What two groups of persons were added to those eligible for Medicare benefits after the initial establishment of the medicare program
people with disabilities and end stage renal disease
To what organization did the secretary of the department of Health and Human Services delegate the responsibility for administering the Medicare program?
CMS (Center for Medicare and Medicaid Services) now known as NGS (National Government Service
What government program handles the funds for the Medicare program?
Social Security Administration
There are three items that Medicare beneficiaries are responsible for paying before Medicare will begin to pay for services. What are these three items?
deductibles, premiums and co-insurance
Medicare publishes the Medicare fee schedule and usually pays what percentage of the amounts indicated for services?
The three components of work, overhead (practice expense) and malpractice are part of an RVU. What does RVU stand for?
Relative value unit
According to the filing guidelines, providers must file claims for their Medicare patients within _____ months of the date of service.
What editions of the Federal Register would the outpatient facilities be interested in?
November and December
Under what act was a major change in Medicare in 1989 made possible
Omnibus Budget Reconciliation
Can a physician charge a patient to complete a Medicare form?
Individuals covered under Medicare are termed?
They ____ do 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 (MAC)
Medicare part C is also know as
HIPAA stands for
Health Insurance Portability and Accountability Act
The most major change to the health care industry as a result of HIPAA was as a result of what portion of the act?
What are the two parts of Administrative Simplification?
Developement and implementation of standardized health-related financial and administrative activities electronically and implementation of privace and security procedures to prevent the misuse of health information by ensuring confidentiality.
HIPAA includes provisions for governing what?
Health coverage portability, Health information privacy, Administrative simplification, Medical savings accounts, and long term care insurance
The number that is assigned to all providers as a result of HIPAA is
National Provider Identification
The transfer of electronic documentation is accomplished through the use of what Interchange Technology?
Electronic Data Interchange Technology
Under the relative value system, ___values are assigned to each service and are determined on the basis of the resources necessary to the physicians performance of the service.
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.
What is the primary purpose of insurance reform?
to provide continuous insurance coverage for workers and their dependents when they change or lose their jobs. Limits the use of preexisting conditions exclusions, prohibits discrimination for part or present poor health, Guarantees certain employees and individuals the right to purchase new health insurance coverage after losing a job and allows renewal of health insurance coverage regardless of an individuals health condition that is covered under the particular policy.
For co-surgeons Medicare pays ___% of the global fee, dividing the payment equally between 2 surgeons
Specific regulations for Medicare are contained in what manual
Internet Only Manual
Within an HMO, there is usually an individual who as been assigned to monitor the services provided to the patient both inside and outside the facility. This person is known as
primary care physician (gate keeper)
In this model of HMO, the HMO directly employs the physicians, __ model?
Group Practice Model
In this model of HMO, the HMO contracts with the physician to provide the service at a set fee. This organization is known as __
Individual Practice Model
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 ___(PACE)
Program all inclusive care for the elderly
In what year was the Medicare program established?
The most major change to the healthcare industry is the
administrative simplification portion of HIPPA
What are the 4 parts of the Administrative Simplification
Electronic transactions and code sets, Privacy requirements, Security requirements, National identifier requirements
What are code sets
numbers and/or letters that identify specific diagnosis and clinical procedures on claims and encounter forms. ie CPT and ICD-9 codes
What type of code sets are used for medical supplies, orthotics, and DME
What type of code sets are used for Physician services?
HCPCS and CPT
This term is the intentional deception or misrepresentation that results in unauthorized benefits
This organization developes a work plan to identify areas of the Medicare program that will be monitored
Office of the Inspector General
The secretary of DHHS has delegated responsibility for Medicare to which department?
CMS or NGS
Who administers funds to Medicare?
What is the fastest growing segment of our population today?
what are the 5 most common managed care plans?
HMO, PPO, IPA, EPO, POS
What is the National Correct Coding initiative (NCCI)?
Developed by the CMS to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B health insurance claims
What two types of edits does NCCI include?
Column 1/Column 2 and Mutually exclusive edits
What is Title 1 of HIPAA?
Column 1/column 2
identifies code pairs that should not be billed together because one code (column 1) includes all the services described by another code (column 2)
What are the consequences for inaccurate coding?
delayed processing and payment of claims, reduced payments; denied claims, fines and/or imprisonment, exclusion from payers programs; loss of physicians license
What is goal of Title 2 of HIPPA?
to focus on the health care practice setting to reduce administrative costs and burdens.
Omnibus Budget Reconciliation Act of 1989
Requires physicians to accept the amount paid for eligible Medicaid Services
What is the range of codes in the cpt manual
the cpt coding system was established in 1966 by what organization
AMA- American Medical Association
How many sections are there in the cpt manual?
3- Category I, II, III
Category I of cpt is divided into 6 subsections. What are they?
E/M, Anesthesia, Surgery, Radiology, Pathology, Medicine
Category II codes
performance measurements- 4 numbers followed by a letter