Compliance
In 1998, the Office of Inspector General issued this guidance for hospitals.
What is the OIG's Compliance Guidance for Hospitals?
The following formula is the calculation for which Medicare payment system:
[(wRVU x wGPCI) + (mpRVU x mpGPCI) + (PE RVU x PE GPCI)] x CF = Payment
What is the Medicare Physician Fee Schedule?
President Harry S. Truman was the very first recipient of this card in 1965.
What is Medicare?
OIG
What is the Office of Inspector General?
These five modifiers are most often utilized to bypass the Correct Coding Initiative Edits (CCI) BUT only when appropriate to do so. High utilization and improper use of these modifiers has resulted in high scrutiny from CMS.
What are 59, XU, XE, XS, XP?
This element of an effective compliance program includes reporting to the governance board audit findings.
What is Auditing and Monitoring?
This form is used for submission to health plans for inpatient hospital and outpatient hospital services.
What is the UB 1450 claim form?
Through the A, B, C's of Medicare, a Medicare Advantage Plan is this for the Medicare Program.
What is Part C?
HIPAA
What is the Health Insurance Portability and Accountability Act?
If the _________ indicator is inappropriately assigned on an inpatient claim then the DRG assignment and reimbursement could result in an overpayment.
What is the Present on Admission indicator?
This law prohibits physicians from referring patients for "Designated Health Services" payable by Medicare/Medicaid from entities with which the physician or an immediate family member has a financial relationship.
What is Stark? Or Physician Self-Referral Law?
This payment methodology is used by payers when hospitals request reimbursement for inpatient stays.
What is a Diagnosis Related Group?
This program only covers Part B services for those that choo choo.
What is Railroad Medicare?
OPPS
What is the Outpatient Prospective Payment System?
This type of transfusion can only be billed once per day.
What is a blood transfusion?
This is the time frame the OIG suggests a provider should take to complete an investigation into allegations of wrongdoing.
What is 6 months?
A ______ is reimbursed based on cost for Medicare.
What is a Critical Access Hospital?
________ is a voluntary election and the beneficiary must pay premiums. Enrollment for Medicare ________ is automatic once eligible.
What is Part B? What is Part A?
ASC
What is Ambulatory Surgery Center?
This coding reflects how sick patients are to ensure Medicare Advantage Plans are funded accordingly.
What is HCC or Risk Adjustment?
The False Claims Act allows the government to impose ____________ and/or to ___________ providers from participation in federal health care programs.
What are civil monetary penalties and exclude?
While under the umbrella of the Medicare program, this type of plan only has to pay for what Medicare covers. It does not have to administer it in the same way i.e. billing rules can be very different.
What is a Medicare Advantage Plan? What is Part C? What is a Medicare replacement plan?
Every year new Medicare rules and regulations are published in this government document.
What is the Federal Register?
ABN and Definition
What is an Advanced Beneficiary Notice of Non- Coverage? A document that is required to be signed by the beneficiary before providing services that may be considered not medically necessary by Medicare. It demonstrates that the patient is aware the services are non-covered and the patient will be responsible for payment.
This code is used to report an ear lavage.
What is 69210?