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