Term
| What is an established patient visit |
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Definition
| 2 out of 3 key elements of E&M services must be met or exceeded in order to bill for this type of visit |
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Term
| What can Monitoring and Auditing do for an Organization |
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Definition
| Provide early identification of Program and Operational weakenesses. Also reduce exposure to Government and Whistle Blower Claims |
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Term
| What is Diagnosis Related Groups (DRGs) |
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Definition
An In-Patient Classification system based on
- Principal diagnosis,
- Secondary diagnosis
- Surgical Factors
- Age
- Sex
- Discharge Status
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Term
| What is an Advance Beneficiary Notice or (ABN) |
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Definition
| A written form that is given to a Medicare Beneficiary that informs the beneficiary that Medicare may not cover the services. This is before services are rendered. |
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Term
| What is the first thing one should consider when doing an effective compliance program |
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Definition
| Identify and focus compliance efforts on those areas of potential risk and concern relevant to one's organization. One can use the OIG's guidance as a guide of what potential risks are out there |
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Term
| The Fomal Commitment to a compliance Program by the Hospitals Governing Body and Senior management is called what? |
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Definition
| An Effective Compliance Program |
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Term
| Name a few of what a successful Compliance Program entails |
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Definition
- Well defined Mission
- Well Organized Department
- Enough Resources both staff and budget to support a compliance program
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Term
| Incorrect Procedure Coding creates a large risk to healthcare organizations which can demonstrate itself by false claims. Name (3) examples |
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Definition
- Biling I/P for O/P services
- Submitting claims for non-Medical Necesity Services
- Duplicate Claims and Unbundled Claims
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Term
| What articulates the Organizations commitment to ethical behavior |
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Definition
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Term
| What is the purpose of conducting Compliance Education within the Health Care setting? |
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Definition
| Helps ensure that each (i) employee (ii) vendor (iii) contractor and (iv) other individuals that function on behalf of the hospital is capable of executing his/her role in compliance within the rules and regulations |
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Term
| What is an Initial Patient Visit |
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Definition
| 3 out of 3 key elements of E&M services must be met or exceeded in order to bill for this type of visit. |
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Term
| A Critical Element of a Compliance Program is a system of Effective Organizational wide training on standards and procedures. What else should exist? |
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Definition
Specific training on identified risk areas; such as:
- Claims Development
- Submissions
- Marketing Practices
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Term
| What is Incident to Services |
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Definition
| Services commonly furnished in a Physician's office by a Nurse Practitioner in which there is direct Physician personal supervision and are billed under the Physicians Provider Number |
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Term
| What are the complexities of Medical Decision Making |
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Definition
- Straight Forward
- Low Complexity
- Moderate Complexity
- High Complexity
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Term
| What is the Code of Conduct |
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Definition
| The commitment of a Compliance Program from not only Management but employees and contractors. Reflects the ethical fuctionality of the organziation and how it operates |
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Term
| When there is poor distribution of responsibility, authority and accountability beyond the Compliance Officer, what happens to the Organization? |
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Definition
| The Program Implementation LAGS and it is not an Effective Program |
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Term
| What is the OIG's voluntary guidance supposed to do? |
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Definition
| Enhance the Internal Controls of the Organization |
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Term
| What is a CMS 1450 or a UB-04 |
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Definition
| Institutional providers use this form to bill Medical, Medicaid, CHAMPUS, and most Private Insurance companies |
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Term
| Organizations have the opportunity to reduce their culpability in accordance with the Federal Sentencing Guidelines by |
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Definition
| Effectively dealing with any offense after it occurs |
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Term
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Definition
| Non-Institutional Providers use this form to bill Medicare, Medicaid, CHAMPUS and most Private Insurance Companies |
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Term
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Definition
| Coverage for the poor - State Health Insurance that helps people who cannot afford medical care |
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Term
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Definition
| Part of MEDICARE that reimburses for Out-Patient Prescription Drugs |
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Term
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Definition
| You must be eligible for PART A and have PART B and it is also referred to as Medicare Advantage |
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Term
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Definition
| Submitting bills by piecemeal or in fragmented fashion to maximize reimbursement |
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Term
| What are the types of History or Examinations |
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Definition
- Problem Focused
- Expanded Problem Focus
- Detailed
- Comprehensive
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Term
| What types of commitment is needed for overall success of resources for an Effective Compliance Progarm |
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Definition
| Annual Budget Commitments |
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Term
Who shoudl lead the compliance Program and who should it report to |
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Definition
| Should be led by the Compliance Officer and report directly to the Board of Directors |
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Term
| How could the Board place undue reliance on its ability to detect vulnerabilities |
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Definition
| The Board must have a clear understanding of the objectives of the compliance program There should not be unrealistic expectations. |
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Term
| How often should the Board review reports on the Status of the Compliance Program |
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Definition
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Term
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Definition
| Part of Medicare that reimburses for Physician Services or Supplier Services |
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Term
| What are the three key components of Evaluation and Management (E&M) Services |
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Definition
- History
- Examination
- Medical Decision Making
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Term
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Definition
| Part of Medicare that reimburses for In-Patient Services by Hospitals or Skilled Nursing Facilities |
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Term
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Definition
| A two digit alpha numeric code used with the CPR and HCPCS code that may increase or decrease reimbrusement |
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Term
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Definition
| Providers use a billing code that reflects a higher payment rate for a device or serice provided than the actual device or service furnished to the patient |
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Term
| What is an Effectie Compliance Program |
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Definition
| A compilation of best practices gathered from similar organizations to adhere to applicable rules and regulations |
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Term
| What is the Centers for Medicare and Medicaid Services |
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Definition
- HHS Agency that establishes payment for providers
- Conducts Research
- Evaluates the Quality of Care provided to beneficiaries
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Term
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Definition
| An Insurance Company that cotracts with CMS to process MEDICAL Part B Claims |
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Term
| What is Fiscal Intermediary (FI) |
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Definition
| An Insurance Company that contracts with CMS to process PART A Claims |
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Term
| What is Internal Classification of Disease, 9th Edition Clinical Modification (ICD-9 CM) |
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Definition
| A Statistical classification system that arranges diseases and injuries into groups according to established criteria |
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Term
| Name three benefits of an Effective Compliance Program |
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Definition
- Demonstrate Organizational Commitment
- Increase likelihood of (i) prevention (ii) detection and (iii) correcting unlawful behaviors
- Encourages employees to report problems
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Term
| What is Helath Care Common Procedure Coding system or (HCPCS) |
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Definition
CMS contracts with the AMA to use CPT coding for Medicare program using this expanded version
These are an extension of the CPT codes and are monitored by CMS |
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Term
| How are Compoliance Risks Mitigated |
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Definition
| Through Internal Controls |
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Term
| What is MEDICARE Secondary Payer Questionnaire |
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Definition
| Used to identify the correct insurance company that must pay health care bills first when MEDICARE pays second |
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Term
|
Definition
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Term
|
Definition
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Term
| What is the Physician Sunshine Act |
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Definition
| Physicians have to disclose their relationships with Pharmacies, Labs etc. |
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Term
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Definition
| Prohibits Filing and Fraudulent Claims for Payment to the Government |
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Term
| What are the penalties for FCA |
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Definition
| Civil Fines upto $11,000 and Treble Damages Criminal Penalties and fines up to 25K |
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Term
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Definition
| Board of Directors should: Act in Good Faith, Level of Care of Prudent Person. |
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Term
| Two Primary Objectives of the Board of Directors |
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Definition
1) Decision Making Function - Apply Duty of Care to specific Deceision
2) Oversight Function Apply Duty of Care to Day-to-Day business activities. BOD can delegate to CEO |
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Term
| To become a MEDICAID biller must do what |
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Definition
| Set-up Condition of Participation |
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Term
| What is the Compliance Program designed to do |
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Definition
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Term
| What impacts the Compliance Programs Infrasturcture |
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Definition
1) Size,
2) Financial Resources
3) Scope of the Compliance Program |
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Term
|
Definition
| Identification of Relevant events that may have a material consequence on Organziations ability to achieve its obejctives |
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Term
| Types of Internal Controls |
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Definition
1) Preventive: Stop risk from occurring
2) Detective: Determine if you had an issue
3) Directive: Put in place to avoid having it happen again (Training & Polcies & Procedures) |
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Term
|
Definition
| Formalized approach - no vested interest in outcome |
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Term
|
Definition
| Day-to-Day reviews - Self reviews, Internal, Detective, Ongoing |
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Term
| 4 Critical Elements of Learning |
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Definition
1) Motivation
2) Reinforcement
3) Retnetion
4) Transference |
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Term
| Common Working File (CWF) |
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Definition
| Identifies Populations of CMS Coverage |
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Term
| Local Coverage Determination (LCD) |
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Definition
| Criteria to pay for a Claim |
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Term
| National Coverage Determination (NCD) |
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Definition
| Different Criterial to Pay for a claim |
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|
Term
| MAC = Medicare Administration Contract |
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Definition
| Contractor for Part A and Part B |
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