Buisness of Medicine Flashcards
Payers, HIPPA,ABN (Chapter 1)
Medicare PT A
Inpatient hospital care
Medicare PT B
Outpatient care, covers denied lines of Medicare A
Required to pay premium, yearly deductible
Medicare PT C
Medicare advantage, managed by private payers. Co-pays, Co-INS, or deductible.
Medically Necessity
Considered appropriate in given circumstances.
ABN Form
Form that explains to the patient why medicare may deny the service or procedure.
CMS
Notifiers must make a good faith effort to insert an estimate with in $100 or 25% of actual cost. Nothing more.
HIPPA Abv.
Health Insurance Portability and Accountability Act
HIPPA Def.
Health information when heals by covered entities. such as doctors, health plan, clearing houses
Fraud and Abuse
is to purposely bill for services not provided or bill for a higher service than what was provided.
OIG Work Plan
sets a plan for the fiscal year, announces possible issues with claim submission.
What is medical coding?
Translation of medical documentation in codes
What is not a covered entity of HIPPA?
Workers Comp
What’s an example of Commercial payer
Aetna
BCBS
Molina
Pres
( Name 1)
When should an ABN be signed?
When it isn’t expected to be covered by Medicare.
How much should an ABN be within to the cost of the patient?
$100 or 25%
What is PHI?
Protected Health Information
Intentional billing of services not provided is considered….?
Fraud
What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year?
OIG Work Plan
