Billing Basics
What is the primary goal of billing specialists?
Help patients get the most out of their insurance AND ensure the organization’s cash flow.
What does HIPAA stand for?
Health Insurance Portability and Accountability Act.
Define fraud vs. abuse.
Fraud = intentional deception; Abuse = improper practices not usually intentional.
Name the four requirements of a valid insurance contract.
Competent parties, Agreement, Consideration, Legal purpose.
Who administers Medicare?
CMS (Centers for Medicare & Medicaid Services).
What does timely claim submission help prevent?
Lost cash flow and financial problems.
What are the three safeguard categories under HIPAA?
Administrative, Technical, Physical.
What law prohibits financial relationships from influencing referrals?
The Stark Law.
What is the difference between an implied vs. expressed contract?
mplied = by actions; Expressed = verbal or written.
What services are covered under Medicare Part A vs. Part B?
Part A = inpatient, hospice, SNF; Part B = outpatient, doctors, preventive.
Name one skill billing specialists must have.
Medical terminology, coding, math, accuracy, compliance knowledge, computer skills, etc.
What is the difference between Use vs. Disclosure of PHI?
Use = inside organization; Disclosure = released outside.
What program audits improper Medicare payments?
RAC (Recovery Audit Contractor).
What is the role of adjudication in claims processing?
The payer reviews the claim and decides payment.
What is Medigap insurance?
Supplemental coverage for costs not paid by Medicare.
What is respondeat superior?
Employers are legally responsible for their employees’ actions on the job.
When must a Notice of Privacy Practices (NPP) be given to a patient?
At first encounter or enrollment.
What federal law from 1863 is the foundation of fraud law?
False Claims Act (FCA).
What is the time limit for submitting Medicare claims?
12 months from the date of service.
What does utilization management aim to balance?
Cost, quality, and access.
What report tracks outstanding payments by 30/60/90/120+ days?
An aging report.
What are the two situations when HIPAA requires disclosure of PHI?
To the patient, and to DHHS for compliance checks.
Name 3 of the 7 key steps of a compliance program.
Written policies, oversight, training, communication, auditing, discipline, corrective actions.
What are two examples of government health programs?
Medicare, Medicaid, TRICARE, Workers’ Compensation.
List the five levels of Medicare appeals.
Redetermination, Reconsideration, OMHA, Medicare Appeals Council, Federal Court.