Legislation/Programs
This initiative, implemented by CMS, prevents improper medical billing practices.
National Correct Coding Initiative (NCCI)
This it the term for the amount a patient must pay before insurance begins covering costs.
Deductible
This coding system is used to report medical procedures.
Current Procedural Terminology (CPT)
This law requires covered entities to keep PHI private and use appropriate measures to keep this information secure.
Health Insurance Portability and Accountability Act (HIPAA)
This illegal practice involves intentionally submitting false claims for financial gain.
Fraud
This law prevents providers from referring patients to healthcare facilities they own or have a financial interest in.
The Stark Law (The Physician Self-Referral Law)
This is the term for the fixed amount is paid by the patient for services like doctor visits.
Copayment
This term refers to the case in which a patient's diagnosis justifies the completed procedure.
Medical necessity
This type of consent involves a provider explaining the risks, benefits, and alternatives of a procedure to a patient prior to service.
Informed consent
A coder makes an error which results in the practice billing for and receiving payment for a more complex procedure than the one that was performed. This would be an example of billing ____________.
Abuse
This program conducts targeted audits in cases of suspected Medicare/Medicaid fraud, waste, and/or abuse
Zone Program Integrity Contract (ZPIC)
This is the term for the percentage of costs that is shared between the patient and the insurer after meeting the deductible.
Coinsurance
This is the process of reviewing claims for errors before submission.
Claim scrubbing
Requiring hospital employees to change their passwords every 30 days ensures the ______________ of healthcare information.
security
This type of error can cause a claim denial for the following reasons: service not covered by the insurance, patient not covered at the time of service, service was not considered medically necessary, preauthorization or precertification not obtained prior to service
coverage error
This organization reviews claims and documentation to identify and recover improper payments made for Medicare patients. They also educate providers to prevent further errors due to documentation.
Recovery Audit Contractor (RAC)
This is the term for an entity, like an insurance company, that pays healthcare costs on behalf of a patient.
Third-party payer
This document explains how a claim was processed and paid by the payer as well as any remaining balance.
Remittance advice (RA)- sent to providers
Explanation of benefits (EOB)- sent to patients
A provider may send a patient's healthcare information without their consent for any of these three reasons.
Treatment, Payment, Operations
This is the process by which a practice can try to receive payment for a claim that was denied.
Appeal
This program reviews Medicaid claims, performs audits, identifies overpayments and educates providers to maintain integrity and quality of care for patients
Medicaid Integrity Contractor (MIC)
This term is used for the person who is covered by and receives benefits from an insurance plan.
Beneficiary
This is an entity that checks medical claims for errors before they are sent to insurers.
Clearinghouse
This type of medical records are not included in medical record requests and must be specifically released by a patient in order to be shared.
Mental health records
This is the practice of separately billing multiple separate codes for procedures that should be billed together under a single, comprehensive code
Unbundling