Medical Billing

Question 1

What is the Resource Based Relative Value Scale (RBRVS)?

Answer 1

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.

Question 2

Under the RBRVS, what are the three components of a HCPCS/CPT code?

Answer 2

Physician work, practice expense, malpractice insurance expense.

Question 3

What is a Remittance Advice?

Answer 3

An explanation of payments made by third-party payers.

Question 4

What is an Advance Beneficiary Notice?

Answer 4

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.

Question 5

What is an Attestation Statement?

Answer 5

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.

Question 6

What are Ambulatory Patient Groups (APG)?

Answer 6

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.

Question 7

What is an Ambulatory Payment Classification (APC)?

Answer 7

Hospital outpatient prospective payment system. The classification is a resource-based reimbursement system.

Question 8

What is an MS-DRG?

Answer 8

An improvement on the DRG system that accounts for severity of illness and resource consumption.

Question 9

How many Major Diagnostic Categories are in the MS-DRG system?

Answer 9

25

Question 10

What is an ASC?

Answer 10

Ambulatory Surgery Center.

Question 11

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 ____?

Answer 11

100%. 50%

Question 12

What is a Medicare Summary Notice?

Answer 12

A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided.

Question 13

What is a Coordination of Benefits?

Answer 13

Coordination of benefits allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities.

Question 14

When an MS-DRG payment is lower than the actual charges, what does the hospital do?

Answer 14

Absorb the loss.

Question 15

Under ASC’s, bilateral procedures are reimbursed at what percentage of the rate for their group?

Answer 15

150%

Question 16

Under HIPAA, insurance claims and accounting records must be kept for how long, unless state law specifies a longer period.

Answer 16

Six

Question 17

What is the False Claims Act?

Answer 17

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.

Question 18

What is the Civil Monetary Penalties Act?

Answer 18

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.

Question 19

What is the Federal Antikickback Statute?

Answer 19

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.

Question 20

What is the Stark I Law?

Answer 20

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.

Question 21

What are Sentinel Events?

Answer 21

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.

Question 22

What are Adverse Preventable Events?

Answer 22

One that causes an injury to a patient as the result of a medical intervention rather than the underlying medical condition.`

Question 23

What are Never Events?

Answer 23

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.

Question 24

What are Potentially Compensable Events?

Answer 24

Any event that can pose the risk of financial loss to a health care institution.

Question 25

What is Fraud?

Answer 25

Willful and intentional misrepresentation that could cause harm or loss to person or property.

Question 26

What is Abuse?

Answer 26

The improper use of something.

Question 27

For doctors who do not accept assignment, what is the limiting charge percentage above Medicare’s approved payment amount.

Answer 27

15%

Question 28

What is a Limiting Charge?

Answer 28

The limiting charge is the maximum amount that most non-participating providers are allowed to charge for services to a Medicare beneficiary on an unassigned basis.

Question 29

What is Indemnity Insurance?

Answer 29

Indemnity plans allow you to direct your own health care and visit almost any doctor or hospital you like. The insurance company then pays a set portion of your total charges. Indemnity plans are also referred to as “fee-for-service” plans.

Question 30

What is Hold Harmless?

Answer 30

A provision in an agreement under which one or both parties agree not to hold the other party responsible for any loss, damage, or legal liability. In effect, this clause indemnifies the parties on a unilateral or reciprocal basis.

Question 31

What is a Pass Through?

Answer 31

The act, action, or process of offsetting increased costs by raising prices.

Question 32

What are Local Coverage Determinations (LCD)?

Answer 32

a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis.

Question 33

What are National Coverage Determinations (NCD)?

Answer 33

A national coverage determination (NCD) is a United States’ nationwide determination of whether Medicare will pay for an item or service.

Question 34

Under APC’s, what does status indicator X mean?

Answer 34

Ancillary Services

Question 35

Under APC’s, what does status indicator V mean?

Answer 35

Clinic or Emergency Department Visit

Question 36

Under APC’s, what does status indicator S mean?

Answer 36

Significant Procedure, multiple procedure reduction does not apply

Question 37

Under APC’s, what does status indicator T mean?

Answer 37

Significant Procedure, multiple procedure reduction applies

Question 38

Under APC’s, what does status indicator C mean?

Answer 38

Inpatient procedures/services

Question 39

What is Capitation?

Answer 39

The payment of a fee or grant to a doctor, school, or other person or body providing services to a number of people, such that the amount paid is determined by the number of patients, students, or customers.