REGULATIONS CLEAN CLAIMS Flashcards
it is the one submitted w/o any errors or implications on the claim…
Clean Claim
it can include incomplete supporting documentation that can delay payment
Errors
it is vital for ensuring a clean claim…
Accuracy of billing
it considers coding and billing one of the main areas for fraud investigation…
Office of inspector general (OIG)
intentionally expecting a payment on a claim when the provider is aware of wrongdoing, billing for services that were not provided…
Fraud
it is a type of fraud where there’s an expectation of getting paid twice…
Double billing
it is the usage of multiple codes to report one service…
Unbundling
it is a billing patterns and practices that are not considered fraudulent, but rather excessive or unnecessary…
Abuse
it includes actions that could directly and indirectly provide financial gain for the healthcare organization…
Abuse
- unintentional billing and coding errors
- unnecessary charges for healthcare services, equipment and or supplies
- billing for non-medically necessary charges
Three categories of billing and coding errors
governs providers for false and fraudulent claim activity and issues appropriate penalties for those in violation of the law…
False Claims Act (FCA)
it has a large effect on the revenue cycle and fraud and abuse…
Correct coding
it is the program develop to prevent coding errors that can lead to inappropriate reimbursement for Medicare claims…
National Correct Coding Initiative (NCCI)
what does the term adjudication mean in healthcare?
It is the act of determining financial responsibility of claim charges among the stakeholders
This starts when the patient first presents for healthcare, but the claim is created after the patient is no longer present
development of an insurance claim
It’s often used to bridge the administrative and clinical departments as both contribute elements do a claim…
Encounter forms
What is the type of claim format where it’s in electronic form used to submit claims for professional services rendered by hc providers?
837P
What is the type of claim format where it’s in paper form used to submit professional claims for reimbursement with various payer groups?
CMS-1500
What is the type of claim format where it’s in electronic form used to submit claims for facility services rendered by inpatient orgs?
837I
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?
UB-04
pt data, insurance info, & codes (based on SOAP) are used to…
create claims
it is the efficient mechanism of proofreading claims…
claims scrubbing or edit checks
they can forward clean claims while returning claims that are incomplete or have errors…
Clearinghouse
What does the term adjudication mean in health care?
The act of determining financial responsibility of claim charges among the stakeholders
it is the foundation of the revenue cycle
Successful claims management
2 categories of denied claims..
pt coverage error & technical errors
this can be performed comparing the encounter notes & all related documentation to the codes that were billed
Medical Record Audits
a chart review used to determine if the documentation correctly supports the codes reported for the service
also called prepayment audit
Internal Medical Record Audit
perform reviews to protect payers & gov’t from fraud & abuse
it performed outside the org
referred to as post payment audits
External audit
law that prevents providers from referring Medicare pts to HCOs in which the physician pr their family member has a financial interest
Self-referral Law (Stark Law)
NCCI edits work in 2 ways…
one of the codes is a component of the other
one of the codes excludes the other by their code description
for denied claims, payers includes reason for denial (reason codes) on what forms?
Explanation of Benefits (EOB) & Remittance Advice (RA)
a program that identify & recover improper payments made to HC providers
collects overpaid claims
assists providers w/ training programs
Recovery Audit Contractor (RAC)
created to combat fraud, waste, & abuse
targeted audits used in suspected Medicare & Medicaid fraud, waste, & abuse at a HC facility
Zone Program Integrity Contractor (ZPIC)
