Week 1
firms are owned by risk-based equity investors who expect the managers of the corporation to maximize shareholder wealth.
RBRVUs
is simply a qualification introduced by the payer to limit its total payment by excluding certain categories of cost or placing limits on costs that the payer deems reasonable
reasonable cost
Benefits under Part B include a wide range of services, such as doctor’s fees, hospital outpatient services, clinical laboratory tests, durable medical equipment, and a number of other preventive medical services.
DRG-Diagnosis related group
simply a list of all items for which the firm has established specific prices.
CDM Charge Description master
Accumulation of actual paper documents or charge slips used to identify services performed, which are then posted to a patient’s account in a batch-processing mode by data processing or the business office. Alternatively, an order entry system may involve direct entry of charges to the patient’s account through a computer terminal.
Charge Capture
prohibits a physician from referring a patient for certain “designated health services” to an entity with which the physician has a “financial relationship.”
Stark Law
Sometimes prior approval for elective services is required by the health plan before a claim can be submitted.
Precertification
Benefits under what part of Medicare include hospital stays, skilled nursing care, hospice care, and some home health services.
Medicare Part A
states that no person may offer or request, give, or receive remuneration in exchange for a referral for a good or service that may be reimbursed under a federal healthcare program (e.g., Medicare).
Anti Kickback Statue
firms are owned by risk-based equity investors who expect the managers of the corporation to maximize shareholder wealth.
investor owned
The part of a healthcare bill for which the patient is responsible. These payments are used to prevent overutilization of services.
co payment
Benefits under what part of Medicare include a wide range of services, such as doctor’s fees, hospital outpatient services, clinical laboratory tests, durable medical equipment, and a number of other preventive medical services.
B
is the federal government’s primary civil remedy for improper or fraudulent claims
False Claims Act
firms are owned by risk-based equity investors who expect the managers of the corporation to maximize shareholder wealth.
sole propritorships
as sets of codes that provide information for both diagnoses and procedures.
ICD-10
What part of Medicare is the pharmacy benefits from
D
actions are also known as “whistleblower” suits.
Qui Tam Action