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link 4 ch 12
| Question | Answer |
|---|---|
| This is a federal health insurance program for hospital coverage ages 65 or older, people younger that 65 with certain disabilities or end stage renal disease | medicare part A |
| This is a federal health insurance program for outpatient coverage that is a supplementary medical insurance benefits for the aged and disabled | medicar part B |
| What federal nationwide health insurance program for persons age 65 or older and certian disabled blind persons regardless of income, administered buy CMS. | Medicare |
| This is an administrater of medicare that divides responsibilities among three divisions, and also enforces the insurance portability and transaction and code set requirements of HIPPA | center for medicare and medicaid services |
| This part of CMS oversees traditional fee-for-service medicare, including development of payment policy and management of fee-for-service contractors | the center for medicare management |
| This part of CMS provides beneficiaries eith info on medicare, medicare select, and medicare plus choice programs and medigap options.It also manages the medicare choice plans, consumer research, and grevance and appeals functions. | the center for beneficiary choices |
| This part of CMS focuses on federal-stat programs such as medicaid, the state childrens health insurance program, insurance regulations, and the clinical lab improcement amendments. | the center for medicaid and stat operations |
| What services are those that assist the patient with personal needs such as dressing, eating, bathing, and getting out of bed. | custodial services |
| A public agency or private organization that is primarily engaged in providing pain relief, symptom managment, and supportive services to terminally ill people and there families is known as | hospice |
| A short-term inpatient stay that may be necessary for the terminally ill patient to give temporary relief to the person who regularly assists with home care is known as | respite care |
| In the medicare program, monthly fee that enrollees pay for medicare part B medical insurance is called a | premium |
| Routine physical exams, routine foot care, eye or hearing exams, and cosmetic surgery unless caused by injury or proformed to improve functioning of a malformed part, in which a physician may bill the patient are known as | nonbenefits |
| This program was formed to increase the number of health care options in addition to those that are otherwise avalible | medicare part C |
| What provides seniors and people living with disabilities with a prescription drug benefits by covering prescriptions used for conditions bot already covered by other plans. | medicare part D |
| This is a list of drugs that a plan covers. | formulary |
| What specialized insurance policy is designed to supplement coverage under a fee-for-service medicare plan that may cover prescription cost and deductible and copayment that are typically the patients responsibility under medicare | medigap |
| A system of medicare reimbursement for HMOs with risk contracts in called | diagnostic cost group |
| Informants who report physicians suspected of defrauding the federal government are called | whistleblowers |
| An action to recover a penalty brought on by an informer in a situation in which one portion of the recovery goes to the informer and the other to the stat or government is known as | qui tam action |
| When a physician agrees to accept payment from medicare plus payment from the patient after the $165 deductible has been met is known as a | participating physician |
| par | this means participating physician |
| When a physician does not have a signed agreement with medicare and has an option about assignment is known as | nonparticipating physician |
| nonpar | this means nonparticipating physician |
| An agreement in which a patient assigns the right to recive payment from the medicare administrative contractor to the physician is known as | assignment |
| This is a percentage limit on fees specified by legislation, that nonpar physicians may bill medicare beneficiaries above the fees schedule amount | limiting charge |
| What form clearly stats that the service is never covered by medicare and the patient is responsible for payment | notice of exclusions from medicare benefits |
| Also known as waiver of liability agreement or responsibility statment is an agreement given to the patient to read and sign before rendering service if the participating physician thinks that it may be denied for payment by medicare | advance beneficiary notice of noncoverage |
| ABN | (advance beneficiary notice of noncoverage) |
| NEMB | (notice of exclusions from medicare benefits) |
| When a surgical procedure that can be scheduled in advance and is not an emergency and is discretionary on the part of the physician and patient it is called an | elective surgery |
| CCI | (correct coding initiative) |
| Federak legislation that attempts to eliminate unbundling or other inappropriat reporting of procedural codes for professional medical services rendered to patients is known as | correct coding initiative |
| This medicare part A program is a method of payment for medicare hospital insurance baced on DRGs ( a fixed dollar amount for a principal diagnosis) is known as | prospective payment system |
| PPS | (prospective payment system) |
| What is the amount that medicare participating providers agree to accept and charges can be higher or lower that the fee the physician lists on the claim | reasonable fee |
| A sodument detailing services billed and describing payment determination issued to providers of medicare or medicaid program. also known as EOB is | remittance advice |
| A bill for services rendered to a patient receiving benefits simultaneously from nedicare or medicaid and a medigap plan in which medicare pays first and then determines the amounts of inmet deductible and coinsurance to be paid by the secondary carrier | crossover claim |
| MG | medigap |
| CMS | (center for medicare and medicaid services) |
| SSI | (supplemental security income) |
| A programof income for low-income, aged, blind, and disabled persons established by title XVI of the social security act | supplemental sercurity income |
| DCGs | (diagnostic cost groups) |
| CLIA | (clinical laboratory improvement amendment) |
| RBRVS | (resource-baced relative value scale) |
| This is a system medicare uses for establishing fees that takes into account work, overhead expense, and malpractice values for all cpt codes that are published in federal register each november | resource-baced relative value scale |
| RVU | (relative value unit) |
| A monetary value assigned to each service on the basis of the amount of physician work, practice expenses, and cost of professional liability insurance. They are then adjusted according to geographic area and used in a formula to determin medicare fees | relative value unit |
| PQRI | (physician quality reporting initiative) |
| What is a voluntary pay-for-reporting program for providers who successfully report quality information related to services provided to patients under medicare part B between july 1 to december 31 | physician quality reporting initiative |
| RAC | (recovery audit contractor initiative) |
| A proposal of legislation thats goals are to identify medicare underpayments and overpayments and recover overpayments using automated review and complex review in which after a complex review is done by human review of the record | recovery audit cintractor initiative |
| ICF | (intermediate care facilities) |
| An institution furnishing health-related care and services to individuals who so not require the degree of care provided by acut care hospitals or nursing facilities | intermediate care facilities |
| MSN | (medicare summary notice) |
| A document designed to be easier for the patient to understand received by the patient explaining amount charged, medicare approved, deductible, and coinsurance for medical services rendered. | medicare summary notice |
| RA | (remittance advice) |
| VPS | (volume performance standard) |
| The desired growth rate for spending on medicare part B physician services, set each year by congress is known as | volume performance standard |
| A type of substitute coverage when a physician is on vacation is known as | locum tenens |
| A type of substitute coverage when on-call situations occur is known as | reciprocal |
Created by:
maryce
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