Podcast
Questions and Answers
What is the definition of a 'hold harmless clause'?
What is the definition of a 'hold harmless clause'?
- Mandates annual reviews of contracts
- Prohibits billing to patient for anything beyond deductibles and co-pays (correct)
- Defines payment terms for providers
- Allows additional charges for services rendered
What are some benefits of a compliance plan?
What are some benefits of a compliance plan?
More accurate payment of claims, fewer billing mistakes, improved documentation and more accurate coding, less chance of violating self-referral and anti-kickback status.
What is a healthcare clearinghouse?
What is a healthcare clearinghouse?
An entity that processes nonstandard health information they receive from another entity into a standard format.
What does the Minimum Necessary requirement in HIPAA imply?
What does the Minimum Necessary requirement in HIPAA imply?
What is a medically necessary service?
What is a medically necessary service?
If a patient sustains an injury to her great saphenous vein, which anatomical site is affected?
If a patient sustains an injury to her great saphenous vein, which anatomical site is affected?
What does APC stand for?
What does APC stand for?
What is ARRA?
What is ARRA?
What are ASC?
What are ASC?
What does it mean when abuse consists of billing errors?
What does it mean when abuse consists of billing errors?
What is an ABN and its purpose?
What is an ABN and its purpose?
What is the definition of fraud in the context of the Affordable Care Act?
What is the definition of fraud in the context of the Affordable Care Act?
How often must all work RVUs be examined?
How often must all work RVUs be examined?
What is the Conversion Factor (CF)?
What is the Conversion Factor (CF)?
What does CMS stand for?
What does CMS stand for?
What legislation regulates medical necessity policies developed by CMS?
What legislation regulates medical necessity policies developed by CMS?
What is the purpose of CMS-R-131?
What is the purpose of CMS-R-131?
What does CPT stand for?
What does CPT stand for?
What year is the Conversion Factor CF $25.0008 for?
What year is the Conversion Factor CF $25.0008 for?
Commercial non-Medicare health plans develop medical policies specified in what?
Commercial non-Medicare health plans develop medical policies specified in what?
What does DRG stand for?
What does DRG stand for?
Does Medicare Part B generally require a yearly deductible and copayment?
Does Medicare Part B generally require a yearly deductible and copayment?
What do E/M or E&M codes refer to?
What do E/M or E&M codes refer to?
What does EHR stand for?
What does EHR stand for?
What is the formula for calculating facility payment amounts?
What is the formula for calculating facility payment amounts?
What is the formula for Non-Facility Pricing Amount?
What is the formula for Non-Facility Pricing Amount?
What does GPCI stand for?
What does GPCI stand for?
What is GPCI used for?
What is GPCI used for?
What does HCPCS stand for?
What does HCPCS stand for?
What does HHS stand for?
What does HHS stand for?
What kind of protections does HIPAA provide?
What kind of protections does HIPAA provide?
What does HIPAA stand for?
What does HIPAA stand for?
What is HITECH?
What is HITECH?
What can patients request under HITECH?
What can patients request under HITECH?
What does HITECH require if there is unauthorized disclosure of health information?
What does HITECH require if there is unauthorized disclosure of health information?
What was HITECH enacted as part of?
What was HITECH enacted as part of?
What does HMO stand for?
What does HMO stand for?
What system is hemiplegia a disorder of?
What system is hemiplegia a disorder of?
What does ICD-9-CM stand for?
What does ICD-9-CM stand for?
What is the non-facility pricing amount for CPT code 99212 using a CF of $33.9764 if Work RVUs = 0.48 and Work GPCI = 1.000?
What is the non-facility pricing amount for CPT code 99212 using a CF of $33.9764 if Work RVUs = 0.48 and Work GPCI = 1.000?
What notice must a practice obtain if a service fails to support medical necessity requirements?
What notice must a practice obtain if a service fails to support medical necessity requirements?
If an NCD doesn't exist for a particular item, whose responsibility is it to determine coverage?
If an NCD doesn't exist for a particular item, whose responsibility is it to determine coverage?
Which part of Medicare should be billed for medication delivered for home use during outpatient chemotherapy?
Which part of Medicare should be billed for medication delivered for home use during outpatient chemotherapy?
Complete the series: Incus, stapes, _____
Complete the series: Incus, stapes, _____
What is considered intentional billing of services not provided?
What is considered intentional billing of services not provided?
What does LCD stand for?
What does LCD stand for?
What governs the jurisdiction of LCDs?
What governs the jurisdiction of LCDs?
When do LCDs give guidance?
When do LCDs give guidance?
What does MP stand for?
What does MP stand for?
What does MS-DRG stand for?
What does MS-DRG stand for?
How is Medicaid defined?
How is Medicaid defined?
On what basis is Medicaid administered?
On what basis is Medicaid administered?
What services does Medicare Part B help cover?
What services does Medicare Part B help cover?
Who pays for Medicare Part B premiums?
Who pays for Medicare Part B premiums?
What does Medicare Part C combine?
What does Medicare Part C combine?
What is another name for Medicare Part C?
What is another name for Medicare Part C?
Who manages Medicare Part C plans?
Who manages Medicare Part C plans?
What is Medicare Part D?
What is Medicare Part D?
Who provides Medicare Part D coverage?
Who provides Medicare Part D coverage?
Is Medicare Part D available to all Medicare beneficiaries?
Is Medicare Part D available to all Medicare beneficiaries?
What services does Medicare Part A help cover?
What services does Medicare Part A help cover?
How are Medicare payments for physician services standardized?
How are Medicare payments for physician services standardized?
What does NCD stand for?
What does NCD stand for?
What does an NCD explain?
What does an NCD explain?
What does NP stand for?
What does NP stand for?
What does OCR stand for?
What does OCR stand for?
What does OIG stand for?
What does OIG stand for?
What are the key actions in OIG Compliance Program for Individual and Small Group Physician Practices?
What are the key actions in OIG Compliance Program for Individual and Small Group Physician Practices?
What does PA stand for?
What does PA stand for?
What does PE stand for?
What does PE stand for?
What does PFS stand for?
What does PFS stand for?
What does PHI stand for?
What does PHI stand for?
What does PLI stand for?
What does PLI stand for?
What was the published conversion factor for CY 2012?
What was the published conversion factor for CY 2012?
What was the published conversion factor for CY 2011?
What was the published conversion factor for CY 2011?
What does RBRVS stand for?
What does RBRVS stand for?
What does RUC stand for?
What does RUC stand for?
What are the resource costs for RBRVS divided into?
What are the resource costs for RBRVS divided into?
What anatomical system do sebaceous glands belong to?
What anatomical system do sebaceous glands belong to?
What is the ABN form entitled?
What is the ABN form entitled?
What does the ABN standardize?
What does the ABN standardize?
What is the OIG mandated to test?
What is the OIG mandated to test?
The amount on an ABN should be within how much of the cost to the patient?
The amount on an ABN should be within how much of the cost to the patient?
Which chamber of the heart is the myocardium thickest around?
Which chamber of the heart is the myocardium thickest around?
What does the term 'medical necessity' refer to?
What does the term 'medical necessity' refer to?
The tunica vaginalis is part of which system?
The tunica vaginalis is part of which system?
Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to what?
Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to what?
What document should a provider review for potential problem areas in the OIG work plan?
What document should a provider review for potential problem areas in the OIG work plan?
What is an NCD interpreted at the MAC level considered?
What is an NCD interpreted at the MAC level considered?
What results from a ureteral blockage?
What results from a ureteral blockage?
When does the OIG release a work plan outlining its priorities for the fiscal year ahead?
When does the OIG release a work plan outlining its priorities for the fiscal year ahead?
When should an ABN be signed?
When should an ABN be signed?
Which of the following has a refraction function in the eye?
Which of the following has a refraction function in the eye?
Which of the following is a function of the pancreas?
Which of the following is a function of the pancreas?
Which of the following is a renal calculus?
Which of the following is a renal calculus?
Who is responsible for interpreting national policies into regional policies called LCDs?
Who is responsible for interpreting national policies into regional policies called LCDs?
Whose responsibility is it to develop and implement policies to meet HIPAA requirements?
Whose responsibility is it to develop and implement policies to meet HIPAA requirements?
What do work RVUs reflect?
What do work RVUs reflect?
Study Notes
Medical Billing and Compliance Terms
- Hold Harmless Clause: Prevents providers from billing patients beyond deductibles or co-pays in some non-Medicare contracts.
- Compliance Plan Benefits: Enhances claim accuracy, reduces billing errors, improves documentation and coding, mitigates self-referral and anti-kickback violations.
- Healthcare Clearinghouse: Converts nonstandard health information into a standardized format.
- HIPAA Minimum Necessary Requirement: Only shares essential protected health information for specific purposes.
- Medically Necessary Service: The simplest effective treatment for a patient's condition.
Anatomy and Medical Coding
- Great Saphenous Vein Injury: Relates to the leg.
- APC: Stands for Ambulatory Payment Classification.
- CMS: Centers for Medicare and Medicaid.
- GPCI: Geographic Practice Cost Index, reflects varying costs due to location.
Medicare and Medicaid Insights
- Medicaid: Health assistance for low-income individuals, state-administered per federal guidelines.
- Medicare Parts Overview:
- Part A: Covers inpatient hospital care, skilled nursing, hospice, and home health care.
- Part B: Encompasses outpatient care and physician services.
- Part C: Combines A and B, known as Medicare Advantage, managed by private insurers.
- Part D: Prescription drug coverage, provided by private companies.
- NCD and LCD: National Coverage Determinations set national guidelines; Local Coverage Determinations are region-specific interpretations by MACs.
Legal and Ethical Considerations
- ABN: Advance Beneficiary Notice protects providers by creating a billing trail upon Medicare denial.
- OIG Compliance Program: Mandates monitoring compliance, training, audits, and addressing potential violations.
- Fraud Definition under ACA: Removed intent requirement for fraud allegations.
Health Information Technology
- EHR: Electronic Health Record, digital version of patients' paper charts.
- HITECH Act: Enhances privacy and security provisions of HIPAA, includes patient rights to audit trails of their health information.
Coding Systems and Payment Models
- CPT: Current Procedural Terminology used for coding medical services.
- DRG: Diagnosis Related Group used to classify hospital cases.
- RBRVS: Resource-Based Relative Value Scale, standardizes physician service payments.
- Formula for Facility Payments: Combines RVUs, GPCI, and CF to determine payment amounts.
Miscellaneous Medical Knowledge
- Hemiplegia: Disorder in the nervous system.
- Sebaceous Glands: Part of the integumentary system.
- Nephrolithiasis: Refers to kidney stones (renal calculus).
- Myocardium: Thickest in the left ventricle of the heart.
Important Government and Regulatory Agencies
- HHS: Department of Health and Human Services responsible for health policy and services.
- OCR: Office of Civil Rights, upholds HIPAA regulations.
- OIG: Office of the Inspector General, investigates healthcare fraud and efficiency in government programs.
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Description
Test your knowledge on key terms and concepts related to medical billing, compliance, and medical coding. This quiz covers essential regulations, the role of healthcare clearinghouses, and important aspects of Medicare and Medicaid. Perfect for students and professionals in the healthcare field.
