Ch. 13-Revenue Compliance

Question 1

Abuse

Answer 1

Unknowing or unintentional submission of an inaccurate claim for payment

Question 2

Administrative denial

Answer 2

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

Question 3

Audit

Answer 3

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

Question 4

Clinical denial

Answer 4

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

Question 5

Clinical validation denial

Answer 5

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

Question 6

CMS program transmittal

Answer 6

Documents used by CMS to communicate policies and procedures for prospective payment system’s program manuals

Question 7

Compliance

Answer 7

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

Question 8

Comprehensive Error Rate Testing (CERT) program

Answer 8

Measures improper payments for the Medicare fee-for-services payment systems as mandated by the Improper Payments Elimination and Recovery Improvement Act of 2012

Question 9

Demand letter

Answer 9

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

Question 10

False Claims Act

Answer 10

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

Question 11

Fraud

Answer 11

Healthcare provider requesting payment or reward when the requester knows it is against healthcare rules and regulations

Question 12

Improper payment reviews

Answer 12

Evaluation of claims to determine whether the items and services are covered, correctly coded, and medically necessary

Question 13

Local coverage determination (LCD)

Answer 13

Reimbursement and medical necessity policies established by Medicare administrative contractors (MACs)
Vary from state to state

Question 14

Medically unlikely edit (MUE)

Answer 14

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

Question 15

Medicare Code Editor (MCE)

Answer 15

Software that detects and reports errors identified on Medicare inpatient claims

Question 16

Medicare Integrity Program

Answer 16

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

Question 17

National correct coding initiative (NCCI)

Answer 17

A set of coding regulations to prevent fraud and abuse in physician and hospital outpatient coding; specifically addresses unbundling and mutually exclusive procedures

Question 18

National coverage determination (NCD)

Answer 18

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

Question 19

Office of Inspector General (OIG)

Answer 19

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

Question 20

Procedure-to-procedure (PTP) edit

Answer 20

Edit that identifies instances in which two procedure codes should not be reported together on the same date of service for a single beneficiary

Question 21

Recovery audit contractor (RAC)

Answer 21

Federal contractor that executes the provisions of the National Recovery Audit Program

Question 22

Recovery Audit Program

Answer 22

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

Question 23

Unbundling

Answer 23

The fraudulent process in which individual component codes are submitted for reimbursement rather than one comprehensive code

Question 24

Upcoding

Answer 24

The fraudulent process of submitting codes for reimbursement that indicate more complex or higher-paying services than those that the patient actually recieved

Question 25

Vulnerability

Answer 25

Claim type that poses a financial risk to the Medicare program because it is susceptible to improper payments

Question 26

Claim denial

Answer 26

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