Chapter 1 Reimbursement, HIPAA, and Compliance
According to the filing guidelines, providers must file claims for their Medicare patients within how many months of the date of service?
12
For co-surgeons, Medicare pays the lesser of the actual charge or what percentage of the global fee? Dividing the payment equally between two surgeons.
125%
What year was the Medicare program established?
1965
Medicare publishes the Medicare fee schedule and usually pays what percentage of the amounts indicated for services?
80%
The most major change to the health care industry as a result of HIPAA was as a result of what portion of the act?
Administrative Simplification
Individuals covered under Medicare are termed what?
Beneficiaries
The operation of Medicare is delegated to who?
CMS
To what government organization did the Secretary of the Department of Health and Human services delegate the responsibility for administering the Medicare program?
CMS
What does CMS stand for?
Centers for Medicare and Medicaid Services
What does DHHS stand for?
Department of Health and Human Services
The transfer of electronic documentation is accomplished through the use of what?
Electronic Data Interchange technology
The Medicare Economic Index is published in what publication?
Federal Register
The physician responsible for controlling and managing the health care of an HMO enrollee is the
Gatekeeper
Within an HMO, there is usually an individual who has been assigned to monitor the services provided to the patient both inside the facility and outside the facility. This person is known as who?
Gatekeeper
The major third-party payer in the United States is ?
Government
HIPPA stands for what?
Health Insurance Portability Accountability Act
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
What does Part A cover?
Hospital
In this model of HMO, the HMO contracts with the physician to provide the service at a set fee. These organizations are known as what?
Individual Practice Associations
Specific regulations for Medicare are contained in the ___ ___ manual.
Internet Only
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
Who does the paperwork for Medicare, and are usually insurance companies?
MACs
What does MAC stand for?
Medicare Administrative Contractors
Who does the paperwork for Medicare and are usually insurance companies that have bid for a contract with CMS to handle the Medicare program for a specific area.
Medicare Administrative Contractors
Medicare Part C is also known as?
Medicare Advantage Organizations
The number that is assigned to all providers as a result of HIPAA:
National Provider Identification
Can a physician charge a patient to complete a Medicare form?
No
What editions of the Federal Register would the outpatient facilities be interested in?
November and December
What issue of the Federal Register contains major outpatient facility changes?
November and December
Under what act was a major change in Medicare in 1989 made possible?
OBRA
This organization develops a work plan to identify areas of the Medicare program that will be monitored
OIG
What issue of the Federal Register contains hospital facility changes?
October
What does OIG stand for?
Office of the Inspector General
What does OBRA stand for?
Omnibus Budget Reconciliation Act of 1990
What does Part B cover?
Physician
There are three items that Medicare beneficiaries are responsible for paying before Medicare will begin to pay for services. What are those three items?
Premium, deductible, and copay.
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?
Program for All-Inclusive Care for the Elderly
PACE means?
Program for All-Inclusive Care for the Elderly
What does QIO stand for?
Quality Improvement Organizations
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 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.
Staff Model
Part B is also known as?
Supplemental Medical Insurance
What does MFS mean?
Termed Medicare Fee Schedule
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
What are the three parts to a RVU?
Work, Overhead, and Malpractice
What two groups of persons were added to those eligible for Medicare benefits after the initial establishment of the Medicare program?
a. Disability b. End stage renal failure
