Chapter 1 Reimbursement, HIPAA, Compliance
Terms in this set (124)
What is 3rd party reimbursement?
What is the job/responsibility of the coder?
optimize payment by using accurate coding data and obtain correct reimbursement for service rendered
What is the 1st party?
you, the patient
What is the 2nd party?
provider of service
What is the 3rd party?
What is the largest 3rd party payor?
What does HIC# stand for?
health insurance contract number
What is upcoding?
applying a code for more services than were actually performed by provider; maximizing
What is downcoding?
applying a code for less than the services that were performed by provider
When is upcoding appropriate?
Which segment of the population is the fastest growing?
Who is Medicare primarily for?
65 and older
When was Medicare program established?
How many major parts does Medicare have?
2 major but a total of 4 parts
What are the Parts of Medicare?
Describe Medicare Part A
Is free to the beneficiary & automatic enrollment and covers hospital portion- the tangible items- bed, room, pillow, etc.
Describe Medicare Part B
Beneficiary pays a premium, deductible, and 20% co insurance. It covers the services by the physician and durable medical equipment at 80% of allowable charges.
What is Medigap?
2ndary companies to Medicare "C+" w/BCBS; payment is made contingent on what B pays.
Describe Medicare Part C
also known as Medicare Advantage Organizations and is a supplemental policy with a set of health care options the been can choose the health care provider they want. Usually covers copays (Medicare + Choice)
Describe Medicare Part D
coverage of prescription drugs
What is a beneficiary?
one who is covered under Medicare
Who does DHHS stand for?
Department of Health and Human Services
What is DHHS and what do they do?
secretary of DHHS is responsible for administration of Federal Medicare program
What does CMS stand for?
Centers for Medicare & Medicaid Services
What did CMS replace?
HCFA-Health Care Financing Administration (HCFA1500)
Who is covered under Medicare? What are the criteria?
65 and over
persons with End Stage Renal Disease (ESRD)
person disabled by Gov't for at least 2 years
persons disabled before the age of 18
What does CMS do?
CMS runs Medicare and Medicaid
Delegates daily operation to Medicare Administrative Contractors (MACs)
What does MAC stand for?
Medicare Administrative Contractors
What does MACs do?
MACs are usually insurance companies, govt benefit administrators, claims administrator in every region that process Medicare Part B; handle day to day operations
Where is funding for Medicare generated and how is it dispersed?
from Social Security taxes w/ equal match from the govt-processed at CMS and sent to MACs-MACs then handle paperwork and pay claims to beneficiaries and providers
Who is payer of last resort?
What is the difference between Medicaid and Medicare?
Medicaid is federally funded and run by the state.
Medicare is federally run exclusively.
Does Medicare take paper claims?
No, electronic only
Who is considered a provider?
Doctors, hospitals, suppliers of DME and all must be licensed by local/state agencies
What is the beneficiary responsible for paying under Part B?
deductible, premium, 20% (co-insurance)
What percentage does Medicare Part B cover?
80% of covered services
What is QIO?
Quality Improvement Organization is a national network of people who work with providers and consumers to refine care systems so that the patient gets the correct care. (aka PRO-Peer Review Organization)
What does it mean to be a QIO provider?
Providers sign QIO agreement with MACs
Providers agreement to accept what MACs pay as pmt in full(accept assignment)
Receive 5%↑ fee schedule than non-QIO
Receive faster payment of claims-14 days
Provider listed in QIO directory
At least one QIO provider referral given by hospital for Outpt services.
What does it mean for Non-QIO provider?
Payment always to patient
5%↓ fee schedule than QIO
Slower claim processing
Which block/box is marked for Assignment?
block 27 on CMS-1500
What is Medicare Part A?
Hospital Portion of billing
What does Part A pay?
semipvt rm, meals, general nursing/drugs, all medically necessary svcs/items[ NOT personal convenience(TV, slippers) or private duty nursing], Rehabilitation, skilled nursing, home health visits, hospice
What % of hospital claims are submitted electronically?
What are hospital paper charges submitted on?
What does MS-DRG stand for?
Medical Severity-Diagnosis Related Groups
What is used as the basis of payment on Part A claims?
Payment based on Dx codes, procedure codes that determine MS-DRG assignment
What is covered under Medicare Part B?
Part B pays:
Outpt hospital svcs
Home Health care
Medically necessary supplies and equipment
Are Part B payments automatic?
No, beneficiary must make monthly premium
What are the 3 coding systems used under Part B?
ICD-10-CM/ICD-9-CM (Vol 1 & 2)
What does CPT stand for?
Current Procedural Terminology
What does HCPCS stand for?
Healthcare Common Procedural Coding System
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
When was HIPAA established?and why?
1996, used to protect patient information and to have uniformity in billing and includes electronic transactions, privacy, security and national identifier requirements for doctors (NPI-National Provider Identification)
What is UB04?
What is CM1500?
What is ANSI5010?
Electronic format for filing
What is EDI?
electronic digital interchange-what the electronic claim travels on to insurance company
What is the Federal Register?
official publication of all presidential rules and regulations for code changes published by the govt
Why is the Federal Register important in insurance?
Coding supervisors use to stay current on coding changes
In what month(s) are hospital facility changes made in Federal Register?
In what month(s) are major Outpt facility changes and physician fee schedules made?
Nov and Dec
How was the fee schedule set initially?
Outpatient Resource-Based Relative Value Scale (RBRVS) paid off of CPT and HCPCS codes
When was the Physician payment reform implemented?
What 3 factors are considered in RBRVS?
paid physicians lowest of:
physicians charge for service
physicians customary charge
prevailing charge in locality
What replaced RBRVS?
National fee schedule or Medicare Fee Schedule(MFS) or Usual Customary and Reasonable (UCR)
What is the % paid on Medicare Fee Schedule (MFS)?
payment of 80% of MFS, after patient deductible
Who is the MFS used for?
drs and suppliers
What is the Relative Value Unit (RVU)?
RVU=nationally, unit values assigned to each CPT code
sometimes referred to as fee schedule
What are the 3 components in local adjustment for RVU?
work and skill required
How often is RVU updated? by whom?
Annually by CMS based on national and local factors
What/How are 3 ways a beneficiary is protected under law?
Physician Payment Reform
Omnibus Budget Reconciliation Act of 1989
Maximum Actual Allowable Charge 1991 (MAAC)
How is the total relative value unit calculated?
The sum of the units established for each component of the service equals the total RVUs
What is GPCI?
geographic practice cost index--measures cost differences in various areas or charge locations which may include the whole state.
What is CF?
Conversion factor--the national dollar amount that is applied to all services paid on the basis of the Medicare Fee schedule. (MFS) by converting RVUs to dollars. 4 RV x 100 CF = 400 payment
What is Medicare fraud?
The intentional deception to benefit-- dr knows code is wrong and files anyway
What is Medicare abuse?
Unintentionally using the wrong code when filing
What is Beneficiary signature on file mean?
When there is a document in bene file sign showing assignment given to provider and is usually a one time signature.
Who can be charged with fraud?
Anyone--hosp dr labs billing YOU
What is kickback?
Bribe or rebate for referring pt for any service cvrd by Medicare. Any personal gain. It is a felony.
What is OIG?
Office of the Inspector General--develops work an every year
-outline monitoring for fraud
-measures fees for procedures in outlieing areas.
How are fraud complaints filed?
Submitted oral/written to MAC or OIG by anyone against anyone and are followed up by MAC/OIG
How can a coder protect themselves from fraud accusations?
Be truthful and accurate
Ask if unsure of code
T/F The coder's responsibility is to ensure that the data are as accurate as possible not only for classification and study purposes but also to obtain appropriate reimbursement.
T/F The Federal Register is the official publication for all "Presidential Documents", "Rules and Regulations", "Proposed Rules", and "Notices".
T/F Nationally, unit values have been assigned for each service by Medicare (CPT and HCPCS) and determined on the basis of the resources necessary for the physician's performance of the service
T/F Fraud is an intentional deception or misrepresentation that an individual knows to be case or does not believe to be true and makes knowing that the deception could result in some unauthorized benefit to him or others.
T/F Kickbacks from patients are allowed under certain circumstances according to Medicare guidelines
The Medicare program was established in ______.
Medicare Part A pays for __________.
Medicare Part B pays for _________.
physician svcs and DME
Who handles the day-to-day operation of the Medicare program for the CMS?
MACs, Medicare Administrative Contractors
Medicare pays for what percentage of covered services?
80% of allowable charge
The incentive to Medicare participating providers is _____________.
direct payment on all claims
5% higher fee schedule
faster processing of claims
Part B services are billed using ______,_____, & ______.
Who is the largest 3rd party payer in the nation?
A major change took place in Medicare in ______ with the enactment of the Omnibus Budget Reconciliation Act.
The physician fee schedule is updated each April 15 and is composed of _____________.
-the relative value units
-a geographic adjustment factor to adj for regional variations in the cost of operating a health care facility
-a national conversion factor
If a surgeon performs more than one procedure on the same patient on the same day, and discounts were made on all subsequent procedures, Medicare would pay what % for the 1st, 2nd, 3rd, 4th, and 5th procedures?
100% for 1st and 50% for 2-5
Medicare sets the payment level for assistant surgeons at a percentage of the fee schedule amount for the _______ surgical service.
What edition of the Federal Register would hospital facilities be especially interested in?
What edition of the Federal Register would Outpt/Physician fee schedules be especially interested in?
Nov and Dec
What are the 3 items that the Medicare beneficiaries are responsible to pay before Medicare will begin to pay for services?
Deductibles, premiums, and co-insurance
Medicare funds are collected by _________
CMS handles the daily operation of the Medicare program through the use of __________.
MACs, Medicare Administrative Contractors
What is the stated goal of the Physician Payment Reform?
decrease Medicare expenditures,
assure quality healthcare at a reasonable cost,
redistribute physician payment more equitably
If a QIO provider renders a covered service that costs $100 and bills Medicare for the service and Medicare allowed $58, what amount would the provider bill to the patient?
The Medicare Prescription Drug, Improvement and Modernization Act of 2003 established these new benefits available under the Medicare program?
This program is known as Medicare Advantage?
________are activities involving the transfer of health care info and ________ means the movement of electronic data between 2 entities and the technology that supports the transfer.
What part has automatic coverage under SS?
What part has optional coverage under SS?
Part B, C, D
What part covers hospice care?
What part covers Rx drug?
What part covers physicians?
What part does the beneficiary pay premium for?
Part B, C, D
What Medicare Parts are the codes assigned for payment using diagnoses, CPT and HCPCS?
Part A, B, C
Supplement Medical Insurance is what part?
What is the issuing office of the Federal Register?
What does MEI stand for?
Medicare Economic Index
What is the MEI published in?
This organization develops a work plan to identify areas of the Medicare program that will be monitored.
OIG, Office of the Inspector General
The physician responsible for controlling and managing the health care of an HMO enrollee is __________.
gatekeeper, primary care physician
What does PACE stand for?
Program for All-Inclusive Care for the Elderly
What is PACE?
Program developed to address the needs of long-term care clients, providers, and payers. Allows clients to live in their homes while receiving care