STUDY GUIDE Flashcards
INFORMED CONSENT
IS REQUIRED IN WRITING AFTER EXPLANATION OF A PROCEDURE WITH TIME TO ASK QUESTIONS
IMPLIED CONSENT
CONSENT THAT IS ASSUMED
CONSENT
IS USED ONLY WHEN THE PERMISSION IS FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS
AUTHORIZATION
IS PERMISSION GRANTED BY THE PATIENT OR THE PATIENT’S REPRESENTATIVE TO RELEASE INFORMATION FOR REASONS OTHER THAN TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS.
AUDITING
REVIEW CLAIMS FOR ACCURACY AND COMPLETENESS
DOCUMENTATION
A COMPLETE, ACCURATE, UP TO DATE RECORD OF THE CARE A PATIENT RECEIVES AT A HEALTH CARE FACILITY
DISCLOSURE
THE WAY HEALTH INFORMATION IS GIVEN TO AN OUTSIDE PERSON OR ORGANIZATION.
FRAUD AND EXAMPLES
INTENTIONAL MISREPRESENTATION OF INFORMATION FOR THE PURPOSE OF RECEIVING HIGHER PAYMENT
-FALSE STATEMENTS OF FATS TO OBTAIN OF PAYMENT NOT ENTITLED TO
-BILLING FOR SERVICES NOT RENDERED
ABUSE
UNINTENTIONAL, OFTEN BECAUSE OF POOR BUSINESS PRACTICES.
UPCODING
ASSIGNING A ODE THAT WILL DELIBERATELY RESULT IN A HIGHER PAYMENT
STARK LAW STATES
PHYSICIANS CANNOT REFER PATIENTS TO PRACTITIONER WITH WHOM THEY HAVE A FINANCIAL RELATIONSHIP
OFFICE OF THE INSPECTOR GENERAL IS RESPONSIBLE FOR
FIGHTING FRAUD
FACTORS THAT AFFECT BILLING
-NUMBER OF INSURANCE PLANS
-COORDINATION OF BENEFITS: AVOID DUPLICATION
-PRIMARY PAYS FIRST
-IF SERVICE COVERED UNDER SECONDARY, PRIMARY PAYS BALANCE
-CANNOT COLLECT MORE THAN CHARGED FOR SERVICE
BIRTHDAY RULES
APPLIES TO DEPENDENT CHILDREN WHOSE PARENTS HAVE MORE THAN ONE INSURANCCE POLICY.
-PARENT BIRHTDAY COMES 1ST IS PRIMARY
-IF BOTH HAVE SAME BIRTHDAY, PLAN THAT HAS COVERED THE LONGEST IS PRIMARY
-PARENT WITH CUSTODY IS PRIMARY
-PLAN OF ACTIVE EMPLOYEE IS PRIMARY
MEDICAID
PAYER OF LAST RESORTS
WHY IS IT IMPORTANT TO VERIFY INSURANCE INFORMATION?
BEFORE SUBMITTING CLAIM IT IS IMPORTANT TO MAKE SURE THAT THE INSURANCE IS VALID, AND THE SERVICES ARE A COVERED BENEFIT
MEDICARE
-65 AND OLDER
-YOUNGER THAN 65 WITH DISABILITIES
-END STAGE RENAL KIDNEY DISEASE
MEDICAID
-LOW INCOME
-NON-GOVERNMENT CARRIERS
PRIVATE INSURANCE
SUBSIDIZED THROUGH PREMIUMS
EMPLOYER HEALTH INSURANCE
-SELF INSURED
-USUALLY LESS EXPENSIVE
MEDICARE PART A
HOSPITALIZATION COVERAGE
-INPATIENT HOSPITAL CARE
-SKILLED NURSING FACILITY CARE
-HOME HEALTH CARE
-HOSPICE CARE
-INPATIENT CARE
-BENEFITS PERIODS
-LIMITATIONS ON PAYMENT
MEDICARE PART B
VOLUNTARY SUPPLEMENTAL INSURANCE
-CALENDAR DEDUCTABLE 20% COINSURANCE
———–COVERS————
-EMERGENCY, OUTPATIENT, HOME HEALTH CARE
-LABORATORY, DIAGNOSTIC TEST
-AMBULATORY SURGERRY
-PHYSICAL, SPEECH, OCCUPATIONAL THERAPY
-RADIATION
-KIDNEY DIALYSIS, TRANSPLANTS
———–NOT COVERED———–
-LONG TERM NURSING CARE
-COSMETIC SURGERY
-DENTAL
-ACUPUNCTURE, HEARING AIDS, EXAMS
MEDICARE PART D
DRUG BENEFITS
-RUN BY PRIVATE INSURANCE COMPANIES
-VARY IN COST, COVERAGE
-BENEFICIARIES CHOOSE BASED ON NEEDS
———–OUT OF POCKET EXPENSES———-
-PATIENTS RESPONSIBLE FOR CHARGES
-COST SHATRING FOR PART B
MEDICARE PART C
MEDICARE ADVANTAGE
COMBINATION PACKAGE
-EXTRA COVERAGE
-VISION
-HEARING
-DENTAL
-HEALTH, WELLNESS
-PRESCRIPTION DRUGS
-REQUIREMENTS FROM CMS