Chapter 1: Reimbursement, HIPAA, & Compliance
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What two groups of persons were added to those eligible for Medicare benefits after the initial establishment of the Medicare program?
- People who were eligible for disability benefits from social security
- Patients experiencing permanent renal failure
To what government organization did the secretary of the Department of Health and Human Services delegate the responibilty for administering the Medicare program?
Centers for Medicare and Medicaid Services (CMS)
What government organization handles the funds for teh Medicare program?
The Social Security Administration
There are 3 items that Medicare beneficiaries are responsible for paying before Medicare will begin to pay for services. What are these three items?
Medicare publishes the Medicare fee schedule and usually pays what percentage of the amounts indicated for services?
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 within _____________ months of the date of service.
What editions of the Federal Register would the outpatient facilities be interested in?
November & December
Under what act was a major change in Medicare in 1989 made possible?
The Omnibus Budget Reconciliation Act of 1989 (OBRA)
Can a physician charge a patient to complete a Medicare form?
Individuals covered under Medicare are termed _____________
The ______ ______ ______ do the paperwork for Medicare and are usually insurance companies that have bid for a contract with CMS to handle the Medicare program for a specific area.
(MAC) Medicare Admimistrative Contractors
Medicare Part C is also known as _______________
HIPAA stands for
Health Insurance Portability and Accountability Act
The most major change to the health care industry as a result of HIPAA was as a result of what portion of the act?
Administrative Simplicification portion
The transfer of electronic documentation is accomplished through the use of ______ ______ Interchange technology.
Electronic Data Interchange (EDI)
The number that is assigned to all providers as a result of HIPAA:
National Provider Identification (NPI)
Under the RVU system, ___________ values are assigned to each service and are determined on the basis of the resources necessary to the physician's performance of the service.
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.
For co-surgeons, Medicare pays _____% of the global fee, dividing the payment equally between the two surgeons.
Specific regulations for Medicare are contained in the _______ ________ Manual.
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 (Primary Care)
In this model of HMO, the HMO directly employes the physicians.
Staff Model HMO
In this model of HMO, the HMO contracts with the physician to provide the service at a set fee. This organization is known as _____________
Individual Practice Associations (IPA)
An all inclusive care program for the elderly that provides a comprehensive package of services that permits the client to continue to live at home is known as what?
PACE - Program for All-Inclusive Care for the Elderly
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