on a claim for reimbursement
The new coding assistant at the Glen Ellyn Medical Group office coded and submitted a claim to Blue Cross for an initial evaluation and management office visit when, in fact, the patient was established with the practice and was seen strictly for a follow-up medical check. The resulting error was an example of ...
upcoding, coding medical records without complete documentation, correct use of encoding software
The policies and procedures section of a Coding Compliance Plan should include ...
making it lower than warranted by the actual service/resource intensity of the facility
The practice of undercoding can affect a hospital's MS-DRG case-mix in which way?
Coding Clinic
The publication for coding guidelines and advice in ICD-10-CM/PCS is the ...
CPT Assistant
The publication for coding issues and guidance in CPT coding is the ...
internal and external
What 2 forms of benchmarking can be used to determine a staff's level of compliance?
development of compliance policies and procedures, appropriate training and education, monitoring and auditing
What are 3 of the 7 OIG elements of an effective compliance plan?
global surgical package, special-procedure package, ambulatory-visit package
What are some versions of the global payment method?
stop-loss benefit, maximum out-of-pocket cost, and catastrophic expense limit
What are the 3 benefit terms that meant the amount beyond which all covered healthcare services for an insured or dependent are paid 100% by the insurance plan?
large size, complexity, intricate payment methods and rules, and programs' broad scopes
What are the 4 characteristics of the US healthcare sector?
policies and procedures, education and training, and auditing and monitoring
What are the core areas of the coding compliance plan?
internal and external benchmarking
What can help a manager determine the coding staff's level of coding compliance?
CPT
What code set what incorporated into the Healthcare Common Procedure Coding System as HCPCS Level I?
payments, rejections, denials, and adjustments
What data elements does the RA notification include?
RACs are paid on a contingency fee basis instead of a contract basis
What differentiates recovery auditors from other entities performing improper payment reviews?
resource-based relative scale (RBRVS)
What discounted fee-schedule does Medicare use to reimburse physicians?
premiums
What do insurers receive in return for assuming the insureds' exposure to risk or loss?
individual or single coverage
What is the term for health insurance that only covers the employee?
adjustment or write-off
What is the term for the difference between the provider's actual charge and the allowable charge?
group
What is the term for the number that identifies the employer, association, or other entity purchasing the healthcare insurance and indicates a common set of healthcare benefits?
IPERA and IPERIA
What legislation supports the CERT program?
Blue Cross and Blue Shield because the Blue Companies insure nearly 1 in 3 Americans
What organization is one of the most influential in the healthcare sector? Why?
NCHS and CMS
What organizations maintain the ICD-10-CM/PCS code set?
the OIG's Work Plan
What resource can managers use to discover current target areas of compliance?
reimbursement
What term in healthcare means compensation or repayment for rendering healthcare services?
disability income protection insurance
What type of insurance policy provides benefits to a homeowner who requires an 8-month recuperation after a fall down her basement stairs?
long-term or extended care insurance
What type of insurance policy provides benefits to a resident requiring nursing home care and services?
accidental death and dismemberment insurance
What type of insurance policy provides benefits to an insured who becomes blind?
A1234
What would be an example of a HCPCS Level II code?
billing for a service not furnished as represented on the claim
What would be an example of fraud?
12345
What would be an example of the correct format for a Category I CPT code?
guarantor
When a patient's healthcare services are covered under a voluntary healthcare insurance plan, who pays the remainder of a healthcare bill after the healthcare insurance company has paid?
in 1929, in Texas when Blue Cross first created a plan for school teachers
Where and when did health insurance become established in the US?
NCHS and CMS websites; additional guidance and advice is available in the Coding Clinic for ICD-10-CM/PCS
Where are the ICD-10-CM/PCS Official Coding Guidelines published?
comprehensive policies and essential benefits policies
Which 2 types of policies offer the widest ranging coverage but require the insured to pay coinsurance until the maximum out-of-pocket costs are met?
CPT
Which coding system was created for reporting procedures and services performed by physicians in clinical practice?
QIO, CERT, RAC, MAC
Which entities perform improper payment reviews for CMS?
Operation Restore Trust
Which government fraud and abuse effort targeted 5 states and made a major push for accurate coding and billing? They recovered $188 million during the first 2 years and paved the way for implementation of a national toll fee fraud and abuse hotline.
private health insurance model
Which of the 3 models of healthcare delivery is used in the US?
geographic plan
Which of the following (benefit cap, cost-sharing provision, geographic plan, use of formulary) is not a type of healthcare policy limitation?
making sure coding salaries are competitive
Which of the following (physician query process, making sure coding salaries are competitive, coding medical records without complete documentation, correct use of encoding software) would not be a part of the coding compliance plan?
semi-automated
Which type of RAC review combines data analysis and submission of medical records to the RAC?
generic
Which type of prescription drug, generic or non-formulary, is less costly for insureds using their drug benefit?
AMA
Who is CPT published by?
RACs
Who is charged with identifying underpayments and overpayments for Medicare?
legally married spouses, children, and young adults until they reach the age of 26, and dependents of the insured individual who have disabilities
Who is included in a healthcare insurance policy offering dependent healthcare coverage?
payer
Who is the third-party in healthcare situations?
OIG
Who released the 7 elements to serve as an effective corporate compliance plan?
Limitations are qualifications or other specifications that limit the extent of benefits. Most health plans have a formulary, or preferred drug list, a continually updated list of safe, effective, and cost-effective drugs that the health care plan prefers that insureds use.
Why can use of a formulary be considered a policy limitation?
The federal Medicare program is the largest, single payer for health services. In addition, Medicaid is the largest source of federal revenue for states. The federal government also pays for health services for other populations, including active-duty, veterans, Native Americans, and injured and disabled workers. Thus, much of the healthcare sector relies on the federal government for reimbursement. The federal government is the first mover in the US healthcare systems.
Why is the US federal government a dominant player in the healthcare situations?
because money is a limited resource; as spending on healthcare increases, the money available for other sectors of the economy, such as education or roads, decreases
Why is the constant trend of increased national spending on healthcare a concern?
because it speeds accurate and correct reimbursement
Why should providers submit clean claims to third-party payers?
party
an entity that receives, renders, or pays for health services
ICD
diagnoses and inpatient procedures
consumer advocates
have voiced concerns about episode-of-care reimbursement, noting that the payment method creates incentives to substitute less expensive diagnostic and therapeutic procedures and laboratory and radiological test and to delay or deny procedures and treatments
covered conditions
health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay covered service (expense)
special-procedure package
including costs associated with a diagnostic or therapeutic procedure
ambulatory-visit package
including physicians' charges, laboratory tests, and x-rays
global surgical package
including the procedure, local/topical anesthesia, preoperative visit, and postoperative care/follow-up
Part A
inpatient hospitalization services
HCPCS Level II
medical and surgical supplies
CPT
physician inpatient and outpatient procedures
healthcare analysts
point out the savings associated with eliminating wasteful or unnecessary procedures and tests, noting that volume and expense do not necessarily define quality
covered services
specific service for which a healthcare insurance company will pay
Part B
supplemental medical insurance
first-party
the patient him- or herself or the person, such as a parent, responsible for the patient's health bill
a healthcare provider unknowingly or unintentionally submits an inaccurate claim
Abuse occurs in Medicare billing when ...
TEFRA
All of the following (Operation Restore Trust, Medicare Integrity Program, TEFRA, Medicare and Medicaid Patient and Program Protection Act) are efforts to fight healthcare fraud and abuse, except ...
self-insured plan
All of the following (global payment, prospective payment, capitation, self-insured plan) are types of episode-of-care reimbursement, except ...
"birthday rule"
Both parents carried healthcare insurance with dependent coverage through their employers. What procedure is used to determine which healthcare insurer is responsible for their child's health expenses?
emerging technology
Category III CPT codes represent ...
refiling claims after denials
Common forms of fraud and abuse include all of the following (upcoding, unbundling, refiling claims after denials, billing for services not furnished), except ...
Federal Employment Program (FEP) or the Service Benefit Plan
Describe the health insurance plan that covers federal government employees:
During this 3-year demonstration project, recovery auditors reviewed claims before payment. Initial results reported in the RAC 2013 Report to Congress revealed that more than 58% of the reviewed claims were improperly billed.
Describe the importance of the RAC prepayment review demonstration project:
outpatient surgeries; diagnostic, interventional, and therapeutic outpatient procedures; physical, occupational, and speech therapies; mental health and dependency care; inpatient care, including surgery, home health, private nurses, and nursing homes; and organ transplants
Describe the types of procedures and services that typically require prior approval:
there in an intentional representation that an individual knows to be false, knowing that the representation could result in some unauthorized benefit to him/her or some other person
Fraud occurs in Medicare billing when ...
its security and privacy provisions
HIPAA of 1996 is widely known for ...
by using historical data; in the absence of historical data, third-party payers and providers must consider several factors to establish per diem rates, such as costs, LOS, volumes of service, and patients' severity of illness
How do third-party payers set per diem payment rates?
remittance advice (RA) and an explanation of benefits (EOB)
How does Blue Cross and Blue Shield notify insureds about the extent of payments made on a claim?
5
How many levels does the RAC appeal process have?
large-employer pools
In the healthcare insurance sector, which type of risk pool has the greatest diversity and the greatest ability to balance risks?
the pool is large enough to pay losses of the entire group
Insurers pool premium payments for all the insureds in a group, then use actuarial data to calculate the groups' premiums so that ...