Medical Billing Flashcards
What is the Resource Based Relative Value Scale (RBRVS)?
A Medicare reimbursement system implemented in 1992 to compensate physicians according to a fee schedule predicated on weights assigned on the basis of the resources required to provide the services.
Under the RBRVS, what are the three components of a HCPCS/CPT code?
Physician work, practice expense, malpractice insurance expense.
What is a Remittance Advice?
An explanation of payments made by third-party payers.
What is an Advance Beneficiary Notice?
A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges.
What is an Attestation Statement?
Insurance companies routinely require physicians to attest to the genuineness of their signatures on medical records and insurance forms, as well as to the accuracy of document contents.
What are Ambulatory Patient Groups (APG)?
The Ambulatory Patient Groups or APG payment methodology is based on the Enhanced Ambulatory Patient Groups classification system, a product of the 3M Health Information Systems, Inc. APGs categorize the amount and type of resources used in various ambulatory visits.
What is an Ambulatory Payment Classification (APC)?
Hospital outpatient prospective payment system. The classification is a resource-based reimbursement system.
What is an MS-DRG?
An improvement on the DRG system that accounts for severity of illness and resource consumption.
How many Major Diagnostic Categories are in the MS-DRG system?
25
What is an ASC?
Ambulatory Surgery Center.
Under ASC’s, when multiple procedures are performed during the same session, the procedure in the highest level group is reimbursed at _____ and the remaining procedures are reimbursed at ____?
100%. 50%
What is a Medicare Summary Notice?
A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided.
What is a Coordination of Benefits?
Coordination of benefits allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities.
When an MS-DRG payment is lower than the actual charges, what does the hospital do?
Absorb the loss.
Under ASC’s, bilateral procedures are reimbursed at what percentage of the rate for their group?
150%
Under HIPAA, insurance claims and accounting records must be kept for how long, unless state law specifies a longer period.
Six
What is the False Claims Act?
The False Claims Act is an American federal law that imposes liability on persons and companies (typically federal contractors) who defraud governmental programs. It is the federal Government’s primary tool in combating fraud against the Government.
What is the Civil Monetary Penalties Act?
Regulations which apply to any claim for an item or service that was not provided as claimed or that was knowingly submitted as false, and which provides guidelines for the levying of fines for such offences.
What is the Federal Antikickback Statute?
The federal Anti-Kickback Statute (“Anti-Kickback Statute”) is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program business.
What is the Stark I Law?
The Stark law is a limitation on certain physician referrals. It prohibits physician referrals of designated health services (“DHS”) for Medicare and Medicaid patients if the physician (or an immediate family member) has a financial relationship with that entity.
What are Sentinel Events?
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.
What are Adverse Preventable Events?
One that causes an injury to a patient as the result of a medical intervention rather than the underlying medical condition.`
What are Never Events?
Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. They include incidents such as: wrong site surgery. retained instrument post operation.
What are Potentially Compensable Events?
Any event that can pose the risk of financial loss to a health care institution.
