Medicare Medical Billing Chapter 12

Questions and Answers

What is the definition of 'benefit period'?

Time during which medical benefits are available to an insurance beneficiary (correct)

Period in which a health insurance premium is paid

Duration of a personal injury claim

Time taken for a health insurance application to be approved

What does COBRA stand for?

Cooperative Outpatient Benefit Relief Act

Comprehensive Outpatient Budget Reimbursement Act

Consolidated Outpatient Benefit Rights Act

Consolidated Omnibus Budget Reconciliation Act (correct)

What does 'crossover' refer to in Medicare?

Reassignment of gaps in coverage that eliminates the need for a beneficiary to file a separate claim with his or her Medigap insurer.

What does ESRD stand for?

End-stage renal disease Signup and view all the answers

What is an Electronic Remittance Advice (ERA)?

A document used to communicate payment information between Medicare and providers. Signup and view all the answers

What does HCPCS stand for?

Healthcare Common Procedure Coding System Signup and view all the answers

What are Local Coverage Determinations (LCDs)?

Updates sent to physicians regarding coding and medical information. Signup and view all the answers

What are Medicare intermediaries?

Private companies that have contracts with Medicare to pay Part A and some Part B bills. Signup and view all the answers

How is the limiting charge calculated?

It is 115% more than the nonparticipating provider's Medicare fee schedule. Signup and view all the answers

What constitutes Medicare abuse?

Improper payments for items or services without a legal entitlement. Signup and view all the answers

What is Medicare Advantage also known as?

Medicare+Choice Signup and view all the answers

What does MAC stand for?

Medicare Administrative Contractor Signup and view all the answers

What is a Medicare Development Letter?

A letter sent to a provider by Medicare requesting additional information to process a claim. Signup and view all the answers

What is Medicare Fraud?

Providing false information to claim medical reimbursements. Signup and view all the answers

What is Medicare Part A?

Hospital insurance Signup and view all the answers

What is Medicare Part B?

Medical insurance Signup and view all the answers

What is Medicare Part C?

Managed care health plans offered under the Medicare Advantage program. Signup and view all the answers

What does Medicare Part D cover?

Drug coverage Signup and view all the answers

What is a Medicare Remittance Notice (MRN)?

A remittance advice from Medicare to providers explaining how payments for claims were determined. Signup and view all the answers

What does MSP stand for?

Medicare Secondary Payer Signup and view all the answers

What is a Medicare Summary Notice (MSN)?

A summary sent to the patient from Medicare that outlines all services provided. Signup and view all the answers

What is Medigap?

A privately offered, Medicare-supplemental health insurance policy. Signup and view all the answers

What is the Non-PAR MFS?

Non-PAR MFS Amount that applies to unassigned services at a lower rate. Signup and view all the answers

What does OIG stand for?

Office of Inspector General Signup and view all the answers

What does PACE stand for?

Program of All-Inclusive Care for the Elderly Signup and view all the answers

What does RAC stand for?

Recovery Audit Contractor program Signup and view all the answers

What is scrubbing in medical billing?

The process of correcting claims that are incorrect to find and fix errors. Signup and view all the answers

What does TRHCA stand for?

Tax Relief and Health Care Act of 2006 Signup and view all the answers

What is telemedicine in relation to Medicare?

Limited coverage for telemedicine services including audio and video telecommunications. Signup and view all the answers

Study Notes

Medicare Medical Billing Key Terms

Benefit Period: Duration during which an insurance beneficiary can access medical benefits.
COBRA: Consolidated Omnibus Budget Reconciliation Act; allows terminated employees or those losing insurance due to reduced work hours to purchase group insurance for a limited time.
Crossover: Process to reassign coverage gaps, eliminating the need for separate claims with Medigap insurers; typically requires a signed release-of-information.
ESRD: End-stage renal disease; Medicare acts as a secondary payer for individuals with employer-sponsored coverage.
ERA: Electronic Remittance Advice; digital summary of payments to providers.
HCPCS: Healthcare Common Procedure Coding System; used for coding outpatient services and supplies for Medicare patients.
LCDs: Local Coverage Determinations; communications sent to physicians for updates on coding and medical information.
Intermediaries: Private companies contracted with Medicare to process Part A and certain Part B bills.
Limiting Charge: 115% over the nonparticipating provider's Medicare fee schedule; maximum amount a non-participating provider can charge an individual.
Medicare Abuse: Involves improper payments for services not legally entitled to reimbursement.
Medicare Advantage: Also known as Medicare+Choice; abbreviated as MA, it includes managed care health plans for beneficiaries.
MAC: Medicare Administrative Contractor; oversees claims processing and administration.
Medicare Development Letter: Official request from Medicare for additional information needed to process claims.
Medicare Fraud: Involves submitting false claims to receive reimbursement beyond actual services rendered.
Medicare Part A: Provides hospital insurance coverage.
Medicare Part B: Covers medical insurance services.
Medicare Part C: Managed care plans available to Medicare beneficiaries under the Medicare Advantage program.
Medicare Part D: Offers coverage for prescription drugs.
Medicare Remittance Notice (MRN): Detailed summary explaining how Medicare payments for claims were determined.
MSP: Medicare Secondary Payer; legislation that transfers payment responsibility from Medicare to other sources; vital for coordinating beneficiary benefits.
Medicare Summary Notice (MSN): Summary document sent to patients detailing services provided and benefits covered over a specific period.
Medigap: Private supplemental health insurance designed to cover costs not covered by Medicare.
Non par MFS: Non-participating Medicare Fee Schedule; applies to unassigned services by non-participating physicians, who may charge up to 115% of the nonparticipating fee.
OIG: Office of Inspector General; responsible for monitoring compliance with health care reimbursement laws.
PACE: Program of All-Inclusive Care for the Elderly; comprehensive care support for seniors.
RAC: Recovery Audit Contractor program; established to identify improper Medicare payments.
Scrubbing: Process of reviewing and correcting errors in claims submissions before processing.
TRHCA: Tax Relief and Health Care Act of 2006; legislation impacting health care provisions.
Telemedicine: Limited Medicare coverage for telehealth services involving audio and video communications.

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