Ch. 13-Revenue Compliance Flashcards
Abuse
Unknowing or unintentional submission of an inaccurate claim for payment
Administrative denial
Type of denial issues when the insurance provider finds fault with the claim. Errors include incorrect coding, failure to obtain pre-authorization, registration issues, failure to submit medical record documentation or an itemized claim when requested by the insurance provider, and duplicate charge or claim
Audit
Function that allows retrospective reconstruction of events, including who executed the events in question, why, and what changes were made as a result; a systematic and objective review of revenue cycle processes to determine the level of compliance with policies, procedures, and regulations
Clinical denial
Type of denial issued when the insurance provider questions a clinical aspect of the admission, such as length of stay of the admission, the level of service, if the encounter meets medical necessity parameters, the site of the service, or if clinical validation is not passed
Clinical validation denial
Type of denial that indicates that there are insufficient clinical indicators or discussion points within the medical record documentation to support the diagnosis assigned to the patient
CMS program transmittal
Documents used by CMS to communicate policies and procedures for prospective payment system’s program manuals
Compliance
Managing a coding or billing department according to the laws, regulations, and guidelines governing it; performing job functions according to the laws, regulations, and guidelines set forth by Medicare and other third-party payers
Comprehensive Error Rate Testing (CERT) program
Measures improper payments for the Medicare fee-for-services payment systems as mandated by the Improper Payments Elimination and Recovery Improvement Act of 2012
Demand letter
Letter issued by an improper payment review contractor that requests a specific amount to be repaid, provides a detailed rationale for the improper payment, and includes instructions for adjudication or appeal
False Claims Act
Legislation passed during the Civil War that prohibits contractors from making a false claim to a governmental program; used to reinforce healthcare against fraud and abuse
Fraud
Healthcare provider requesting payment or reward when the requester knows it is against healthcare rules and regulations
Improper payment reviews
Evaluation of claims to determine whether the items and services are covered, correctly coded, and medically necessary
Local coverage determination (LCD)
Reimbursement and medical necessity policies established by Medicare administrative contractors (MACs)
Vary from state to state
Medically unlikely edit (MUE)
Edit that identifies the maximum number of units of service that are allowable for a HCPCS code for a single beneficiary on a single date of service
Medicare Code Editor (MCE)
Software that detects and reports errors identified on Medicare inpatient claims
Medicare Integrity Program
First comprehensive federal strategy to prevent and reduce provider fraud, waste, and abuse. This program includes the review of provider claims, cost reports, and payment determinations and ensures that ongoing compliance education is provided
National correct coding initiative (NCCI)
A set of coding regulations to prevent fraud and abuse in physician and hospital outpatient coding; specifically addresses unbundling and mutually exclusive procedures
National coverage determination (NCD)
National medical necessity and reimbursement regulations. Includes a description of the circumstances under which medical supplies, services, or procedures are covered nationwide by Medicare under title XVIII of the Social Security Act and other medical regulations and rulings
Office of Inspector General (OIG)
A division of the Department of Health and Human Services (HHS) that investigates issues of noncompliance in the Medicare and Medicaid programs, such as fraud and abuse
Procedure-to-procedure (PTP) edit
Edit that identifies instances in which two procedure codes should not be reported together on the same date of service for a single beneficiary
Recovery audit contractor (RAC)
Federal contractor that executes the provisions of the National Recovery Audit Program
Recovery Audit Program
Improper payment review program executed under the Medicare Integrity Program. This program began as a demonstration project but was made permanent due to it’s overwhelming success at recovering improper payments
Unbundling
The fraudulent process in which individual component codes are submitted for reimbursement rather than one comprehensive code
Upcoding
The fraudulent process of submitting codes for reimbursement that indicate more complex or higher-paying services than those that the patient actually recieved
Vulnerability
Claim type that poses a financial risk to the Medicare program because it is susceptible to improper payments
Claim denial
The refusal of an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for healthcare services obtained from a healthcare professional