Medicare Flashcards
DHHS
Department of Health and Human Services
Who administers the Federal Medicare program?
The Secretary of DHHS
CMS
Centers for Medicare and Medicaid Services
Who operates the Federal Medicare program?
CMS (Centers for Medicare and Medicaid Services)
What is Medicare Part A?
Hospital Insurance
Which part of the Medicare program covers inpatient care in a hospital, skilled nursing, or hospice facility?
Part A
Which part of the Medicare program can cover home health services?
Part A
When they meet Medicare eligibility beneficiaries are automatically eligible to enroll in which part of the Medicare program?
Part A
Which part of the Medicare program provides supplemental insurance and must be purchased by the beneficiary?
Part B
Which part of the Medicare program provides coverage for outpatient services and durable medical equipment (DME)?
Part B
Which part of the Medicare program is an alternative option for Medicare beneficiaries and covers all the same services that part A and B cover?
Part C
Which part of the Medicare program is also known as the Medicare advantage plan?
Part C
Which part of the Medicare program may offer the option to purchase additional benefits, such as vision, hearing dental and or health wellness programs, and prescription drug coverage that the original Medicare does not offer?
Part C
The Medicare prescription drug improvement and modernization act of 2003 (MMA) established a prescription drug benefit under which part of the Medicare program?
Part D
Which part of the Medicare program provides automatic coverage under Social Security?
Part A
Which part of the Medicare program provides optional coverage under Social Security?
Parts B, C, and D
Which part of the Medicare program provides hospice care coverage?
Part A
Which part of the Medicare program provides prescription drug coverage?
Part D
For which parts of the Medicare program do beneficiaries pay premium for coverage?
Parts B, C, and D
For which parts of the Medicare program are codes assigned for payment using diagnoses, CPT, & HCPCS?
Parts A, B, and C
The Medicare program was established in what year?
1965
Hospital insurance is Medicare part ___?
A
Supplemental medical insurance is Medicare part ___?
B
The Kennedy-Kassebaum Law is another name for?
HIPAA, the health insurance portability and accountability act of 1996
What are “transactions” in regards to the Medicare program?
Activities involving the transfer of healthcare information
What is “transmission” in regards to the Medicare program?
The movement of electronic data between two entities in the technology that supports the transfer
Which part of the Medicare program covers office visits?
Part B
Which part of the Medicare program covers inpatient nursing care and the room and board?
Part A
What are QIO’s?
Quality improvement organizations
Which type of QIO‘s are directed by CMS (Centers for Medicare and Medicaid Services, formerly HCFA)?
BFCC (beneficiary and family centered care) and QIN (quality innovation network)
Which QIO‘s assist Medicare beneficiaries with quality of care reviews and complaints?
Beneficiary and family centered care
Which QIO‘s assist Medicare beneficiaries by handling appeals related to provider decisions on discharges or discontinuation of services?
Beneficiary and family centered care
Which QIO’s bring together, beneficiaries providers and communities to work on data driven initiatives involving safety, health quality, and care coordination?
Quality innovation network (QIN)
What percentage of deductibles, premiums, and coinsurance are paid by the beneficiary?
20%
Which entity is responsible for collecting and handling the funds for the Medicare program?
The Social Security Administration
The funds to run Medicare are generated from what?
Payroll taxes paid by employers and employees
Who operates the Medicare program and promotes the general welfare of the public?
Centers for Medicare and Medicaid Services
Insurance companies bid for a contract with CMS to what end?
To handle the Medicare program in a specific area as a Medicare Administrative Contractor (MAC)
How does money for the Medicare program flow?
From the Social Security administration through the CMS, to the MACs, and paid to beneficiaries and providers.
What is Medicare Part B?
Medical Insurance
What is document cloning?
When an earlier medical record entry is duplicated for a patient returning with the same dx
What are the next steps after a document is cloned?
Coder must carefully verify the elements of the document and confirm authorization or assignment by the provider
What is used to determine the utilization of codes in regards to document cloning?
An audit tool/utilization report used by Medicare
What is Medicare’s list of codes that cannot be reported together called?
National Correct Coding Initiatives’ “edits” (NCCI edits)
What were established to be sure that services are not reported separately (unbundled) if they are included in a pre-established bundle of codes?
NCCI (National Correct Coding Initiatives) edits
What is another term used for NCCI edits?
Procedure to Procedure (PTP) edits
What happens if an NCCI or PTP edit discovers an incorrect code?
Review documentation and verify accurate code assignment.
Where can NCCI edits for bundled codes be found?
The Medicare website
When Medicare claims are received by the MAC, ___ are used as an edit tool.
NCCI and PTP edits
What is the surgical package in regards to coding?
A code used to bundle the preop visit, surgical procedure, and follow up visit within the global period.
Who has provisions for submitting electronic health insurance claims?
Health insurance Portability, and Accountability Act of 1996 (HIPAA)
Which entity governs health coverage portability?
HIPAA 
Which entity governs health information privacy?
HIPAA
Who is responsible for governing medical savings accounts?
HIPAA
Who governs long-term care insurance and administrative simplification?
HIPAA
True or false? Administrative simplification is the most major change to the healthcare industry.
True
True or false? Administrative Simplification has four provisions.
True
What are the four provisions of Administrative Simplification for?
- Electronic Transactions and Code Set Standard requirements
- Privacy requirements
- Security requirements
- National Provider Identifier (NPI) requirements
True or false? Providers in healthcare may omit an NPI with the submission of claims.
False. Every provider must use a national provider identifier with submission of claims.
True or false? When the government institutes any national changes, they are published in the Federal Register.
True
True or false? The federal register publishes Medicare compliance for outpatient service claims.
True
When are changes published in the federal register?
Early in the year as proposed changes in the federal register.
Official final rules available in November and December .
True or false? The rules for Medicare compliance for outpatient service claims are specific to government payers and commercial insurance companies (third-party payers).
False. Changes published in the federal register are specific to government payers, and a third-party payers (not funded by the government) will often adopt the same requirements for claim submission.
True or false? Medical coders, attend to ethical issues.
True
How do medical coders validate services provided?
By consulting the medical record or provider
Which two national organizations support the medical coding field?
AHIMA – American Health Information Management Association
AAPC – American Academy of Professional Coders
What are the eight codes of ethics in medical coding?
- Represent maintain and enhance the integrity and standards of the profession.
- Maintain honesty, and refuse to participate in or conceal unethical practices or procedures, and report such practices.
- Know, respect and comply with existing laws and regulations and standards.
- Use technology, data and information in a way they are intended to be used.
- Preserve, protect and secure a patient’s personal health information.
- Respect the privacy of others and honor confidentialities.
- Strive to achieve the highest quality, effectiveness and dignity in the process of professional work.
- Advance the profession through continued professional development and education by acquiring and maintaining professional competence. Accurately represent credentials earned and the status of membership in the organization.
The healthcare professional must accurately represent earned_____.
Credentials
The healthcare professionals code of ethics includes accurately representing credentials earned, and_____.
The status of membership in the organization
The healthcare professional must maintain honesty and report ___ practices.
Unethical
Preservation, protection, and security of a patient’s personal information represents____.
Confidentiality
The medical coder must know, respect and_____ with existing laws, regulations and standards
Comply
Advancing the medical coding profession through continued professional development and_____should be accomplished by the medical coder to acquire and maintain professional competence.
Education
What RBRVS an acronym for?
(Outpatient) Resource-based Relative Value Scale
What is RBRVS?
A physician payment system that replaced another called “reasonable charge”
What was payment via the relative charge system based on?
Payment was based on the lowest actual customary or prevailing charges in a geographic area
What is payment through RBRVS based on?
Payment is based on the facility, or the physicians cost to provide a service.
Which three components are considered in the RBRVS payment system?
Physicians work
Expense to the practice
Risk of malpractice for the service
What do the three components considered in RBRVS make up?
Physician Fee Schedule (PFS); for each procedure code
How often is the physician fee schedule updated?
Annually
What are Physician Fees Schedule (PFS) updates based on?
(RVU) Relative Value Units
A Geographic adjustment factor (for regional economic variation)
A National conversion factor
What is a Relative Value Unit?
A value of service, based on:
Amount of work for provider
The amount of overhead for the practice
The risk of malpractice for the service
What is “managed healthcare”?
The establishment of networks or groups of healthcare providers that deliver healthcare services under one organization with the purpose of providing these services at a lower cost
Name three different kinds of Managed Care Organizations (MCOs)
PPO - preferred provider organization
HMO - health maintenance organization
EPO - exclusive provider organization
What is Point-of-Service (POS) coverage?
An open ended coverage option that provides more flexibility for healthcare services
What drawbacks are there to MCO (managed care organization) plans in comparison to traditional fee-for-service plans?
Limited access to services
Requirement of a PCP (gatekeeper’s permission) to gain access to healthcare services (beneficiary is required to stay in network, and only see their PCP)
The ___ charge historically was specific for each physician, but in 1993, the charge for a service was the same for all physicians within a locality, regardless of specialty.
Limiting
For co surgeons, Medicare pays ___% of the global, see, dividing the payment equally between the two surgeons.
125%
Specific regulations for___ are contained in the Internet Only Manual
Medicare
Within an HMO, there is usually an individual who has been assigned it to monitor the services provided to the patient both inside the facility and outside the facility. This person is known as the ___.
PCP/gatekeeper
In this model of HMO, the HMO directly employs the physicians
Staff
In this model of HMO, the HMO contracts with the physician to provide the service at a set fee. ___ Practice Associations
Individual
The Medicare ___ Contractors do the paperwork for Medicare and are usually insurance companies that have bid for a contract with CMS to handle the Medicare program for a specific area
Administrative
What edition of the federal register with outpatient facilities be especially interested in?
November or December
What is the largest third-party payer?
The American government
What government organization is responsible for administering the Medicare program?
Centers for Medicare and Medicaid Services (CMS)
What are the three items that the Medicare beneficiaries are responsible to pay before Medicare will begin to pay for services?
Deductibles, premiums, and coinsurance
Medicare funds are collected by ___.
Social Security Administration
CMS handles the daily operation of the Medicare program through the use of ___ ___ ___, formally Fiscal Intermediaries.
Medicare Administrative Contractors
Which of the following is not a stated goal of the physician payment reform?
•Limit provider liabilities
•Redistribute physician payment more equitably
•Assure quality healthcare at a reasonable cost
•Decrease Medicare expenditures
Limit provider liabilities
The Medicare Prescription Drug, Improvement, and Modernization act of 2003 established this new benefit available under the Medicare program.
Part D
This program is also known as Medicare Advantage Organization (MAO).
Part C
___ are activities involving the transfer of healthcare information and ___ means the movement of electronic data between two entities and the technology that supports the transfer.
Transactions, transmissions
What is the purpose of an OIG work plan?
The OIG’s Work Plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the department’s major entities.
What is the purpose of an OIG work plan?
To monitor and identify fraud and abuse
