Reimbursement, HIPAA, and Compliance Flashcards
What two groups of persons were added to those eligible for Medicare benefits after the initial establishment of the Medicare program?
People eligible for disability benefits from Social Security and patients experiencing end stage renal disease
To what government organization did the Secretary of the Department of Health and Human Services delegate he responsibility for administering the Medicare program?
Center for Medicare and Medicaid Services (CMS)
What government organization handles the funds for the Medicare program?
Social Security Administration
There are three items that Medicare beneficiaries are responsible for paying before Medicare will begin to pay for services. What are these three items?
Deductibles, premiums, and co-insurance
Medicare publishes the Medicare fee schedule and usually pays what percentage of the amounts indicated for services?
80%
The three components of work, overhead (practice expense), and malpractice are part of an RVU. What do the initials RVU stand for?
Relative Value Unit
According to the filing guidelines, providers must file claims for their Medicare patients in within what time frame?
Within 12 months of date of services
What editions of the Federal Register would the outpatient facilities be interested in?
November and December Editions
Under what act was a major change in Medicare in 1989 made possible?
OBRA (Omnibus Budget Reconciliation Act)
Can a physician charge a patient to complete and Medicare form?
No
Individuals covered under under Medicare are termed what?
Beneficiaries
What are MAC’s and what do they do?
Medicare Administrative Contractors, and they do the paperwork for Medicare. Are usually insurance companies
Medicare Part C is also known as?
Medicare Advantage Organizations
HIPAA stands for?
Health Insurance Portability and Accountability Act
The most major Change to the health care industry as a result of HIPAA was a result of what portion of the act?
Administrative Simplification Act
The transfer of electronic documentation is accomplished through the use of What?
Electronic Data Interchange technology
The number that is assigned to all providers as a result of HIPAA is called what?
National Provider Identification (NPI)
Under the Relative Value Unit system _______ values are assigned to each service and are determined on the basis of he resources necessary to the physician’s performance of the service
Unit
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 the specialty.
limiting
For co-surgeons, Medicare pays the lesser of the actual charge or ________ % of the global fee, dividing get payment equally between two surgeons.
125
Specific regulations for Medicare are contained in the _______ ______ Manual.
Internet Only
Within an HMO, there is usually an individual who has been assigned to monitor the services provided to the patient both inside the facility and outside the facility. This person is known as the _____________.
Gatekeeper
In this model of HMO, the HMO contract directly employs the physicians.
Staff Model
In this model of HMO, the HMO Contracts with the physician to provide service at a set fee. These organizations are known as ___________. _____________ Associations.
Individual Practice
