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WEEK 4 (MOD 1) > REGULATIONS CLEAN CLAIMS > Flashcards

REGULATIONS CLEAN CLAIMS Flashcards

1
Q

it is the one submitted w/o any errors or implications on the claim…

A

Clean Claim

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2
Q

it can include incomplete supporting documentation that can delay payment

A

Errors

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3
Q

it is vital for ensuring a clean claim…

A

Accuracy of billing

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4
Q

it considers coding and billing one of the main areas for fraud investigation…

A

Office of inspector general (OIG)

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5
Q

intentionally expecting a payment on a claim when the provider is aware of wrongdoing, billing for services that were not provided…

A

Fraud

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6
Q

it is a type of fraud where there’s an expectation of getting paid twice…

A

Double billing

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7
Q

it is the usage of multiple codes to report one service…

A

Unbundling

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8
Q

it is a billing patterns and practices that are not considered fraudulent, but rather excessive or unnecessary…

A

Abuse

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9
Q

it includes actions that could directly and indirectly provide financial gain for the healthcare organization…

A

Abuse

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10
Q
  • unintentional billing and coding errors
  • unnecessary charges for healthcare services, equipment and or supplies
  • billing for non-medically necessary charges
A

Three categories of billing and coding errors

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11
Q

governs providers for false and fraudulent claim activity and issues appropriate penalties for those in violation of the law…

A

False Claims Act (FCA)

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12
Q

it has a large effect on the revenue cycle and fraud and abuse…

A

Correct coding

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13
Q

it is the program develop to prevent coding errors that can lead to inappropriate reimbursement for Medicare claims…

A

National Correct Coding Initiative (NCCI)

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14
Q

what does the term adjudication mean in healthcare?

A

It is the act of determining financial responsibility of claim charges among the stakeholders

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15
Q

This starts when the patient first presents for healthcare, but the claim is created after the patient is no longer present

A

development of an insurance claim

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16
Q

It’s often used to bridge the administrative and clinical departments as both contribute elements do a claim…

A

Encounter forms

17
Q

What is the type of claim format where it’s in electronic form used to submit claims for professional services rendered by hc providers?

A

837P

18
Q

What is the type of claim format where it’s in paper form used to submit professional claims for reimbursement with various payer groups?

A

CMS-1500

19
Q

What is the type of claim format where it’s in electronic form used to submit claims for facility services rendered by inpatient orgs?

A

837I

20
Q

What is the type of claim format where it’s in paper form used to submit hospital & facility claims for reimbursement with various payer groups?

A

UB-04

21
Q

pt data, insurance info, & codes (based on SOAP) are used to…

A

create claims

22
Q

it is the efficient mechanism of proofreading claims…

A

claims scrubbing or edit checks

23
Q

they can forward clean claims while returning claims that are incomplete or have errors…

A

Clearinghouse

24
Q

What does the term adjudication mean in health care?

A

The act of determining financial responsibility of claim charges among the stakeholders

25
Q

it is the foundation of the revenue cycle

A

Successful claims management

26
Q

2 categories of denied claims..

A

pt coverage error & technical errors

27
Q

this can be performed comparing the encounter notes & all related documentation to the codes that were billed

A

Medical Record Audits

28
Q

a chart review used to determine if the documentation correctly supports the codes reported for the service
also called prepayment audit

A

Internal Medical Record Audit

29
Q

perform reviews to protect payers & gov’t from fraud & abuse
it performed outside the org
referred to as post payment audits

A

External audit

30
Q

law that prevents providers from referring Medicare pts to HCOs in which the physician pr their family member has a financial interest

A

Self-referral Law (Stark Law)

31
Q

NCCI edits work in 2 ways…

A

one of the codes is a component of the other
one of the codes excludes the other by their code description

32
Q

for denied claims, payers includes reason for denial (reason codes) on what forms?

A

Explanation of Benefits (EOB) & Remittance Advice (RA)

33
Q

a program that identify & recover improper payments made to HC providers
collects overpaid claims
assists providers w/ training programs

A

Recovery Audit Contractor (RAC)

34
Q

created to combat fraud, waste, & abuse
targeted audits used in suspected Medicare & Medicaid fraud, waste, & abuse at a HC facility

A

Zone Program Integrity Contractor (ZPIC)

WEEK 4 (MOD 1) (5 decks)

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