Reimbursement, HIPAA, and Compliance

Question 1

What two groups of persons were added to those eligible for Medicare benefits after the initial establishment of the Medicare program?

Answer 1

People eligible for disability benefits from Social Security and patients experiencing end stage renal disease

Question 2

To what government organization did the Secretary of the Department of Health and Human Services delegate he responsibility for administering the Medicare program?

Answer 2

Center for Medicare and Medicaid Services (CMS)

Question 3

What government organization handles the funds for the Medicare program?

Answer 3

Social Security Administration

Question 4

There are three items that Medicare beneficiaries are responsible for paying before Medicare will begin to pay for services. What are these three items?

Answer 4

Deductibles, premiums, and co-insurance

Question 5

Medicare publishes the Medicare fee schedule and usually pays what percentage of the amounts indicated for services?

Answer 5

80%

Question 6

The three components of work, overhead (practice expense), and malpractice are part of an RVU. What do the initials RVU stand for?

Answer 6

Relative Value Unit

Question 7

According to the filing guidelines, providers must file claims for their Medicare patients in within what time frame?

Answer 7

Within 12 months of date of services

Question 8

What editions of the Federal Register would the outpatient facilities be interested in?

Answer 8

November and December Editions

Question 9

Under what act was a major change in Medicare in 1989 made possible?

Answer 9

OBRA (Omnibus Budget Reconciliation Act)

Question 10

Can a physician charge a patient to complete and Medicare form?

Answer 10

No

Question 11

Individuals covered under under Medicare are termed what?

Answer 11

Beneficiaries

Question 12

What are MAC’s and what do they do?

Answer 12

Medicare Administrative Contractors, and they do the paperwork for Medicare. Are usually insurance companies

Question 13

Medicare Part C is also known as?

Answer 13

Medicare Advantage Organizations

Question 14

HIPAA stands for?

Answer 14

Health Insurance Portability and Accountability Act

Question 15

The most major Change to the health care industry as a result of HIPAA was a result of what portion of the act?

Answer 15

Administrative Simplification Act

Question 16

The transfer of electronic documentation is accomplished through the use of What?

Answer 16

Electronic Data Interchange technology

Question 17

The number that is assigned to all providers as a result of HIPAA is called what?

Answer 17

National Provider Identification (NPI)

Question 18

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

Answer 18

Unit

Question 19

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.

Answer 19

limiting

Question 20

For co-surgeons, Medicare pays the lesser of the actual charge or ________ % of the global fee, dividing get payment equally between two surgeons.

Answer 20

125

Question 21

Specific regulations for Medicare are contained in the _______ ______ Manual.

Answer 21

Internet Only

Question 22

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 _____________.

Answer 22

Gatekeeper

Question 23

In this model of HMO, the HMO contract directly employs the physicians.

Answer 23

Staff Model

Question 24

In this model of HMO, the HMO Contracts with the physician to provide service at a set fee. These organizations are known as ___________. _____________ Associations.

Answer 24

Individual Practice

Question 25

An all-inclusive care program for the elderly that provides a comprehensive package for services that permits the client to continue to live at home is known as?

Answer 25

All Inclusive Care for the Elderly (PACE)

Question 26

What does Part A (hospital insurance) cover in Medicare?

Answer 26

Pays for the cost of hospital/facility care:

Semiprivate room
Meals and special diets in hospital
All medically necessary services
Home health visits 
Hospice care
Rehabilitation

Question 27

What does Medicare Part B cover?

Answer 27

Non-hospital such as physicians services and medical equipment

Question 28

What does Medicare Part D cover?

Answer 28

Prescription drugs

Question 29

What does DHHS stand for?

Answer 29

Department of Health and Human Services

Question 30

What does QIO stand for?

Answer 30

Quality Insurance Organizations

Question 31

What are incentives for QIO providers?

Answer 31

Direct payment made to providers
5% higher fee schedule
Faster processing of claims

Question 32

What is the Federal Register?

Answer 32

Official publication for all “Presidential Documents” Rules and Regulations, Proposed Rules, and Notices

Question 33

What edition of the Federal Register are of special interest to hospital facilities?

Answer 33

October Editions

Question 34

What’s is RBRVS?

Answer 34

Resource Based Relative Value Scale