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Definition
| The amount paid by Medicare for a return to the operating room for treatment of a complication is limited to the ________ portion of the code that best describes the treatment of the complications. |
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Term
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Definition
| When an unlisted procedure is reported because no other code exists to describe the treatment of a complication (that requires returning to operating room), payment is based on a maximum of ___% of the value of the intraoperative services originally performed. |
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Term
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Definition
| Modifier for Assistant Surgeon |
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Term
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Definition
| Modifier for Minimum Assistant Surgeon |
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Term
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Definition
| Modifier for Assitant Surgeon when qualified resident surgeon not available |
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Term
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Definition
| HCPCS modifier for Assistant at Surgery |
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Term
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Definition
| Modifier for Two Surgeons |
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Term
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Definition
| Modifier for Surgical Team |
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Term
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Definition
| Modifier for Return to Operating Procedure Room for a Related Procedure During the Postoperative Period |
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Term
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Definition
| Modifier for Unrelated Procedure or Service by the Same Physician During the Postoperative Period |
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Term
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Definition
| the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes it knowing that the deception cold result in some unauthroized benefit to himself/herself or some other person |
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Term
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Definition
| a form that a Medicare patient signs that allows their claims to be filed automatically without their signature |
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Term
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Definition
What is considered fraud:
a) billing for services not furnished
b) misrepresenting a diagnosis to justify a payment
c) soliciting, offering, or receiving a kickback
d) unbundling or exploding charges
e) falsifying certificiates of medical necessity, plans of treatment, and medical records to justify payment
f) billing for additional services not furnished as billed--up coding
g) routine waiver of copayment
h) all of the above
i) all but c |
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Term
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Definition
| A delivery system that allows the enrollee access to all health care services. Enrollee is assigned a primary care physician who manages all the health care needs |
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Term
| Office of Benefits Integrity |
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Definition
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Term
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Definition
| overseas Medicare's payment safeguard program related to fraud, audit, medical review, the collection of overpayments, and the imposition of civil monetary penalties for certain violations of Medicare law. |
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Term
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Definition
| What does CMPs stand for? |
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Term
| Officer of the Inspector General |
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Definition
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Term
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Definition
| Of the DHHS, responsible for developing an annual work plan that outlines the ways in which the Medicare program is monitored to identify fraud and abuse |
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Term
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Definition
| What does IOMs stand for? |
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Term
| Certificates of Medical Necessity |
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Definition
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Term
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Definition
Which are examples of fraud?
a) billing both Medicare and a beneficiary for the same service
b) billing Medicare and another insurance company for the same service
c) billing for noncovered services
d) using another person's Medicare card to obtain medical care
e) billing for procedures over a series of days rather than the day it occurred
f) physician visits a nursing home and bills for 20 nursing home visits without furnishing any specific service to individual patients
g) all of the above
h) all but a and d |
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Term
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Definition
| concept of establishing networks of health care providers that offer an array of health care services under the umbrella of a single organization |
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Term
| Health Maintenance Organizations |
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Definition
| What does HMOs stand for? |
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Term
| Individual Practice Associations |
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Definition
| What does IPAs stand for? |
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Term
| Preferred Provider Organizations |
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Definition
| What does PPOs stand for? |
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Term
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Definition
What are examples of managed health care?
a) HMOs
b) IPAs
c) Group Practice
d) Multiple Option Plan
e) Medicare Risk HMOs
f) PPOs
g) Staff model
h) all of the above
i) a, b, e, f |
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Term
| Managed Care Organization |
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Definition
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Term
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Definition
| Group that is responsible for the health care services offered to an enrolled group or person. The organization coordinates or manages the care of the enrollee. It negotiaties with various health care netities for a disc ounted rate for services provided to its enrollees. Providers must get approval before services are rendered |
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Term
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Definition
| A group of providers who forma network and who have agreed to provide services to enrollees at a discounted rate. Enrollees are usually responsible for paying a portion of costs. |
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