Term
Diagnosis Related Group
DRG |
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Definition
| Determines the payment rate/total payment for each case |
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Term
| AMBULATORY PAYMENT CLASSIFICATION |
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Definition
Medicare's PPs method for hospital outpatient.
Places services into groups based on similar procedures and resource use
APC system uses CPT and HCPCS codes |
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Term
REQUEST FOR PROPOSAL
Should include |
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Definition
RFP -
List providers needs
Software compatibility with billing system
Claim editing
Initial and ongoing costs
Customer support
Training |
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Term
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Definition
Takes data and create claims
Submit claims electronically
Check claim status
Receive ERA's |
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Term
| HIPAA TRANSACTION CODE SETS |
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Definition
CPT AND HCPSC- Outpatient procedures
ICD-9/ICD-10- Diagnoses; Inpatient procedure
NPI- Provider Identification
Taxonomy |
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Term
HIPAA TRANSACTION
HINT- CLAIM OR INQUIRY |
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Definition
| Helps to standardizing many health care electronic transactions |
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Term
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Definition
| Medicare Severity gives more weight to patients with complication and co-morbidities |
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Term
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Definition
Medicare payment for outpatient services to include-
Lab
Mammography
Physical Therapy |
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Term
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Definition
| Minimal data stets- determines RUGs and payments |
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Term
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Definition
| Resource Utilization Groups to determine payment rate. |
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Term
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Definition
| Out and Assessment Information Set determines payment rate |
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Term
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Definition
A- Inpatient
B- Outpatient
C-Medicare Advantages Plan
D-Prescription Drug Plan |
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Term
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Definition
| Instituted PPS system for Home Health Claims |
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Term
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Definition
| Request for Anticipated Payment - HH may receive half of the payment from MCR upfront and remainder when the actual claim is submitted |
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Term
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Definition
Small rural hospitals
25 beds or less
ALOS of 96 hours or less
Located within a certain distance from other hospitals
24/7 emergency room
Not Subject to MCR DRG's
Paid 101 % allowable MCR cost |
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Term
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Definition
Small rural hospital serving as an acute or SNF care facility
Must have CMS approval |
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Term
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Definition
Provider is paid a set of dollar amount for each patient for a specific time period that completely covers all cost
Shifts a great deal of risk to the provider |
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Term
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Definition
| Providers are paid a predetermined amount for each day of inpatient stay |
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Term
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Definition
| % of charges the claim is paid at a predetermined % discount rate |
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Term
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Definition
| Charges are due in full without discounts |
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Term
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Definition
Medicare Administrative Contract
Private firms that process MCR claims
Formally Fiscal Intermediaries and Carriers |
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Term
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Definition
Used to determine if MCR is the secondary payer
Beneficiary or spouse coverage
Accident, third-party liability, no fault coverage
W/C, black lung, VA
Research Studies
Third-party liability cases allows for conditional billing to Medicare |
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Term
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Definition
Three types
Coordinate Care Plans- including HMO, PSO, PPO and RFB
Private Fee For Service Plans
Medical savings account |
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Term
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Definition
Skilled services and limited home assistance
Payment is based on a 60 day episodes |
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Term
| DENIALS CORRECTION PROCESS |
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Definition
Correct and resubmit
Follow-up with patient regarding insurance coverage
File an appeal |
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Term
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Definition
Redetermination- 120 days
Reconsideration- 180 days
Administrative Law Judge- 60 days |
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Term
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Definition
| Medicare Administrative Contract |
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Term
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Definition
| Once Medicare is billed, the provider is prohibited from accepting a 3rd-party liability payments |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| PROVIDER SPONSORED ORGANIZATION |
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Term
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Definition
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Term
| FIRST LEVEL OF APPEAL- MCR |
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Definition
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Term
| DAYS ALLOTED FOR REDETERMINATION |
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Definition
| 120 DAYS - of original determination |
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Term
| SECOND LEVEL OF APPEAL PROCESS-MCR |
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Definition
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Term
| DAYS ALLOTED FOR RECONSIDATION |
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Definition
| 180 DAYS of receiving redetermination letter |
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Term
| ADMINISTRATIVE LAW JUDGE DOLLAR AMOUNT AND DAYS - MCR |
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Definition
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Term
| DEPARTMENT OF APPEALS DAYS |
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Definition
| 60 DAYS of last decisions |
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Term
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Definition
| Have their own rules for appeals process with various time line |
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Term
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Definition
| The total number of and reasons for the denial for training purposes |
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Term
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Definition
MCR - one year
Commercial payers - 60 days
Claims that are not filled by deadline can not be written off |
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Term
| OTHER CONSIDERATION OF DENIALS |
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Definition
| problem with payer consider denials when renegotiating contracts |
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Term
| HOSPITAL/PRACTITIONER RELATIONSHIPS |
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Definition
physicians work with the hospital to balance patient care
Help secure reimbursement
Documentation of medical records
Physicians at as gatekeepers
Participate in Case Management |
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Term
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Definition
Private Practitioner
Independent Contractor
Employee |
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Term
| Hospital / DR relationship |
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Definition
| Both must keep track of internal and external rules regarding medical care and medical billing compliance |
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Term
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Definition
Durable Medical Equipment
Equipment that has repeated use
For a medical purpose
Has no use absent illness
Use in the Home |
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Term
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Definition
Crutches
Wheelchairs
Hospitals Beds
Oxygen Concentration |
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Term
| ITEMS EXEMPT FROM DME MAC BILLING |
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Definition
Items that require billing by a hospital to the FI which include:
Intraocular lenses
Pacemakers
Home Dialysis supplies |
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Term
| COMPLIANCE- CLAIM BILLING MAKE-UP |
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Definition
Being uptodate on billing requirements and regulation
Edits to catch errors
Best practices should be used when coding
Education is available from local MAC |
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Term
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Definition
| Standard billing form used by many providers |
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Term
| GOVERNANCE COMMITTEE FOR UB-04 FORMS |
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Definition
| Form is governed by the National Uniform Billing Committee (NUBC) |
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Term
| SEGMENTS of UB-04 ARE CALLED |
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Definition
| Divided into boxes call locator's |
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Term
| GOVERNANCE COMMITTEE FOR 837 FORMS |
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Definition
| American National Standard Institute (ANSI) |
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Term
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Definition
HIPAA standard form used by hospitals for electronic claims
All MCR claims must be filled electronically |
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Term
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Definition
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Term
| DATE REQUIRED FOR MEDICARE ELECTRONICALLY FILLING FOR HIPAA TRANSACTIONS |
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Definition
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Term
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Definition
3-day payment window
Inpatient- MCR DRG payment
Outpatient services received prior to admission must be included in claim also diagnostics services
non-diagnostic services must also be included |
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Term
| POST ACUTE TRANSFER POLICY |
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Definition
Inpatient transfers before ALOS are met must be transfered to a hospital, SNF or HH care plan
Can also constitute a reduced per diem payment rate |
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Term
| BALANCE BUDGET ACT 1997 and POST-ACUTE TRANSFERS |
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Definition
| Mandated that hospitals be paid a per diem rate for inpatient who were transfered before the average lenght of stay for the DRG to be met |
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Term
CCI CODING EDITS
Editing systems used by fiscal Intermediary (FI) and carrier -related claims |
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Definition
Used for carrier processing of physician services under the MCR Physician Fee Schedule
Consist of HCPCS codes |
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Term
OCE EDITS
Editing systems used by fiscal Intermediary (FI) and carrier -related claims |
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Definition
Used by intermediaries for processing hospital outpatient services under the hospital OPPS
> 50 edits and includes CCI |
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Term
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Definition
Two tables
Column 1/ column 2 correct coding edits table and the other - mutually |
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Term
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Definition
| Arranged into numerical order with description for each edit and claim disposition for each edit |
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Term
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Definition
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Term
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Definition
used to reduce the paid claims error rate for MCR claims as a result of clerical entries and incorrect coding based upon anatomic considerations
HCPSC/CPT code description
CPI Instructions
CMS Policy
Nature of analytic and equipment
Unlikely clinical treatment |
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Term
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Definition
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Term
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Definition
CMS mandate use of POA indicators for inpatient claims
Used to help identify non-payable complications i.e. hospital -acquired infections, sponges left in patients |
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Term
| POA INDICATORS ARE PAIRED WITH? |
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Definition
| Indicators are paired with diagnosis codes in the medical record |
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Term
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Definition
HIPAA standard form replaces the 1500 with the 837
The paper form is governed by NUCC |
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Term
| 1500 ISSUES- ASSIGNMENTS TYPES |
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Definition
Participation
Non-participation |
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Term
| NON PARTICIPATING BILLING ALLOWANCE |
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Definition
| Phys. can only bill for 115% of the allowable MCR amount; limited charge and based upon a 95% of the fee schedule |
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Term
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Definition
Physician accepts what MCR allows as payment in full
Can not use ABNs to get patients to pay more
Payment will be sent directly to Phys. office |
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Term
| WHEN AE OFFICES EXEMPTED FROM ELECTRONIC BILLING? |
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Definition
| Small offices are exempted from electronic billing requirement |
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Term
| 1500 ISSUES CODING AND PAYMENT TYPES |
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Definition
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Term
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Definition
Relative Value Units
bases value of a procedure on three factors
Work
Practice exam
Malpractice insurance |
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Term
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Definition
Resource-Based Relative Value Units
Determine value of practitioner service
CPT relative value
Adjusted for geographic regions
Multiplied by conversion factors |
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Term
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Definition
| Surgical procedures performed by physicians in which any related services are not separated for a period range from 0 to 90 days |
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Term
| EVALUATION AND MANAGEMENT |
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Definition
| The process and the charge for examining a patient and formulating a treatment plan |
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Term
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Definition
Level assignment depends upon 7 components
history
examination
medical decision making
counseling
coordination of care
nature of presenting problem
time spent |
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Term
| MEDICARE PART A DEDUCTIBLE COVER WHAT PORTION OF HOSPITAL STAY? |
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Definition
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Term
| WHAT IS THE MEDICARE PART B CO- INSURANCE AMOUNT |
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Definition
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Term
| WHAT TYPE OF BENEFICIARY IS DEDFINED BY THE FOLLOWING: MEDICAID PROGRAM FOR BENEFICIARIES WHO NEED HELP PAYING FOR MEDICARE SERVICES. MUST HAVE MCR A COVERAGE WITH LIMITED INCOME AND RESOURCES? |
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Definition
| Qualified Medicare Beneficiaries (QMB) |
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Term
| QMB PAYS FOR WHAT PART OF MCR COVERAGE? |
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Definition
MCR Part A premiums
Part B premiums
MCR deductibles and coinsurance amounts |
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Term
| WHAT PAYMENT MEDHODOLOGY IS DEFINED BY A CLSSSIFICATION SYSTEM THAT GROUPS PATIENTS CLASSIFICATION SYSTEM ACCORDING TO DIAGNOSIS TYPES, TREATMENT, AGE AND OTHER RELEVANT CRITERIA? |
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Definition
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Term
| WHAT DOES DRG PAY HOSPITALS? |
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Definition
| A set fee for treating patients in a single category regardless of actual cost of individual care |
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Term
| WHO ARE ELIGIBLE FOR MEDICARE HEALTH INSURANCE? |
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Definition
65 year or older
Certain disabilities under age 65
End-stage renal disease |
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Term
| 2010 AMOUNT YOU PAY UNDER MEDICARE COVERAGE- HOSPITAL STAY OF 0-60 DAYS? |
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Definition
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Term
| 2010 AMOUNT YOU PAY UNDER MEDICARE COVERAGE- HOSPITAL STAY DAYS 61-90 DAYS? |
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Definition
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Term
| 2010 AMOUNT YOU PAY UNDER MEDICARE COVERAGE- HOSPITAL STAY 91-150 DAYS? |
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Definition
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Term
| 2010 AMOUNT YOU PAY UNDER MEDICARE COVERAGE- HOSPITAL STAY BEYOND 150 DAYS? |
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Definition
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Term
| 2010 AMOUNT YOU PAY UNDER MEDICARE COVERAGE-SNF CARE AT LEAST 3 DAY COVERED HOSPITAL STAY - THE FIRST 20 DAYS? |
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Definition
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Term
| 2010 AMOUNT YOU PAY UNDER MEDICARE COVERAGE-SNF CARE AT LEAST 3 DAY COVERED HOSPITAL STAY - DAYS 21 TO 10O? |
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Definition
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Term
| 2010 AMOUNT YOU PAY UNDER MEDICARE COVERAGE-SNF CARE AT LEAST 3 DAY COVERED HOSPITAL STAY - DAYS BEYOND 100? |
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Definition
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Term
MEDICARE PART B COVERAGE UNDER 2010-
DEDUCTIBLE? |
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Definition
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Term
| MEDICARE PART B COVERAGE UNDER 2010-COINSURANCE AFTER DEDUCTIBLE? |
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Definition
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Term
MEDICARE PART B COVERAGE UNDER 2010-
PHYSICAL W/IN 1ST 6 MON OF CVG? |
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Definition
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Term
| MEDICARE PART B COVERAGE UNDER 2010-COINSURANCE FOR OP MENTAL HEALTH? |
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Definition
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Term
MEDICARE PART B COVERAGE UNDER 2010-
MEDICARE APPROVED LAB SVCS. |
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Definition
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Term
MEDICARE PART B COVERAGE UNDER 2010-
MEDICARE APPROVED HOME HEALTH? |
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Definition
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Term
| MEDICARE PART B COVERAGE UNDER 2010-MEDICARE APPROVED DME? |
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Definition
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Term
MEDICARE PART B COVERAGE UNDER 2010-
OP SVC FOR DIAG/TREATMENT OF ILLNESS/INJ? |
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Definition
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Term
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Definition
Intentional or illegal deception or misrepresentation made for the purpose of gain, to harm or manipulate another person or organization
Act must be committed knowingly and willfully
IE
Offering kickbacks
Routinely waving beneficiary co-payments |
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Term
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Definition
The misuse of person, substance, service or financial matters such that harm is caused
I.e.
abuse of privacy
pharmaceuticals
services |
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Term
| REVIEW BILLING MATRIX QUESTIONS |
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Definition
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Term
| PATIENT PORTIONS BILL ITEMS? |
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Definition
Patient deductible
visitor meals and telephone
private room differential |
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Term
| WHAT IS THE 72 HOUR RULE? |
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Definition
| IT APPLIES TO PPS PROVIDERS PAID BY DRG AND REQUIRES ALL DIAGNOSTICS OR OUTPATIENT SERVICES FURNISHED IN CONNECTION WITH THE PRINCIPLE PATIENT ACCESS DIAGNOSIS WITHIN THREE DAYS PRIOR TO A HOSPITAL ADMISSION TO BE BUNDLED TOGETHER WITH THE INPATIENT SERVICES FOR MEDICARE BILLING. |
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Term
| WHAT DOES 72 HOUR RULE NOT APPLY TO? |
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Definition
| AMPULANCE SERVICES AND NON-DIAGNOSIS OUTPATIENT SERVICES UNRELATED TO THE PRIMARY IMPATIENT DIAGNOSIS PROVIDED WITHIN 72 HOURS OF AN ADMISSION BECAUSE THESE SERVICES ARE UNBUNDLED. |
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Term
| WHAT HOSPITALS ARE EXEMPTED FROM THE 72 HOUR RULE? |
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Definition
| PSYCHIATRIC HOSPITALS REHAB HOSPITALS CHILDREN'S HOSPITALS LONG-TERM HOSPITALS CANCER HOSPITALS ANY HOSPITAL OUTSIDE 50 STATES. DISTRICT OF COLUMBIA AND PUERTO RICO |
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Term
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Definition
TAKE DATA AND CREATES CLAIMS
SUBMIT CLAIMS ELECTRONICALLY
CHECK CLAIM STATUS
RECEIVE ERA'S
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Term
| MCR CLAIMS MIN. REQUIREMENT |
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Definition
ELECTRONIC BILLING
INTERNET ACCESS |
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Term
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Definition
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Term
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Definition
PROVIDER NEEDS ARE LISTED
INFORMATION ABOUT THE PRODUCT IS REQUESTED |
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Term
What is a no pay bill-
claim 110 |
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Definition
| For Medicare recipients-- must submit a no pay bill when UR has determined that a Medicare admission isn't medically necessary but the physician feel the admission is warranted. |
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Term
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Definition
MEDICAID
COMMERICAL
SELF-PAY
SELF-INSURED
TRICARE
LIABILITY
W/C
HSA'S |
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Term
|
Definition
SIGNED INTO EFFECT 1965. INTENTED TO ASSURE THAT VULNERABLE WOULD HAVE ACCESS TO HEALTH INSURANCE.
FUNDED BY THE STATE AND FEDERAL GOVERNMENT.
MARJORITY OF DOLLARS GO TO PAY FOR CUSTODIAL CARE FACILITIES |
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Term
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Definition
HEALTH INSURANCE THAT COVERS INDIVIDUALS
MOST ARE FROM EMPLOYERS
INDIVIDUAL POLICIES CAN BE PURCHASED
PRECERTIFICATION OR PREAUTHORIZATION IS A COMMONLY USED TOOL |
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Term
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Definition
| NO COMMERCIAL INSURANCE- important to consider if offering `discounts'. |
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Term
| COMMERCIAL INSURANCE TYPES |
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Definition
Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPOs)
Fee-for-service
Point-of-Service (POS)
Managed care
Traditional Health Insurance
Catastrophic Health Insurance |
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Term
| Preferred Provider Organizations (PPOs) |
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Definition
PPOs have made arrangements for lower fees with a network of health care providers.
PPOs give their policyholders a financial incentive to stay within that network.
Deductible if you choose to go outside the network may be required.
Pay the difference between what the in-network and out-of-network doctors charge. |
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Term
| Catastrophic Health Insurance |
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Definition
| This sort of policy is basically meant for the people who have the financial means to manage regular illnesses and hospitalizations. |
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Term
|
Definition
| You have complete autonomy when it comes to choosing doctors, hospitals and other health care providers. You can refer yourself to any specialist without getting permission. |
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Term
|
Definition
Usually involve more out-of-pocket expenses.
A deductible may apply, usually of about $200-$2,500.
Once deductible is paid, the insurer may pay 80 percent of any doctor bills.
Might have to pay up front and submit bill for reimbursement.
Provider may bill insurer directly. |
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Term
| Health Maintenance Organizations (HMOs) |
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Definition
Exchange for a low co-payment or no co-pay,low premiums and minimal paperwork HMO requires that you see its doctors.
Referral from a primary care physician before see a specialist.
An HMO may have central medical offices or clinics.
May consist of a network of individual practices.
HMOs have the best reputation for covering preventive care services and health improvement programs. |
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Term
|
Definition
Gatekeeper, or Primary Care Physician
PCP from among the plan's network of doctors required.
Referral to a specialist from PCP required.
POS plans may cover more preventive care services or offer health improvement programs like workshops on nutrition and smoking cessation and discounts at health clubs. |
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Term
|
Definition
By choosing a self-insured plan, the employer agrees to bear the financial
risk of providing health care benefits to its employees. In essence, your employer would pay for your trip to the doctor or hospital rather than pay a monthly fixed premium to a health insurance provider.
The employer agrees to bear the financial risk of providing health care benefits to its employees
rather than pay a monthly fixed premium to a health insurance provider.
Employers benefit from improved cash flow.
Contract with the health care providers of their choice to best suit their employees' needs.
Employers assume the risk to pay for health care and must have available cash.
Needs can be unpredictable. |
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Term
|
Definition
Gatekeeper, or Primary Care Physician
PCP from among the plan's network of doctors required.
Referral to a specialist from PCP required.
POS plans may cover more preventive care services or offer health improvement programs like workshops on nutrition and smoking cessation and discounts at health clubs. |
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Term
|
Definition
A tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP).
The funds contributed to the account are not subject to federal income tax at the time of deposit. |
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Term
|
Definition
Each state has its own workers' compensation laws to handle claims from employees who are injured on the job.
Laws are strict liability - fault and negligence by the employer are not considered in order to collect benefits.
Punitive damages are not available to the employee. |
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Term
|
Definition
| Liability insurance is a part of the general insurance system of risk financing to protect the purchaser (the "insured") from the risks of liabilities imposed by lawsuits and similar claims. It protects the insured in the event he or she is sued for claims that come within the coverage of the insurance policy. |
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|
Term
|
Definition
| A regionally managed health coverage program for active dutyand retired members of teh uniformed services, families and survivors. |
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Term
|
Definition
| The Civilian Health and Medical Program of the VA. VA shares cost of medical bills of veterans with total or permanent service connected disabilites. |
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Term
|
Definition
| Civilian Health and Medical Program of the Uniformed Service. Federally funded, provides hospital and medical coverage to active duy or deceased active duty victim and retired members and their families. |
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Term
HIPAA Transaction
Institution Claim |
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Definition
|
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Term
HIPAA Transaction
PROFESSIONAL CLAIM |
|
Definition
|
|
Term
HIPAA Transaction
DENTAL CLAIM |
|
Definition
|
|
Term
HIPAA Transaction
REMITTANCE ADVICE |
|
Definition
|
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Term
HIPAA Transaction
HEALTH CARE ELIGIBILITY INQUIRY |
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Definition
|
|
Term
HIPAA Transaction
HEALTH CARE ELIGIBILITY RESPONSE |
|
Definition
|
|
Term
HIPAA Transaction
HEALTHCARE CLAIM STATUS INQUIRY |
|
Definition
|
|
Term
HIPAA Transaction
HEALTH CARE CLAIM STATUS RESPONSE |
|
Definition
|
|
Term
|
Definition
patient age
diagnosis- including severity and co-morbidity
discharge disposition
procedure to determine payment rate |
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|
Term
|
Definition
| Medicare Severity; gives more weight to patients with complications and co-morbidities |
|
|
Term
|
Definition
Patient age
diagnosis including severity and co-morbidity
Discharge disposition
Procedures to determine payment rate |
|
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Term
|
Definition
| Identify the type and specialty of a provider |
|
|
Term
|
Definition
No limitof 60 day episodes
MCR pays for skilled services as well as limited home assistance
Must complete OASIS, and RAP |
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Term
|
Definition
| payment for Skill Nursing uses RUG to determine rates, cover all patient care during the stay with certain exceptions like Therapy performed at hospital outpatient dept. |
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Term
|
Definition
Inpatient
Skilled care
Hospice
Home Health |
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|
Term
|
Definition
Doctors visits
Outpatients
Lab
Radiology
ASC Charges
DME
Home Health
Has a monthly premium |
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Term
|
Definition
| Replaces standard MCR has added benefit like vision, dental and other preventative services |
|
|
Term
|
Definition
Covers prescription drug
Subject to an $250 annual deductible
Donut hole of $2250
Out of pocket expense $2850 |
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|
Term
| List seven componets of OIG Compliance Plan |
|
Definition
Designate Compliance officer and compliance commitee
Write policies and procedures
Effective and open lines of communication
Appropriae and effective training and education
Internal auditing and monitoring
Responding to detected deficies, offences and developing corrective action plan
Enforcement of disciplinary standards |
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|
Term
|
Definition
| Encompasses the entire service performed |
|
|
Term
|
Definition
| Part of the comprehensive code |
|
|
Term
What is an ABN--
Advance Beneficiary Notice |
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Definition
| A written notice given to a Medicare beneficiary before items or services aer furnished wen the supplier believes Medicare may not pay. I allows the beneficiaries to make an informed decision whether to receive the service offered |
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Term
| What information should be included in on an ADN |
|
Definition
Identify information of the billing entity
Patients Name
Medicare #
Listining of the test or Part B services
described in sufficient detail so that the patient can make an informed decision
Reasons why it is expected to Medicare will deny payment
Expected cost
Opt 1 AND 2 boxes
Opt 1- receive the item
Opt 2 - decline the item
Blank date line to be complet at time of service
Confidentiality statement |
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|
Term
| What causes a bill backlog? |
|
Definition
Staffing shortage
Weather
Insurance verification and coding delays
Medical record coding delays
System crashes
System conversions
Bill holds
Inaccurate charge masters
Mapping problems
Incorrect auto write-off processing
Data entry errors
Manual processing and bills suppressed
Lack of reports and management controls
Unaligned financial clinical goals, objectives adn priorties |
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|
Term
| Short-term strategies for dealing with billing backlog |
|
Definition
Check for timely production of bills
Check for backlogs in medical records
Check for staffing shortages - Most Medicare biller replace
Develop a team to handle backlog
After cost analysis consider outsourcing |
|
|
Term
| Long-term strategies for dealing with billing backlog |
|
Definition
Set goals
Automate where possible; check automation
Track performance
Measure results
Training of staff |
|
|
Term
|
Definition
| A process to determine whether the data in a provider's medical record supports services listed on the bill- Also known as a charge review |
|
|
Term
| What are the steps to deal with a bill audit |
|
Definition
Notification
Autorization
Pre-Audit payment percentage
auditing performance and reporting
Post Audit Settlement
Discounts
Nurse review of external auditors findings
Reconciliation of patient accounting system |
|
|
Term
| List seven high risk areas for compliance |
|
Definition
Billing for items or services not documented or furnished
Biling for charged disallowed by by a carrier
Unbundling, upcoding or exploding charges
Inappropriate balance billing
Exceeding balances billing limits
Violating a participation agreement
Inadequate resolution of overpayments
Failure to maintain confidentiality |
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Term
| Ways a corprate compliance Plan can protect a provider |
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Definition
Help to avoid mor strigent requirments that the governent may other wise impose
Provide evidence of good faith effort to adher to applicable billing and regulator requirements
Position Provider to reach industry standards
Implemented compliance plan are view favorable in Federal Corporate Sentencing Guidelines when found guilty of violation |
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Term
| Ways to ensure compliance in Patient Accounting Dept. |
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Definition
Review deparmental encounter forms to ensure accuracy, up to date info
Review charge description master and related system to ensure all CPT and HCPCS codes are uptodate and accurate and mapping and coding is occuring
Assess staff copentencies and training needs
Establish and encourage open communication among staff in detecting,reporting and helping to correct problems or issues
Identify fraud and abuse resources, educate staff and establish points of contact in various departments |
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Term
| List the services covered by PART A hospital insurance |
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Definition
Hospitalization
Skilled Nursing Facility
Home Health Care
Hospice Care
Nursing Home Care |
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Term
| Advantages of electronic billing |
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Definition
Faster payment
Less paper
Speed claim to the payer
Provides proof fo receipt
Requires fewer clerical interventions
Can increase interest due as resuld of delayed payments
Automation can reduce staff resources
Better follow-up capabilities |
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Term
| Disadvantages of electronic billing |
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Definition
Lack of payer electron capability
Technology can't accommodate attachments
Vendor reports (missing, inflexible,edits)
Upload or download problems
Unexplained rejections
Inability of electronic payments
Uneducated staffing resources |
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Term
Define EDI
Electronic Data Interchange |
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Definition
| Movement of informationelectronically between provider and payer for the purpose of facilitating a busines tranaction without human intervention. |
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Term
| What is the role of a Charge Master |
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Definition
Facilitate accurate service code usage
Point data through APC pathways flow via VOF options
Interact with APC grouper
Link between charge reinbhursement and cost
Serve as statistical base for payer and billing compliacne |
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Term
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Definition
| A master pricelist including services, supplies and medication charges for inpatient and outpatient sevice by a healthcare facility. It is a link between services provided, general ledger and the generation of claims and billing. |
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Term
| Steps to protect tax exempt status |
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Definition
Establish and maintain specific adjustments codes differentiating between charity, bad debt,and contractual allowances
Make sure Hill Burton requirements are satisfied and all documentation criteria are met
Make sure a Medicaid application is obtained on all self-pay inpatient accounts
Ensure consistency in the hospital's fiscal policies and procedures
Ensure hospital's written fiscal policies include:
Patient bill responsibility
Definition of bad bebt and other uncompensated care catetories
Charity determination guidelines |
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Term
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Definition
| Designed to assit hospitals by providing loans for construction projects. Once the hospital was operational funds were to be paid back in form of charity care, regardless of race, creed or color. |
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Term
| Hill Burton compliance reguirements |
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Definition
Annual publication of allocation plan
Individual notification fo avalibility
Sinage and posting requirments
Applications and timely dispositions
Proverty level guidelines
Record keeping and documentation |
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Term
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Definition
| Invoice used to document the services ordered or rendered during the patient visit. Composed of most commonly used procedure codes. A tool used to eliminate the need for transcribing the medical record notes from the patient chart and streamline the charge capture process. |
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Term
| Non-availability Statement |
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Definition
| Required for non emergent inpatients service may be provided by Tricare by a non military treatment facility. Valid for 30 days after the date of issuance and 15 days after discharge for any follow-up. |
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Term
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Definition
1st digit- type of facility
2nd digit- bill classification
3rd digit- frequency codes |
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Term
| List key information to collect when handling a worker compensation claim |
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Definition
Time and date of injury
Type of injury
First report of injury
Address of where the injury occured
Name of employer and contact person
Supervisors information
Complete incident report
Filling information
Date state agency was notified
Date employer was notified
Attorney info if litigation occurs |
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Term
APC
Ambulatory Payment Classification |
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Definition
Method of paying for facility outpatient services for the Medicare (United States) program.
Payments are made to hospitals when the Medicare outpatient is discharged from the Emergency Department or clinic or is transferred to another hospital (or other facility) which is not affiliated with the initial hospital where the patient received outpatient services.
If the patient is admitted from a hospital clinic or Emergency Department Medicare will pay the hospital under inpatient Diagnosis-related group DRG methodology |
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Term
| Outpatient prospective payment system (OPPS) |
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Definition
Used for hospital outpatient services -analogous to the Medicare prospective payment system for hospital inpatients known as Diagnosis-related group or DRGs
Affecting communications, coding procedures, patient records, billing, and reimbursement. |
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Term
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Definition
| A comprehensive listing of fee maximums used to reimburse a physician and/other providers on a free for-for-service bases. |
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Term
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Definition
Non payment for services thought to be resonable or necessary.
Should not exceed 5 percent of claims submitted monthly |
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Term
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Definition
| Without required and missing information |
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Term
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Definition
| Contain necessary and complete information, however the information is incorrect or illogical |
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Term
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Definition
| Can not be processed must be corrected and resubmitted |
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