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Questions and Answers
What is the process of paying claims submitted or denying them after comparing the claim to benefit and coverage requirements called?
What is the process of paying claims submitted or denying them after comparing the claim to benefit and coverage requirements called?
What is the term for any change to the balance due of an account such as additional payment or write-off?
What is the term for any change to the balance due of an account such as additional payment or write-off?
Adjustment
The Advanced Beneficiary Notice of Noncoverage (ABN) is an agreement for patients to sign if a physician thinks a service may be denied for payment.
The Advanced Beneficiary Notice of Noncoverage (ABN) is an agreement for patients to sign if a physician thinks a service may be denied for payment.
True
What is the system for medical reimbursement that provides additional compensation as an incentive for high-quality healthcare called?
What is the system for medical reimbursement that provides additional compensation as an incentive for high-quality healthcare called?
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What phrase describes a fee determined by an insurance carrier for a medical service?
What phrase describes a fee determined by an insurance carrier for a medical service?
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What is the term for the agreement allowing the insurance carrier to send payments directly to the service provider?
What is the term for the agreement allowing the insurance carrier to send payments directly to the service provider?
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Who are the patients entitled to receive Medicare benefits?
Who are the patients entitled to receive Medicare benefits?
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The Medicare benefit period begins the day a patient enters a hospital and ends when the patient has not been a bed patient in any hospital or nursing facility for ___ consecutive days.
The Medicare benefit period begins the day a patient enters a hospital and ends when the patient has not been a bed patient in any hospital or nursing facility for ___ consecutive days.
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What is the name of the federal agency responsible for Medicare and Medicaid?
What is the name of the federal agency responsible for Medicare and Medicaid?
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The Correct Coding Initiative (CCI) is aimed at promoting unbundling of procedural codes.
The Correct Coding Initiative (CCI) is aimed at promoting unbundling of procedural codes.
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What is the coverage gap in Medicare Part D known as?
What is the coverage gap in Medicare Part D known as?
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What type of equipment provides therapeutic benefits to patients in need?
What type of equipment provides therapeutic benefits to patients in need?
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What is defined as chronic kidney disease in an advanced state, eligible for Medicare?
What is defined as chronic kidney disease in an advanced state, eligible for Medicare?
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What is a list of covered drugs in each Medicare drug plan called?
What is a list of covered drugs in each Medicare drug plan called?
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A public agency or private organization primarily engaged in providing pain relief and supportive services to terminally ill patients is known as ___ .
A public agency or private organization primarily engaged in providing pain relief and supportive services to terminally ill patients is known as ___ .
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What is the term for Medicare Part A, which covers inpatient care?
What is the term for Medicare Part A, which covers inpatient care?
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Jurisdiction defines a geographical area over which a Medicare Administrative Contractor oversees processing of claims.
Jurisdiction defines a geographical area over which a Medicare Administrative Contractor oversees processing of claims.
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What limits the fees that nonparticipating physicians may bill Medicare beneficiaries above the fee schedule amount?
What limits the fees that nonparticipating physicians may bill Medicare beneficiaries above the fee schedule amount?
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What are decisions made by a Medicare contractor that dictate coverage for services called?
What are decisions made by a Medicare contractor that dictate coverage for services called?
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Medical necessity requires services to be consistent with diagnosis according to good medical practices.
Medical necessity requires services to be consistent with diagnosis according to good medical practices.
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What is the joint federal and state program that helps pay medical costs for individuals with limited income?
What is the joint federal and state program that helps pay medical costs for individuals with limited income?
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What established national health coverage for Americans 65 and older in 1965?
What established national health coverage for Americans 65 and older in 1965?
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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) removed Social Security numbers from Medicare cards.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) removed Social Security numbers from Medicare cards.
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Who is a private insurance carrier contracted by CMS to process Medicare Part A and B claims?
Who is a private insurance carrier contracted by CMS to process Medicare Part A and B claims?
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Medicare Advantage plans are offered by the government as part of traditional Medicare.
Medicare Advantage plans are offered by the government as part of traditional Medicare.
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What index was created to replace Social Security numbers on Medicare insurance cards?
What index was created to replace Social Security numbers on Medicare insurance cards?
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What publication provides Medicare's general billing requirements for healthcare professionals?
What publication provides Medicare's general billing requirements for healthcare professionals?
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What comprehensive listing is used by Medicare to pay doctors or other providers?
What comprehensive listing is used by Medicare to pay doctors or other providers?
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The Medicare Improvements for Patients and Providers Act (MIPPA) does not contain provisions for assistance to older adults.
The Medicare Improvements for Patients and Providers Act (MIPPA) does not contain provisions for assistance to older adults.
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What term is used for patients who are on both Medicare and Medicaid simultaneously?
What term is used for patients who are on both Medicare and Medicaid simultaneously?
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Medicare Part A covers a bed patient in a hospital up to ___ days.
Medicare Part A covers a bed patient in a hospital up to ___ days.
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Medicare Part B covers outpatient care, preventive services, and ___ services.
Medicare Part B covers outpatient care, preventive services, and ___ services.
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What part of Medicare offers drug benefits under the Medicare Prescription Drug Improvement and Modernization Act?
What part of Medicare offers drug benefits under the Medicare Prescription Drug Improvement and Modernization Act?
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The primary insurance plan of a Medicare beneficiary that must pay for medical care before Medicare is called what?
The primary insurance plan of a Medicare beneficiary that must pay for medical care before Medicare is called what?
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What document explains the amount charged and covered by Medicare for services rendered?
What document explains the amount charged and covered by Medicare for services rendered?
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What specialized supplemental insurance policy helps cover costs not covered by Medicare?
What specialized supplemental insurance policy helps cover costs not covered by Medicare?
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What program established to monitor and improve the quality of care for Medicare beneficiaries?
What program established to monitor and improve the quality of care for Medicare beneficiaries?
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The Recovery Audit Contractor (RAC) Initiative allows CMS to contract with audit companies for recovering overpayments.
The Recovery Audit Contractor (RAC) Initiative allows CMS to contract with audit companies for recovering overpayments.
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What document is generated after a claim is processed, explaining the decision made on the claim?
What document is generated after a claim is processed, explaining the decision made on the claim?
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What scale ranks physician services to determine Medicare fee schedules?
What scale ranks physician services to determine Medicare fee schedules?
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Respite care provides temporary relief for caregivers of terminally ill patients during a ___ stay.
Respite care provides temporary relief for caregivers of terminally ill patients during a ___ stay.
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What program offers income support for low-income individuals established by the Social Security Act?
What program offers income support for low-income individuals established by the Social Security Act?
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What type of programs reward healthcare organizations based on the quality and efficiency of care?
What type of programs reward healthcare organizations based on the quality and efficiency of care?
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Study Notes
Adjudication and Adjustment
- Adjudication: Process of paying or denying submitted claims based on benefit and coverage requirements.
- Adjustment: Changes to account balances, including payments, write-offs, or error corrections in billing.
Beneficiary Notices and Payment Models
- Advance Beneficiary Notice of Noncoverage (ABN): Agreement for patients to sign when a service may be denied by Medicare, acknowledging responsibility for payment.
- Advanced Alternative Payment Model (APM): System incentivizing providers for delivering high-quality, cost-efficient healthcare.
Charges and Payments
- Approved Charges: Fees deemed acceptable by insurance carriers, which may differ from the billed amount.
- Assignment: Patient agreement for direct payment from the insurance carrier to the service provider.
Medicare Structure
- Beneficiaries: Individuals entitled to Medicare benefits.
- Benefit Period: Starts when a patient is hospitalized and ends after 60 consecutive days without hospitalization.
- Medicare: Established in 1965 to provide national health coverage for those aged 65 and over.
Agencies and Programs
- Centers for Medicare and Medicaid Services (CMS): Federal agency managing Medicare and Medicaid among other health services.
- Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): Legislation eliminating Social Security numbers on Medicare cards to combat identity theft.
Coverage Determinations
- Medical Necessity: Services must align with diagnoses and good medical practice, requiring adequate documentation for payment.
- Local Coverage Determination (LCD): Specific Medicare contractor decisions on coverage based on medical necessity in their jurisdiction.
- National Coverage Determination (NCD): Federal guidelines determining Medicare service coverage.
Medicare Parts
- Medicare Part A: Covers inpatient care, nursing facilities (up to 100 days), hospice, and some home health care.
- Medicare Part B: Outpatient services, preventive care, durable medical equipment, with costs shared between the government and enrollees.
- Medicare Part C: Medicare Advantage plans providing alternative coverage through private insurers.
- Medicare Part D: Prescription drug coverage under the Medicare Prescription Drug Improvement and Modernization Act.
Claims and Payments
- Crossover Claim: Bill for services covered by both Medicare and another payer (Medicaid; Medigap), processed sequentially.
- Medicare Claims Processing Manual: Guidelines for various health care professionals’ billing and claims submission.
Financial Aspects
- Premium: Regular payment required for insurance coverage.
- Doughnut Hole: Coverage gap in Medicare Part D leading to increased out-of-pocket costs for prescription drugs.
- Remittance Advice (RA): Document detailing claims decisions sent to service providers after claim processing.
Quality and Regulations
- Quality Improvement Organization (QIO): Program monitoring care quality for Medicare beneficiaries to enhance service delivery.
- Merit-based Incentive Payment System (MIPS): Adjusts Medicare payments based on provider performance metrics.
- Value-based Programs: Reward systems incentivizing healthcare organizations based on the quality and efficiency of care rather than service volume.
Additional Terms
- Medigap: Supplemental insurance for covering costs not met by Medicare.
- Nursing Facility (NF): Facilities providing skilled nursing care and medically necessary services.
- Recovery Audit Contractor (RAC) Initiative: A program for auditing Medicare claims to identify and recover overpayments.
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Description
Test your knowledge with these flashcards covering essential terms from Medicare Chapter 6. Understand key concepts like adjudication and adjustment in the context of Medicare claims and billing processes.
