Ch. 12 Terms

Question 1

Advance Beneficiary Notice of Noncoverage (ABN)

Answer 1

An agreement given to the patient to read and sign before rendering a service if the participating doctor thinks that it may be denied for payment because of medical necessity or limitation of liability by Medicare. The patient agrees to pay for the service’ also known as a “waiver of liability agreement” or “responsibility statement”.

Question 2

Approved charges

Answer 2

A fee that Medicare decides the medical service is worth, which may or may not be the same as the actual amount billed. The patient may or may not be responsible for the service

Question 3

Assignment

Answer 3

A transfer, after an event insured against, or an individual’s legal right to collect an amount payable under an insurance contract. The provider accepts the terms of the insurance contract between the patient and carrier; for Medicare, the provider accepts 80% of the allowed amount as payment in full once the deductible has been met.

Question 4

Benefit period

Answer 4

A period of time during which payments for Medicare inpatient hospital benefits are available (begins the first day an enrollee is given inpatient hospital care and ends when they haven’t been an inpatient for 60 consecutive days).

Question 5

Centers for Medicare and Medicaid Services

Answer 5

Formerly known as the Health Care Financing Administration (HCFA), CMS divides responsibilities among 3 divisions: the Center for Medicare Management, the Center for Beneficiary Choices, and the Center for Medicaid and State Operations

Question 6

Correct Coding Initiative

Answer 6

Federal legislation that attempt to eliminate unbundling or other inappropriate reporting of procedural codes for professional medical services rendered to patients.

Question 7

Crossover claim

Answer 7

Also known as claims transfer, this is a when a bill of services are first paid by Medicare and whatever unmet amount is automatically electronically transferred to the secondary insurance for additional payment

Question 8

Diagnostic cost groups (DCGs)

Answer 8

A system of Medicare reimbursement for HMOs with risk contracts in which enrollees are classified into various DCGs on the basis of each beneficiary’s prior 12 month hospitalization history.

Question 9

Disabled

Answer 9

Individuals younger than 65 who have been entitled to disability benefits under the Social Security Act or the Railroad Retirement system for at least 24 months are considered disabled and are entitled to Medicare.

Question 10

End- stage renal disease (ESRD)

Answer 10

Individuals who have chronic kidney disease requiring dialysis or kidney transplant are considered to have ESRD. Medicare coverage begins with the third month after beginning a course of renal dialysis.

Question 11

Formulary

Answer 11

List of drugs that a health insurance plan covers as a benefit.

Question 12

Hospice

Answer 12

A public agency or private organization primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill patients and their families in their own homes or in a homelike center.

Question 13

Hospital insurance

Answer 13

Known as Medicare Part A

Question 14

Intermediate care facilities

Answer 14

Institutions furnishing health related care and services to individuals who don’t require the degree of care provided by acute care hospitals or nursing facilities.

Question 15

Limiting charge

Answer 15

A percentage limit on fees, specified by laws, that non participating doctors may bill medicare beneficiary above the fee schedule amount

Question 16

Medical necessity

Answer 16

The performance of services and procedures that are consistent with the diagnosis. Medical necessity must be established before the carrier may make payment

Question 17

Medicare

Answer 17

Nationwide health insurance plan for people 65 years or older and certain disabled and blind people regardless of income, administered by CMS. Local social security offices take applications and supply info to the program

Question 18

Medicare administrative contractors (MAC)

Answer 18

Insurance carrier that receives and processes claims from providers for Medicare Part B

Question 19

Medicare Part A

Answer 19

Hospital benefits for people age 65 and older and certain disabled individuals regardless of income

Question 20

Medicare Part C

Answer 20

Medicare Plus Choice plans offer a number of health care options in addition to those available under Medicare Part A and B. Plans may include Medicare medical savings accounts, fee for service plans, etc.

Question 21

Medicare Part D

Answer 21

Stand alone prescription drug plan

Question 22

Medicare Secondary Payer

Answer 22

When Medicare is secondary; the primary insurance plan must pay for any medical services first, before Medicare picks up

Question 23

Medicare Summary Notice

Answer 23

A document received by the patient explaining amount charged, deductible, etc, of medical services.

Question 24

Medigap

Answer 24

Additional insurance policy for the medicare beneficiary that covers the deductible and copayment that’s not typically covered under the main Medicare policy

Question 25

National Alphanumeric codes

Answer 25

Also known as HCPCS (coding system for services)

Question 26

Non participating physician

Answer 26

A provider who doesn’t have a signed agreement with Medicare and has an option about assignment. The doctor has an option to accept assignment on some services or none

Question 27

Physician quality reporting initiative

Answer 27

Voluntary pay for reporting program for providers who successfully report quality info related to services provided to patients under Medicare Part B between July 1 and December 31, 2007

Question 28

Premium

Answer 28

The cost of insurance coverage paid to keep policy in force.

Question 29

Prospective payment system

Answer 29

Method of payment for Medical hospital insurance based on DRGs (a fixed dollar amount for a principal diagnosis)

Question 30

Quality improvement (QIO)

Answer 30

Program that replaces the peer review organization (PRO) program and is designed to monitor and improve the usage and quality of care for Medicare beneficiaries.

Question 31

Qui tam action

Answer 31

An action to recover a penalty brought on by an informer in a situation in which one portion of the recovery goes to the informer and the other portion to the state or govt

Question 32

Reasonable fee

Answer 32

If the fee is acceptable after peer review even though it doesn’t meet the customary or prevailing criteria. This includes unusual circumstances requiring additional time, skill or experience in connection with a particular service or procedure.

Question 33

Recovery audit contractor (RAC) initiative

Answer 33

Goals are the identify Medicare underpayments, overpaments and to recover overpayments using automated review (done electronically) and complex review (done with human review)

Question 34

Relative value unit (RVU)

Answer 34

A monetary value assigned to each service on the basis of the amount of doctor’s work, practice expenses, and cost of professional liability insurance. These three RVUs are then adjusted according to geographic area and used in a formula to determine Medicare fees.

Question 35

Remittance advice (RA)

Answer 35

A document detailing services billed and describing payment determination issued to providers of the CMS program (also known as explanation of benefits)

Question 36

Resource based relative value scale (RBRVS)

Answer 36

System that ranks doctor services by units and provides a formula to determine a Medicare Fee Schedule

Question 37

Respite care

Answer 37

Short term hospice inpatient stay for a terminally ill patient to give temporary relief to the person who regularly assists with home care of a patient.

Question 38

Supplemental security income

Answer 38

Program of income support for low income aged, blind, and disabled persons establed by Title 16 of the Social Security Act

Question 39

Supplementary medical insurance

Answer 39

Part B - Medical benefits of Medicare Program

Question 40

Volume performance standard (VPS)

Answer 40

The desired growth rate for spending on Medicare Part B physician services, set each year by Congress

Question 41

Whistleblowers

Answer 41

Informants who report doctors suspected of defrauding the federal government