The Revenue Cycle
What is the first step of the revenue cycle?
Registration (Or Preregistration)
____ provide or pay for the cost of healthcare.
Health Plans (Insurance)
A physician invests in a clinical laboratory and refers Medicare patients to that laboratory for testing. In this scenario, a _____ has occurred.
Self-Referral
Which type of improper billing practice has occurred when the billing code reflects a more expensive medical procedure than the one provided?
Upcoding
What is the purpose of a baseline audit in a compliance program?
To provide a benchmark for measuring compliance risks and activities
Why should a patient’s insurance coverage be recorded as primary, secondary, and tertiary?
To submit claims in the order in which each plan should pay.
What code sets are required by the HIPAA Transaction and Code Set standard?
Name at least one. (3 possible answers)
Current Procedure Terminology (CPT®)
International Classification of Diseases (ICD-10-CM)
International Classification of Diseases (ICD-10-PCS)
Which improper billing practice is sometimes a misguided attempt to avoid an audit?
Undercoding
How does undercoding differ from upcoding?
Undercoding does not report the full extent of services, whereas upcoding bills for more expensive services than those provided.
How do monitoring and auditing differ in a compliance program?
Monitoring is an ongoing part of business operations, whereas auditing occurs periodically.
After a patient receives a healthcare service, what is the next step before claims submission?
Charge Capture
The HIPAA Privacy Rule’s focus is to make sure that _____ remains privacy and secure.
Protected Health Information
A nursing home intentionally misrepresents the care provided to residents when billing Medicare to increase the nursing home’s reimbursement. This nursing home has violated the ____ Act.
False Claims Act
Which law includes a requirement that healthcare providers develop a compliance program?
Affordable Care Act (ACA)
Overcoding charges are considered noncompliant and can lead to ________.
Audits
What does a clearinghouse scrub for when processing a medical claim?
Name at least one (4 items)
Incorrect diagnosis coding
Terminated insurance plans
Incorrect insurance plan number
Incorrect spelling of a patient’s name
The HIPAA ____ National Identifier Standard Transaction Set requires that providers and their business associates have policies and procedures in place to ensure confidentiality of protected health information (PHI).
Privacy Rule
The _____ is an analytics technology that runs algorithms to detect potential fraud and abuse in Medicare Fee-for-Service claims before payment.
Fraud Prevention System (FPS)
The ______ prohibits certain individuals from participating in federal healthcare programs if they have committed Medicare or Medicaid fraud or other health-related criminal offenses.
Exclusion Statute
If an external audit reveals overpayments from a federal healthcare program, the healthcare provider must return the funds within _____ of the date of identification to avoid serious penalties.
60 Days
What information is provided to the healthcare provider on an electronic remittance advice (ERA)?
(List at least 2)
Date of Service
Amount paid for the Service
Amount charged by the provider
Patients Name
What act was established to improve healthcare quality, safety, and efficiency using health information technology?
HITECH ACT
Health Information Technology for Economic and Clinical Health Act
Which resource stores reports about acts of fraud and abuse committed by healthcare providers and suppliers?
National Practitioner Data Bank (NPDB)
A healthcare provider identifies several overpayments during the self-disclosure process outlined in the OIG provider self-disclosure protocol. What must the provider do?
(two options)
During a self-audit, what would a healthcare organization evaluate during a standards and procedures review?
List at least one item
(4 possible answers)
Policy manuals
Staff training programs
Information on coding practices
Mechanisms for reporting billing fraud and abuse