CHC Study Q Healthcare Compliance Certification (5) Billing & Reimbursement

Question Answer
CMS Centers for Medicare & Medicaid Services-HHS establishes payment policies for providers, conducts research, evaluates the quality of care provided to beneficiaries.
HHS U.S. Department of Health & Human Services
Medicare Part A Pays for inpatient services – hospital, skill nursing facilities
Medicare Part B Pays for physician and supplier services
Medicare Part C Formerly known as Medicare+Choice, Medicare advantage, Managed Care. You must be eligible for Parts A & have B to get Part C.
Medicare Part D Part of Medicare that reimburse for out-patient prescription drugs
Medicaid Each individual State has a criteria for providing Medicaid services. It is coverage for the poor State health insurance that helps people who cannot afford medical care. Established via the Deficit Reduction Act of 2005
Basic billing and reimbursement requirements The documentation (medical records) has to support the services given.
Hospital Value Based Purchasing (VBP) Program Medicare rewards hospitals that provide high quality care and will receive incentive payments based on as follows:1-How well the hospital performs on each measure2-How much the hospital improves during a baseline period.
Physician Value Based Payment Modifier Began in 2015 and is to be phased in by 2017, physician quality reporting system in which payments are based on a quality reward system for providing quality care at low cost.
Fiscal Intermediary (FI) An insurance company that contracts with CMS to process Medicare Part A (hosp., nursing facilities) claims
Carrier An insurance company that contracts with CMS to process Medicare Part B (physicians, supplies) claims.
Medicare Administrative Contractor (MAC) Agency who process claims for both Part A (hosp. nursing facilities) and Part B (physicians, supplies)
Conditions of Participation (CoPs) CMS standards
International Classification of Disease, Ninth Edition, Clinical Modification ICD-10CM Billing standards used to report health care diagnosis and procedures
Focused Medical Review (FMR) To determined if the medical documents support the claim on problem areas that demonstrate significant risk to the Medicare program as a result of inappropriate billing to examine data & request supporting documentation for claims submitted to Medicare
Diagnosis Related Groups (DRG) Medicare system that categorize hosp costs for the inpatient hospitalization. Helps determine cost of care to reimburse & includes all the information about the patient. Medicare pays the hospital a fixed amount based on the patients DRG diagnosis
Current Procedural Terminology (CPT) Medical code set that is used to report medical, surgical,diagnostic procedures, services to entities such as physicians, health ins companies and accreditation organizations. American Medical Association (AMA) publishes and maintains this coding system
Healthcare Common Procedure Coding System (HCPCS) Is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT). CMS contracts with the AMA to use CPT coding for the Medicare program using this expended version
Modifiers A two digit alpha/numeric codes used in conjunction with CPT or HCPCS code that may increase or decrease reimbursement
Outliners Payments are used to pay for patients who are at the hospital for a long periods of times.
CMS Allowable Amount allowed for reimbursement
Third Party Carrier whoever the government contracts to process claims on behalf of the beneficiary
Electronic Data Interchange (EDI) Standards to follow to process the claim electronically
Common Working File (CWF) The patient file with all the information
Return to Provider (RTP) Report This is for hospitals only, when the hospital is informed that something is wrong with the claim and it needs to be fixed.
Participating Provider to Supplier Payment is accepted in full
Assignment Once you accept payment in full, you accept the assignment
Reassignment When a provider has changed a position, the reassignment of the provider number
Certificate of Medical Necessity Certifying medical services is medical necessary
Coordination of Benefits The order in which benefits will be paid
Health Professional Shortage Area Physicians get incentives for providers to give care in an area without access to care
Local Coverage Determination To determine rules and standards for the region
National Coverage Determination To determine rules and standards for the country
Medicare Code Editor A software system that tells you something is wrong with the claim
Grouper Takes information about the claim and tells you what Diagnosis Related Group (DRG) you can bill under
Pricer Tells you how much you will get paid
Remittance Advice When you get paid, tells you everything about the payment
CMS 1500 Form A paper claim for the patient
CMS 1450 or UB -04 A paper claim for the hospital
837P Electronic version claim for doctors/providers
837I Electronic version of claim for hospital/facilities
Three key components in selecting the level of Evaluation & Management Services History, Examination, Medical Decision Making
Types of History 1-Problem focused history. 2- Expanded problem focused history. 3-Detailed history. 4- Comprehensive history
Types of Examinations 1-Problem focused examination. 2- Expended problem focus examination. 3-Detailed examination. 4-Comprehensive examination
Complexity of Medical Decision Making Straight forward, low complexity, moderate complexity and high complexity. The higher the complexity, the higher the payment
Initial/ new patient visit 3 of 3 elements of Evaluation & Management services must be met or exceeded in order to bill for this type of visit
Established patient visit 2 of 3 elements of Evaluation & Management services must be met or exceeded in order to bill for this type of visit
Upcoding Providers use a billing code that reflects a higher payment rate for a devise or service provided than the actual devise or service furnished to the patient
Diagnosis Related Group Creep The practices of healthcare providers that intentionally regroup patients according to more resource intensive DRG classification in order to increase hospital income. Like e.g. upcoding
Unbundling Take a claim and bill by piece mail, each item separately
Duplicate Claims Bill a claim twice to get more money
Physicians at Teaching Hospitals (PATH) Physicians have to be involved in inpatient care and oversee residents at teaching hospitals
Incident to billing Doctors have to supervise, first see the patient and e determine the care. Note: this does not pertain to the hospital setting
72 Hour Rule/ 3 Day Window Project It requires all diagnostic or outpatient services given during the DRG payment window (the day of, 3 days prior to inpatient admission) to be bundled with the inpatient services for Medicare billing.
False Cost Reports Reports that include costs for non-covered services or products. Reports that seek reimbursement for costs that can be apportioned to non-Medicare patients.
Credit Balances – Failure to Refund You have 60 days to get refund back
PPS Transfer Project When a patient is transferred and has not stayed a full average length of stay and got paid as discharged to home and not discharged to another facility
Medicare Secondary Payer List of questions to determine who is the primary and/or secondary payer
Advance Beneficiary Notice (ABN) A notice provided to the patient before services are provided informing then that there is no coverage for payment
Hospital Out patient Cardiac Rehabilitation Dr supervises patient treatment while treatment is going on. Note: issues concerning this, is the location of the Dr while needing to provide supervision. It is stated that the physician must be on site only.

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