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CRCS Chapter 4

AAHAM CRCS CERTIFICATION Chapter 4

Question	Answer
What is billing?	The process of submitting and following up on claims in order to be paid for healthcare services provided.
What are the different types of insurances and payers?	Medicare, medigap, Medicaid, workers compensation, Tricare, CHIP, self-insured, commercial, liability insurance, self-pay, HSA
Who does Medicare cover?	It covers individuals who are elderly (age 65 or order) an individuals with permanent disabilities, and end stage renal disease, Lou Gehrig's disease.
What is a person called who is covered under Medicare?	Beneficiary
What does ESRD mean?	End stage renal disease
How many parts does Medicare have?	Four
What is Medicare part A called?	Hospital insurance
What does Medicare part A cover?	Medically necessary inpatient hospitalization, care in a skilled nursing facility following a 3-day hospital. Home health care, and hospice.
Do most beneficiaries pay premium for part A Medicare coverage?	No
How does a beneficiary get per a Medicare coverage?	Beneficiaries who have worked enough quarters per SSA requirements will qualify for coverage without a premium.
Does Medicare part A have a deductible?	Yes, a patient pays the deductible once per spell of illness, which begins when he besnificiary enters the hospital and 60 days after discharge from the hospital or from an SNF.
What is The Medicare part A benefit called lifetime reserve?	It's 60 days of inpatient hospital services than a beneficiary can opt to use after having used 90 days of inpatient hospital services in a benefit.
How often can the lifetime reserve days be used?	Once in the beneficiaries lifetime, but it can be split among multiple hospital stays.
Is there a higher coinsurance when using the lifetime reserve days?	Yes, it comes with a high coinsurance, 50% of the Medicare part A deductible per day.
If a patient did not want to use their lifetime reserve days, what would happen after 90 days?	Any covered puppy services would be billed.
What is Medicare part b called?	Medical insurance
What does Medicare part b cover?	It helps pays for doctors services, outpatient hospital care, other things, Medicare part A does not cover.
Is enrollment in Medicare part b voluntary?
	Yes
When must a beneficiary sign up for Medicare part b?	They can enroll in Medicare part b coverage anytime within the 7-month period that begins 3 months before turning 65 their birthday month and 3 months after they turn 65.
Does a beneficiary pay for Medicare part b coverage?	Yes, they pay a premium each month
Does Medicare part b cover preventative services?	Yes
What are Medicare part b covered preventative services?	Annual well visit, bone mass measurements, screenings for heart, diabetes, glaucoma, hepatitis, HIV, lung, breast, prostate, pap, HPV, depression, sti, aortic aneurysm, and vaccines, tobacco sensation, behavioral counseling, MNT, diabetes training, etc
What vaccines are covered under Medicare part b prevented services?	Hepatitis b, flu shot, pneumonia shot,
What are other items? Part b helps pay for?	Ambulance, artificial limbs and eyes, arm leg back and neck braces, chiropractic services, emergency care, kidney dialysis and kidney transplants, medical supplies such as ostomy bag, surgical dressings, prosthetic devices, transplants, diagnostic testing
Who qualifies for an annual wellness visit?	All Medicare beneficiaries who are more than 12 months after the effective date of their Medicare part b coverage and who have not received an initial IPPE or AWV within 12 months
What does AWV stand for?	Annual wellness visit
What does IPPE stand for?	Initial preventative physical exam
What is the beneficiary obligation in the original Medicare plan for an annual wellness visit?	Go payment, coinsurance, deductible or waived
How often is a bone mass measurement covered?	Berries with health status; covered once every 24 months or more often if determined to be medically necessary
What beneficiaries are eligible for a bone mass measurement?	Certain beneficiaries at risk for losing bull mass or developing osteoporosis.
What is the beneficiaries obligation in the original Medicare plan for a bone mass measurement?	Topayment, coinsurance, and deductible or waived
How often is cardiovascular disease screening covered?	It is covered once every 5 years
What is included in a cardiovascular disease screening?	A lipid panel, cholesterol, lipoprotein, and triglycerides
Who is eligible for a cardiovascular disease screening?	All asymptomatic Medicare beneficiaries
What is the beneficiary obligation in the original Medicare plan for cardiovascular disease screening?	Copayment, coinsurance, and deductible or waived
How often can a beneficiary get a colorectal cancer screening?	FOBT once every 12 months, flexig once every 4 years or 10 years after having a screening colonoscopy, colonoscopy once every 24 months for high risk in every 10 years for not high risk. Barium enema once every 24 months for high risk or 4 years if not.
What beneficiary is eligible for colorectal cancer screening?
	Beneficiary age 50 in order. However, there is no age limit for having a colonoscopy.
What is the beneficiary obligation in the original Medicare plan for colorectal cancer screening?	For FOBT , flexig, colonoscopy- copayment coinsurance and deductible waived. Barium enema coinsurance applies, deductible waved. For a multi-target stool DNA test. If polyp found and removed, 20% copayment applies.
How often is diabetes screening test covered?	Two screening test per year if diagnosed with pre-diabetes or one screening test per year if previously tested but not diagnosed with diabetes or if never tested.
Who qualifies for diabetes screening test?	Beneficiaries who have certain risk factors for diabetes or who have Venn diagnosed with diabetes.
What is the beneficiary obligation in the original Medicare plan for diabetes screening test?	Copayment, coinsurance, and deductible are waived.
What is the coverage for diabetes self-management training?	Up to 10 hours of initial training within a 12-month period. In subsequent years, up to 2 hours of follow-up training are allowed each year.
What is the beneficiary obligation in the original Medicare plan for diabetes self-management training?	Copayment, coinsurance, and deductible applies
How often is a glaucoma screening covered?	Once every 12 months. Must be done or supervised by an eye doctor who is legally allowed to do the service and the beneficiary state of residence.
Who is eligible for glaucoma screening?	Bennett fisheries that high risk of glaucoma, including people with diabetes or family history of glaucoma, African Americans who are age 50 and older, and Hispanic American age 65 and older.
What is the beneficiary obligation in the original Medicare plan for glaucoma screening?	Copayment, coinsurance, and deductible apply
How often is hepatitis b vaccine covered?	Scheduled doses as required
Who is eligible for a hepatitis b vaccine?	Beneficiaries who are intermediate or high risk for contracting Hep b. But beneficiaries who are currently positive for hepatitis be antibodies are not eligible for this benefit.
What is the beneficiary obligation in the original Medicare plan for hepatitis b vaccine?	Co-payment, coinsurance, and deductible are waived
Who is eligible for hepatitis c virus screening?	Beneficiaries who are at high risk for hepatitis c. Virus infection or who were born between 1945 and 1965.
How often is hepatitis c virus screening covered?	Annually for high risk beneficiaries with continued illicit drug use with injection, or who had a blood transfusion before 1992. Once in a lifetime if born between 1945 and 1965 and not at high risk.
What is the beneficiary obligation in the original Medicare plan for hepatitis c virus screening?	Copayment, coinsurance, and deductible or waived.
How often is HIV screening covered?	Annually for high-risk cases and three times per pregnancy (one screening per trimester) for those beneficiaries who are pregnant.
Who is eligible for HIV screening?	Beneficiaries who are at an increased risk for HIV, who may be pregnant, or who are between ages 15 through 65 and ask for the test
What is the beneficiary obligation in the original Medicare plan for HIV screening?	Copayment, coinsurance, and deductible are waived
How often is an initial preventative physical exam covered?	One visit a lifetime
What does IPPE stand for?	Initial preventative physical examination
Who is covered for an IPPE?	All new Medicare beneficiaries who are within the first 12 months of the first Medicare part b coverage.
What is the beneficiary obligation in the original Medicare plan for an IPPE?	For an IPPE without EKG- copayment and coinsurance apply; deductible waved. For an IPPE with EKG- copayment, coinsurance, and deductible apply
How often is intensive behavioral therapy for cardiovascular disease covered?	1 CVD risk reduction visit annually
What does IBT stand for?	Intensive behavioral therapy
what does CVD stand for?	Cardiovascular disease
Who is eligible for intensive behavioral therapy for cardiovascular disease?	All Medicare beneficiaries who are competent in alert at the time the counseling is provided, and who's counseling is furnished by qualified primary care physician or other primary care practitioner and in a primary care setting.
What is the Medicare beneficiaries obligation in the original Medicare plan for intensive behavioral therapy for cardiovascular disease?	Copayment, coinsurance, and deductible or waived
How often is intensive behavioral therapy for obesity covered?	Annually for all beneficiaries; frequency of coverage includes one visit every week for month one; one visit every other week for months two through six; in one visit every month for months 7 through 12.
Who is covered for intensive behavioral therapy for obesity?	Beneficiaries with a BMI of greater than 30, who are competent and alert at the time that counseling is provided and who's counseling is furnished by qualified primary care physician or other primary care practitioner in a primary care setting
What is the beneficiary obligation in the original Medicare plan for intensive behavioral therapy for obesity?	Copayment, coinsurance, and deductible are waived
How often is lung cancer screening covered?	Annually for beneficiaries between ages 55 through 77
Who qualifies for lung cancer screening?	Beneficiaries who show no signs or symptoms of lung cancer and you have a history of smoking at least 30 packs, a year; who are current smokers or have quit smoking within the past 15 years. There also must be a written order for the service that criteria
What is the beneficiary obligation in the original Medicare plan for lung cancer screening?	Car insurance and deductible waived. If all criteria are meant, there is a written order, and the physician accepts assignment.
How often is mammogram screening covered?	One baseline screening for females between ages 35 through 39 then once every 12 months for females over 40.
It's screening and diagnostic mammograms are built on the same day. What modifier should be used to show a screening mammogram with turned into a diagnostic mammogram at the time of service?	Modifier GG
Who qualifies for screening mammogram?	Female beneficiaries age 35 or older
What is the beneficiary obligation in the original Medicare plan for screening mammograms?	Coinsurance, copayment and deductible waived
How often is diagnostic mammograms covered?	When medically necessary
Who is covered for diagnostic mammograms?	Female beneficiaries when the service is medically necessary.
What is the beneficiary obligation in the original Medicare plan for diagnostic mammograms?	Coinsurance and deductible apply
What does MNT stand for?	Medical nutrition therapy
How often is medical nutrition therapy covered?	First year- 3 hours of 1 on 1 counseling ; subsequent years- 2 hours of one-on-one counseling
What is the beneficiary obligation for original Medicare plan for medical nutrition therapy?	Copayment, coinsurance in deductible waived. Note- if the patient is receiving dialysis in a dialysis facility, Medicare will cover MNT as part of the overall dialysis care.
	Beneficiaries diagnosed with diabetes or a renal disease or who have received a kidney transplant within the last 3 years
How often is a pap smear and pelvic exam covered, including a clinical breast exam?	Once every 24 months or once every 12 months if at risk for cervical or vaginal cancer or a childbearing age with an abnormal pap smear in the proceeding 36 months.
Who is covered for a pap smear and pelvic exam?	Female beneficiaries
What is the beneficiary obligation in the original Medicare plan for pap smear and pelvic exam?	Copayment, coinsurance, and deductible or waived
How often is a prostate cancer screening covered?	Did digital rectal exam- once every 12 months. Prostate specific antigen or PSA test is covered once every 12 months.
Who is covered for a prostate cancer screening?	Male beneficiaries age 50 in order- beginning the day after the 50th birthday
What is the beneficiaries obligation in the original Medicare plan for prostate cancer screening?	Digital rectal exam- co. Payment, coinsurance, and deductible apply PSA test- co-payment, coinsurance, and deductible waived
Who is eligible for medical nutrition therapy?
How often is screening and behavioral counseling to reduce alcohol misuse covered?	Annually for all beneficiaries; face- to face counseling up to four times per year for those who screen positive.
Who is eligible for screening and behavioral counseling to reduce alcohol misuse?	All Medicare beneficiaries who screen positive are eligible if they are competent and alert at the time the counseling is provided and counseling is furnished by qualified physician in a primary care setting.
What is the beneficiary obligation in the original Medicare plan for screening and behavioral counseling to reduce alcohol misuse?	Copayment, coinsurance, and deductible or waived
How often is screening for cervical cancer with human papilloma virus were the HPV test covered?	Once every 5 years
Who is eligible for screening for cervical cancer with human papilloma virus or HPV test?	All asymptomatic female Medicare beneficiaries age 30 to 65 years
What is the beneficiary obligation in the original Medicare plan for screening for cervical cancer with human papilloma virus or HPV?	Copayment, coinsurance, and deductible or waived
How often is screening for depression covered?	Annually for all beneficiaries
Who is eligible for screening for depression?	All Medicare beneficiaries
What is the beneficiary obligation in the original Medicare plan for screening for depression?	Copayment, coinsurance, and deductible or waived
How often is sexually transmitted infection screenings and high intensity behavioral counseling to prevent STI's covered?	Annually for all beneficiaries; frequency of coverage depends on the type of STI's being treated.
Who is eligible for sexually transmitted infection screenings and high intensity behavioral counseling to prevent STIs?	Adolescent in adult beneficiaries who are sexually active in our and increased risk for STIs
What is the beneficiary obligation in the original Medicare plan for sexually transmitted infection screenings and high intensity behavioral counseling to prevent STIs?	Go payment, coinsurance, and deductible or waived. Behavioral counseling sessions conducted in an inappropriate setting will not be covered as a preventative service.
How often is smoking in tobacco? Use sensation counseling covered?	Two sensation attempts per year; each attempt includes a maximum of four intermediate or intensive sessions; up to eight sessions within a 12-month.
Who is covered for smoking and tobacco use sensation counseling?	Beneficiaries who used tobacco and have a disease or adverse health effect linked to tobacco use
What is the beneficiary obligation in the original Medicare plan for smoking and tobacco use sensation counseling?	Copayment, coinsurance, and deductible waived
How often is ultrasound screening for abdominal aortic aneurysm covered?	Once in a lifetime
Who is eligible for ultrasound screening for abdominal aortic aneurysm?	Beneficiaries with certain risk factors for AAA to receive a referral from their physician, physician assistant, nurse practitioner, or clinical nurse specialist
What is the beneficiary obligation in the original Medicare plan for ultrasound screening for abdominal aortic aneurysm?	Copayment, coinsurance, and deductible or waived
How often is flu shot covered?	Once a year per flu season
How often is the pneumonia vaccine covered?	One shot can be followed by a second, different shot one year later
Who is eligible for vaccinations?	All beneficiaries with part b coverage
What is the beneficiary obligation in the original Medicare plan for vaccinations?	Copayment, coinsurance, and deductible or waived
What are some things that Medicare part A or part b original Medicare plan does not cover?	Acupuncture, routine dental services, cosmetic surgery, hearing aids and exams, orthopedic shoes, outpatient prescription drugs, routine foot care, routine. Eye care, routine. Physical exams, care while traveling outside the u.s, custodial care
What is Medicare part c?	Medicare advantage or a replacement plan from the traditional Medicare plan.
Do Medicare advantage plans need to follow the minimal rules set by Medicare?	Yes
What are the five types of Medicare advantage plans?	HMOs, PPOs, private fee for service plans, special needs plans, medical savings accounts
What does HMO stand for?	Health maintenance organization
HMOs	These are plans in which members must generally get health care from providers in the plans network
What does PPO stand for?	Preferred provider organizations
PPO	Plans which are similar to HMOs, but members can see any doctor or provider that accepts Medicare and they don't need a referral to see a specialist
Private fee for service plans	Plans which allow numbers to go to any provider that accept the plans terms. The private company decides how much it will pay and how much the members pay for services
Special needs plans	These are plans which limit all or most of their membership to people in some long-term care facilities such as nursing homes, and who are eligible for Medicare and Medicaid. These plans are available in limited areas only
What does MSAs stand for?	Medical savings accounts
MSAs	Plans which have two parts: one part is a Medicare advantage hot deductible plan and the other part is a medical savings account into which Medicare deposits money that people can use to pay health care cost
What is the Medicare advantage billing.	The period when a patient enrolls or disenrolls in a Medicare advantage organization during a period of service.
What are the two factors that determine whether the Medicare advantage organization is liable for the payment?	1. Whether the provider is included in an inpatient hospital or health perspective payment system. 2. The date of enrollment
If a patient changes Medicare advantage status druing a inpatient hospital admission what determines who is responsible for the bill?	The patient status, admission or start of care determines liability. If the hospital inpatient was not a Medicare advantage and Rowley upon a mission but enrolls before the discharge, the Medicare advantage organization is not responsible for payment.
If the provider is not a PPS provider, is the Medicare advantage organization responsible for payment for services one in after the day of enrollment up through the day that the disenrollment is effective?	Yes
What is Medicare part d?	Medicare prescription drug plan
Is the prescription drug plan subject to a deductible?	Yes, an annual deductible
What is the Medicare drug plan list of covered drugs?	Formulary
Are the drugs placed into tiers and if so what do the tiers mean?	Yes they are categorized into tears in each tier. Can have a different cost
What does MAC stand for?	Medicare administrative contractor
What are Medicare administrative contractors?	They are private firms that process Medicare claims. Formally known as fiscal intermediaries or carriers. Serve as the primary contact for providers. They enroll providers in the Medicare program, provide education and answer provider and pt inquiries
How many Medicare administrative contractors are there?	Currently there are 12 part a/ part b. 4 DME
What is Medicare participating physician program?	Under the program, the providers sign a participation agreement, buying them to accept assignment for all services provided to Medicare patients for the following year.
When is the acceptment of benefits normally acquired?	Normally acquired at registration or admission
Is it essential to obtain assignment of benefits prior to rendering treatment?	No but must be got in prior to discharge
If a provider accepts assignment, what are they agreeing to?	To be paid by Medicare, to get only the amount Medicare approves further services, to charge beneficiaries only the cost of non-cover services in the Medicare deductible/co insurance amounts
Can a provider use an ABN were similar contract to get the patient to pay more than what Medicare would pay?	No
If they provider does not accept assignment, what can they do?	Ken, charge more than the Medicare approved amount, can ask the beneficiary to pay the entire charge at the time of service, must determine if the services there furnishing are covered under Medicare, must still submit a claim to Medicare with all info
If a provider does not accept assignment, what is the maximum amount that they are allowed to charge the patient?	Maximum of 115% of the Medicare approved amount
What are advantages of participating in the Medicare physician program?	Higher fee schedule payments, fewer collection efforts, publicity, government imprimatur , accurate calculation of coinsurance, lower maintenance fees
How much does Medicare part b pay directly to the provider?	80%
What does government imprimatur mean?	Sanction or approval; ability to display Medicare emblems and literature
When submitting a claim to Medicare, does the name on the claim have to match the name on the card exactly?	Yes
What did the Medicare access and chip reauthorization act of 2015 require?	It required CMS to remove social security numbers from all Medicare cards by 2019
What is the identification number on the Medicare card called	MBI or Medicare beneficiary identifier
What are the parameters for an MBI?	Contains uppercase letters in numbers but no special characters, be unique to each beneficiary, have no common mystery letters such as S, L, O, B, I, and Z
What is medigap?	Medigap is a health insurance sold to fill the gaps of coverage like deductibles, coinsurance and copayments under the original Medicare plan
What is a medigap policy also known as?	Medicare supplemental insurance
Who can have a medigap plan?	Only beneficiaries with the original Medicare plan. It's a beneficiary with a Medicare advantage plan joins. It will not pay for any deductibles, co-payments or other cost sharing amounts
What is Medicaid?	It is a program intended to ensure that the vulnerable have access to medical care. It is known as title xix. It covers eligible low income people and people with disabilities.
Who is responsible for the funding of Medicaid programs?	Both the federal government and stage share the responsibility
What is the vast majority of Medicare dollars go towards?	Paying for the care of patience residing in custodial care facilities
Regarding Medicaid, what do states have the authority to do?	Establish eligibility standards, determine what benefits and services to cover, set payment rates
What is dual eligibility?	Dual eligible benefits are individuals who are entitled to Medicare part A/ part B and are also eligible for some form of Medicaid benefit
What is workers compensation?	When a worker is injured in the course of performing job duties, treatment for that condition is usually covered by workers compensation plan.
When billing for workers compensation claim, it is important to do what?	Gather as much information as possible regarding the patient's coverage, including any group health insurance, secure a worker's compensation claim number for the case
What is Tricare?	Tricare covers active duty service numbers, their spouses, dependence, and retirees unless they are eligible for Medicare.
For Tricare, what is a military member called?	Sponsor
When does Tricare coverage start for a sponsor and their dependents?	For the sponsor, it starts on the first day of active orders. Other members are eligible after the sponsor has been on active duty for 30 days
What is Tricare for life?	This is a program for qualified service. Retirees that acts as a supplement to Medicare
What is a non--availability statement?	It is required before any non-emergent inpatient services may be performed to a Tricare extra or standard eligible beneficiary by a non-military treatment facility
Who issues the NAS?	It is issued by or at the discretion of the MTF commander
How long is an NAS good for?	It is valid for 30 days after the date of issue for the specific reason requested an obtained. The NAS remains valid from the date of admission until 15 days after discharge for any follow-up treatment related to the admissions stay
What is an MTF?	It is a military treatment facility established for the purpose of furnishing medical/ dental care to eligible individuals. There is a 40 mi catchment area in which active duty personnel should go to the MTF to receive their treatment
What is children's health insurance program or CHIP?	This is a program for children whose family's failed to qualify for Medicaid but cannot afford to purchase private insurance. The program is jointly financed by the federal and state governments and administered by the states.
What is self-insured	Wear a company will put premium payments into a fun to cover services and pay a third party to administer benefits from the fund
Are self-insured health plans regulated under federal law?	Yes they are regulated through the employee retirement income security act
Does self insured health plans have to follow the state timely payment regulations	No, not unless the state statute specifically states that ERiSA plans are included
What is commercial insurance?	This refers to health insurance that covers individuals. Most people dolph obtain this a type of insurance as a benefit of employment.
What is liability insurance?	This is insurance for someone who is injured to a non-work-related accident. This may be covered through property and casualty or auto insurance.
What is MedPay coverage for liability insurance?	It is quite limited but will pick quickly
What is no fault coverage?	This is offered in several states and follow state new fault laws. Typically each injured party in an accident must buy a claim with his or her own auto insurance
What is self-pay?	This is a common term for patients who have no insurance.
What should any discounting of South Bay accounts be vetted through?	Legal compliance in the contracting department to ensure that contracts and regulations are not violated
What is health savings accounts or HSAs?	These are bank accounts maintained by patients to pay medical expenses not covered by their insurance. Vons and interest in the HSA are not taxed. To be eligible for an HSA account. You must be enrolled in a specific high deductible health plan.
P who can put money into an HSA account?	The patient were their employer. If the funds are not spent the patient can keep them and if they are never spent the patient can use them in retirement.
According to the CMS, what is coordination of benefits?	A program that determines which plan or insurance policy will pay first. If two health plans or insurance policies cover the same benefits. If one of the plans is a Medicare health plan, federal law may decide who pays first.
If a person has Medicare and and a commercial insurance. When is Medicare the secondary pair?	The working age, individ who are under 65, disabled and are covered by a LGH plan, individ who rec services under WC, the black lung benefit acy, auto, no fault, or liability plans, covered under the VA, has other primary cov admit other than Medicare.
What does EGHP stand for?	Employer group health plan
What is no fault insurance?	Insurance that pays medical expenses related to an injury resulting from an accident regardless of who may be at fault.
What are the various types of no-fault insurance?	Homeowners insurance, commercial insurance, auto insurance.
What is liability insurance?	Any source that provides payment on a claim based on a legal liability for illnesses, damages to properties, or injuries.
What are examples of liability plans?	Malpractice, wrongful death, product liability, and uninsured motorist.
Can a veteran choose whether to receive services covered under the VA or Medicare?	Veterans who have benefits under the VA have the options of choosing Medicare or the VA as the primary payer.
If a patient chooses the VA over Medicare, how does billing work?	The provider bills the VA first. If the VA denies the service, then the provider can submit the claim to Medicare as primary.
If the patient chooses Medicare over the VA, how does billing work?	The claim must be submitted to Medicare as primary in the claim should not be submitted to the VA.
What are other COB determining factors?	GHP of currently employed are always primary to Medicare if size req is meant, if patient changes from original Medicare to MCA during hospital stay, Medicare is responsible. Medicaid is always the pair of last resort except for Indian health services.
When wouldn't Tricare be the last pair?	If the patient has Medicaid, Tricare supplements, the Indian health service, and other programs are plans as identified by the Tricare management activity.
	Yes
If Tricare is secondary, how will Tricare pay?	They will only pay for Tricare covered services and the maximum allowed Tricare amounts, and all Tricare policies and procedures must still be followed.
If a person has a liability, property and casualty insurance along with other insurance who was primary and who is secondary?	All pairs are secondary to any liability or property and casualty insurance. Exception very few commercial insurances will always pay primary.
If a person is covered by two commercial insurances, what is used to determine who primary coverage depends on?	A person's own coverage is primary to that of a spouse. Then children are covered by both parents. Determination is based on the birthday rule, if a person has auto or liability plan, individuals who have VA benefits.
What is the birthday rule? If parents are married.	If married, the birthday rule dictates that the parent with the first birthday in the counter year will provide the primary coverage. Not the birth year. Just the birthday. For example, mom has 6/1/1970 and dad has of 1/16/70. Dad would be primary
What is the birthday rule if parents are divorced for separated?	The parent who has custody pays first, the new spouse of the parent with custody pays second, and finally the plan of the parent who doesn't have custody pays last. Exception court order said otherwise.
What is conditional payment?	When another pair is responsible but the claim is not expected to be paid promptly, usually within 120 days. Medicare will make a conditional payment to prevent the patient from paying out of pocket.
What is HIPAA's impact on billing?	Attempt at administrative simplification to use standard transaction to aid an electronic claim transmission.
Did HIPAA require standard transaction code sets?	Yes with limited exceptions
What are some, HIPAA required standard transaction code sets?	270, 271, 276, 277, 278, 354, 834, 835, 837D, 837I, 847P
What do code sets 270 and 271 relate to?	Healthcare eligibility. 270 is inquiry and 271 is the response.
What does transaction code sets 276 and 277 relate to?	Healthcare claim status. 276 is inquiry and 277 is the response.
What does transaction code set 278 relate to?	Referral certification and authorization
What does transaction code 354 relate to?	Claim status response
What does transaction code 834 relate to ?	Enrollment and disenrollment in a health plan
What does transaction code 835 relate to?	Healthcare payment and remittance advice
What does transaction code 837D relate to?	Dental claim
What does transaction code 837i relate to?	Institutional claim
What does transaction code 837P relate to?	Professional claim
Is it important to maintain a provider's coding master files on an annual basis?	Yes, because these specifications for these transactions are updated as a requirement change in health care often and our critical to a provider's financial health.
What are the names of some of the mandated transaction code sets?	ICD, present on admission indicators, CPT, HCPCS, NPI, taxonomy code,
What does ICD-10 stand for?	International classification of disease, 10th revision
What does POA stand for?	Present one admission indicators
What does HCPCS stand for?	Healthcare Common procedure Coding system
What does CPT -4 stand for?	Current procedural terminology
What does NPI stand for?	national provider identification
What is ICD-10?	Diagnosis and inpatient procedures
What are POA indicators used one?	Inpatient claims
What are CPT codes used for?	Outpatient procedures
What are HCPCS codes used for?	Outpatient procedures
What are NPIs?	Provider identification, as directed by CMS's administrative simplification identifier standards
What are taxonomy codes?	Administrative codes to identify practitioner type and specialty for healthcare providers
What do ICD-10 codes set consist of?	Tubular list, inclusions and exclusion terms, alphabetical index, descriptions, guidelines, and resources to assist with the accurate coding of claims
How many ICD-10 codes are there?	68,000 codes to allow for great specificity and identifying and tracking services offered in the medical field
What do you need to do when assigning ICD-10 codes?	Code the primary diagnosis 1st, followed by 2nd, 3rs and so forth. Code any coexisting cond that affect the visit or pro c as supp, code the principal in disch dx to the highest level of specificity, code any coexisting dx to the lowest level of specif.
What are POA indicators?	CMS mandated the use of POA indicators for most inpatient claims. The indicator is paired with each dike nurses code in the medical record. They are used to identify non-payable complications such as hospital acquired conditions.
How many levels are HCPCS codes divided into?	3
What is level one of the HCPCS codes?	CPT codes. CPT is a system of descriptive terms in five digit numbers that are used to identify medical services and procedures furnished by health care professionals. They do not include codes regularly build by suppliers other than physicians.
What is level 2 of the HCPCS system?	5 digit numeric codes with alphabetic prefixes a. Through v, assigned by CMS to identify products, supplies, and services not included in the CPT codes, such as ambulance, DME, orthotics and dmepos.
What is level 3 HCPCS Codes?	Codes that are used at the state level by Medicaid and other pairs to designate additional services. They are often referred to as local codes and our prohibited under HIPAA but still required by some state programs.
What are evaluation and management codes?	P a range of CPT codes applies to e&m and this is determined on the process and the charge for examining a patient and formulating treatment. The code is assigned a level based on seven components.
What are the seven components to E&M coding?	History, examination, medical decision making, counseling, coordination of care, nature presenting problem, time spent
Do e&m coating different for new or established patients?	Yes, except emergency department where there is no distinction.
What are HCPCS in CPT? Modifiers?	A. Two-digit numeric or alpha code that is used in medical billing to indicate that the medical procedure or service performed has been changed under specific circumstances or performed in a different way.
What is an NPI?	It is a unique 10 digit identifier issued to healthcare providers in the United States by CMS
What are taxonomy codes?	Administrative codes to identify practitioner type and specialty for healthcare practitioners. It is a hierarchical code that consists of codes, descriptions and definitions.
What is an NDC or national drug code?	A unique 11 digit three segment numeric identifier that is assigned to each medication listed under the FDA.
P what are the three segments of the NDC code?	The first identifies the labeler, second is type of product, third identifies the size and type of the package
What are payment methodologies?	A way to determine how much payers will pay for different charges.
What are the different methods of payment methodologies ?	MS-drg, APC, the schedule, RBRVS, UCR, SNF PPS, CAH, capitation, per diem, percent of charges, fee schedule
What is Medicare severity diagnosis- related group or MS-DRG?	Applies to inpatient service. It combines the patient age , diagnosis, discharge, and procedures to calculate a payment rate.
How many major diagnostic categories are MS-DRGS grouped?	25
How many days does a hospital have to file subsequent inpatient DRG adjustments from the date of the remittance advice for Medicare patients?	60
Who gets paid under the ambulatory payment classification or APC?	Hospital outpatient services, certain Part B services, furnished to hospitals inpatients who have no part A coverage, and partial hospitalization services furnished by community mental health centers.
What is ambulatory payment classification or APCs?	Services in each APC are similarly clinically and in terms of the resources they require. A payment rate is established for each group.
Can a hospital be paid for more than one APC for a single encounter?	Yes
What are the elements required to assign an APC?	HCPCS/ CPT codes, e and m codes, diagnosis code, site of service.
When is the only time that Medicare will pay an inpatient only procedure on an outpatient claim.	When the patient dies before admission. They would need to add the CPT code for the inpatient only procedure and then add a CA modifier indicating that the patient died prior to admission as an inpatient.
Who is exempt from APCs?	Critical access hospitals, certain hospitals in Maryland, cancer hospitals, Indian health service facilities.
Is the OPPS and APC the same type of payment methodology?	Yes
Who is affected by outpatient PPS?	Acute care hospital outpatient services, hospital and distinct part hospital units exempt from inpatient PPS, partial hospitalization programs associated with community mental health centers.
What is the fee schedule? Payment mythology?	A fee associated with the CPT and HCPTC codes that Medicare will allow. These are used for outpatient services including lab, screening, mammogram, and outpatient PT. Similar to how physician services are paid..
What is resource-based relative value scale or RBRVS payment mythology?	How Medicare pays for physician services. Not based on charges but based on three major elements.
What are the three major elements of RBRVS's?	Reschedule based on RVU's, MVPS, and limits on the amount non-participating physicians can charge beneficiaries.
What are the three separate RVs associated with the calculation of a payment under the Medicare perspective Payment system or MIPPS?	Work required or work RVU, practice expense or PE, malpractice insurance expense or MP
What is usual, customary, and reasonable or UCR payment mythology?	Payment method that relies on physician charge data accumulated over time. After ranking the charges for a giving service from lowest to highest, the pair uses a specific point as the basis for UCR payments.
What is skilled nursing facility perspective payment or SNF PPS?	Payment is based on provider completing MDS. MDS then determines the RUG and hence the payment. NSF claims are billed with HIPPS codes. These are five digit codes
What are the components of HIPPS or health insurance perspective? Payment system codes?	A three-digit classification code assigned to each RUG, and a two-digit assessment indicator that specifies the type of assessment used to support the billing of the claim.
What is a critical access hospital or CAH?	Hospital that serves rural communities. may not have any more than 25 inpt beds that may be used for swing bed services. They may op as a distinct part. Rehab/ psych unit with up to 10 beds. Have an alos of 96 hours or less per patient for acute care.
Do critical access hospitals have to have a 24-hour emergency care service 7 days a week?	Yes
What is the mileage requirement for critical access hospitals to be located from?	Must be located more than 35 mi drive from any hospital or CAH in an area with mountainous train or only secondary roads.
Are critical access hospital subject to the IPPS or OPPS payment mythologies?	No
What are critical access hospitals paid?	They are paid for most inpatient and outpace services at 101% of reasonable costs
Are critical access hospitals subject to Medicare Part A and Part B deductible and Co insurancees?	Yes
What is capitation payment mythology?	Method of pmt in which a prov is paid a set $ amount for each pt for a spec time prd & that pmt covers all care of the grps of pts rec for that period no matter act charges. shifts a great deal of risk to the prov. Claims must still be sub to the payer.
What is per diem payment mythology?	Providers are paid a predetermined amount for each day. An inpatient is in the facility, regardless of actual charges or cost occurred.
What is percent of charges? Payment mythology?	Percent of charges means that the claim is paid at a predetermined percentage discount rates
What is fee for services payment mythology?	It is the oldest method of payment. It is the mythology providers are paid for each medical service rendered to a patient.
What is a chargemaster?	Electronic file that resides in the providers information system and that contains charges that can be posted to a patient's account.
What are other names for a chargemaster?	Charge description, master, fee schedule, itemasters, and other similar names
What are some elements of a chargemaster?	Department numbers, revenue codes, chargemaster numbers, charge descriptions, charge amounts, CPT/ HCPCS codes, modifiers, general ledger numbers.
How often should I charge master be reviewed?	At least annually
What is an insurance pair contract?	When insurance payer contracts with providers to receive discounts off Normally build charges.
What are some elements of a pair contract?	Effective and renold date, fee schedule revision, termination provision, timely filing, refund request allowance, denial rates, medical policies, prior off, reimbursement rate, credentialing, etc
What is locum tenens?	A temporary substitute, especially for a doctor or a member of the clergy. Situation like weekends and when they provider is on vacation or absent. A substitute provider can be paid for services provided to a Medicare patient.
When can a substitute provider be paid for services provided to a medical care patient?	The regular physician is unable to provide the services, the patient had a previously scheduled appointment or treatment with the regular physician, the substitute doesn't provide services to the patient for more than 60 days.
What are some common billing forms used to complete the billing and collection activities within the revenue cycle?	UB-04 and 837i, super Bill, CMS-1500 and 837 p, itemist statement, statement, MSN, EOB, RA, and 835.
What does MSN stand for?	Medicare submarine notice
What does RA stand for?	Remittance advice
What does EOB stand for?	Explanation of benefits
What is a UB-04 form in an 837i?	The UB-04 refers to the hard copy version of the hospital claim form in the 837i refers to the electronic data set to submit claims to a payer.
What are the differences between a UB form and a electronic 837i?	UB formats have distinct SL numbers and names assigned to each data element reported , UB formats do not distinctly different between patient data and subscriber data, UB contains 81 data elements and reports info about treat and con of PT.
Who governs the standards of the ubo4 and 837i?	National uniform, billing committee or NUBC
How is each form divided?	Did UBO or paper format is divided into 81 boxes called field locators. The electronic version is divided into loops in segments
What is the other name that the UB04 form is known as?	CMS-1450
What is a condition code?	A two-digit code that clarifies an event or condition related to the bill that may affect payer processing
What are some common condition codes?	04- information only bill, 08- beneficiary would not provide info concerning other insurance coverage, 21- billing for denial notice.
What are some common occurrence codes?	11- one set of symptoms/ illness, 24- date insurance denied, 32- date that an ABN, form CMS-R-131, was given to a beneficiary
What is an incurrence code?	A two-digit code and a date that together clarify a significant event or condition related to a claim
What is an occurrence span?	A two-digit code followed by two dates that identify a span of time relevant to claim processing
What are some common occurrence span codes?	70- non-utilization days, day for which the beneficiary has exhausted all regular coin days. 74 -9. Level of care, period non-cover level of care in a covered stay, 76- Pt liability , period non-covered care for which the hosp is perm to charge the pt
What is a value code?	P a two-digit code and it's related amount of value that together clarifying an event or condition related to a claim
What are common value codes?	08- lifetime reserve amount in the first calendar year in billing. 48- latest hemoglobin reading , A0- 5 digit zip code of location where the patient is initially placed on board the ambulance.
What is a revenue code?	Four digit code that specifies an accommodation or ancillary service
What are common revenue codes?	0120- rum and board semi-private two beds. 0310- laboratory pathology general, 0450- emergency room general
What is a type of bill code?	A three digit excluding the leading zero code in field locator for the describes the type of bill the hospital is submitting to the payer
What is the first digit of the type of bill code show?	Type of facility
What are the first digit type of bill codes and what they mean?	1 - hospital, 2- skilled nursing, 3- home health, 4-religious non-medical hospital, 5- religious non -medical extended care, 7- clinic, 8- special facility, ACS.
What is the second digit for type of bill code mean for Bill classification except clinics and special facilities , the first digit is 1-5?	1 - inpatient (Part A), 2- inpatient (part B), 3- output, 4- other (part b), 5- intermediate level 1, 6- intermediate level 2, 7- subacute inpt, 8- swing bed.
What is the second digit for type of bill code mean for Bill classification clinics only, first digit is a 7?	1- RHC, 2- hospital-based or independent renal dialysis facility, 3 - FQHC, 4- ORF, 5- CORF, 6-CMHC
What is the second digit for type of build code mean for Bill classification special facilities only, first digit is an 8?	1- hospice, non-hospital-based, 2- hospice hospital based, 3- ASC to hospital outpatients, 4-free standing birth center, 5 - critical access hospital
What does the third digit for type of bill code relate to?	Frequency
What are the codes for the third digit type of bill code?	A, B, C, D, E, F, G, H, I, J, K, M, P. 0, 1, 2, 3, 4, 5, 7, 8, 9
What does the third digit type of bill code digit A mean?	Hospice admission notice- use when the hospice or religious non-medical health care institution is submitting form CMS-1450 as an admission notice
What does the third digit for type of bill code digit B mean?	Hospice/medicare coordinated care demonstration/religious non-medical health care institution termination/revocation notice- use when the form CMS-1450 is used as a notice of termination/ revocation for a previously posted election.
What does the third digit C Mean for type of bill code?	Hospice change of provider notice- use wind form CMS-1450 is used as a notice of change to the hospice provider
What does the third digit D type of bill code mean?	Hospice/medicare coordinated Care demonstration/religious non-medicalhealthcare institution void/cancel- used when form CMS -1450 is used as a notice of a void/cancel of election
What does the third digit E for type of bill code mean?	Hospice change of ownership- You've been form CMS-1450 is used as a notice of change in ownership for the hospice
What does the third digit F for type of bill code mean?	Beneficiary initiated adjustment claim- used to identify adjustments initiated by the beneficiary for FI use only
What does the third digit G for type of bill code mean?	CWF initiated adjustment claim - you used to identify adjustments initiated by CWF. For FI use only
What does the third digit H mean for type of bill code?	CMS initiated adjustment claim- used to identify adjustments initiated by CMS. For FI use only.
What does the third digit I mean for type of bill code?	FI adjustment claim other than qio or provider- used to identify adjustments initiated by the FI. For FI use only.
What does the third digit j mean for type of Bill code?	Initiated adjustment. Claim- other- used toy identify adjustments initiated by other entities. For FI use only.
What does the third digit k mean for type of bill code?	OIG initiated adjustment. Claim- used to identify adjustments initiated by OIG. For FI use only.
What does the third digit? M mean for type of bill code?	MSP initiated adjustment claim- used to identify adjustments initiated by MSP. For FI use only. Note: MSP takes precedence over other adjustment sources.
What does the third digit P mean for type of bill code?	QIO adjustment claim- used to identify and adjustment initiated as a result of a QIO review. For FI use only.
What does the third digit 0 mean for type of bill code?	Non-payment/zero claims- used when it does not anticipate payment from the payer for the bill, but is informing the pair about a period of non-payable confinement or termination of care.
What does the third digit 1 mean for type of bill code?	Admit through discharge claim- used for a bill and compensating an entire inpt confinement or course of outpatient treatment for which it expects pmt from the payer or which it will update ded or inp t or Part B claims when Medicare is secondary to EGHP
What does the third digit 2 Mean for type of bill claim?	Interim- first claim- used for the first of an expected series of bills for which utilization is chargeable or which will update inpt ded for the same confinement of course of treatment. For HHAs, used for the submission of org or replacement are RAPs.
What does the third digit 3 mean for type of bill code?	Interim- continuing claims- used when a bill for which utilization is chargeable for the same. Confinement or course of treatment had already been submitted and further bills are expected to be submitted later.
What does the third digit 4 mean for type of bill code?	Interim- last claim- used for a bill for which utilization is chargeable and which is the last of a series for this confinements or course of treatments.
What does the third digit 5 mean for type of bill code?	Late charge only- used for outpatient claims only. Late charges are not accepted for Medicare inpatient, home health, or ambulatory surgical center claims.
What does the third digit 7 mean for type of bill code?	Replacement of prior claim- used to correct a previously submitted bill. The provider applies this code to the corrected bill along with the original claim number.
What does the third digit 8 mean for type of bill code?	Void/Cancel of prior claim
What does the third digit 9 mean for type of bill code?	Final claim for a home health PPS episode- used to indicate the HH bill should be processed as a debit or credit adjustment to the request of anticipated payment.
What is a super bill or encounter form?	Is she used to record certain data related to the patients encounters. Usually has E&M, procedures, diagnosis that are commonly performed. This is everything that the patient had done that day or needs done for patient accounting and for billing purposes.
Should super bills be thrown away?	No
What billing form is used to submit physician and professional services?	CMS-1500 and 837P
What form is used for paper submissions, the CMS 1500 or the 837P?	CMS- 1500
Should all Medicare claims be submitted electronically according to the administrative simplification compliance act?	Yes unless there is an exception outlined in the Medicare claims processing manual, chapter 26, section 10
What is an itemized statement?	A complete listing or detailed account of every service posted to a patient account to include the data, service, description, service code, charge amount, estimated insurance amounts, patient payment, and totals.
What is another name for itemized statement?	I- Bill
What is a data mailer or a statement?	Assistant generated statement used to communicate the status of a patient's account/ to bill the patient for an unpaid amount remaining on the account.
What is a Medicare summary notice or MSN?	A quarterly statement to the beneficiary reflecting services received, charges submitted, charges allowed, amount for which the beneficiary is responsible, in the amount that was paid to the provider or beneficiaries. They must specify ded and coin amts.
What are other names that the MSN is also known as?	Remittance advice and was formerly known as the Medicare explanation of benefits.
Are MSNs recognize as a powerful tool to help detect fraud and abuse?	Yes
What is an explanation of benefits or a remittance Advice/ 835?	It is a statement sent by the health insurance company to covered individuals explaining what medical treatments/ services were paid for when they're behalf. The RA is the same information but to the provider.
What are the only distinct differences between EOB and an RA?	The EOB may or may not have a check attached for payment of services. The RA should have a check or a voucher for an electronic payment that was sent to the bank.
What are electronic EOBs called?	EDI 835 files
Do EOBs contain protected health information?	Yes
What do EOBs typically indicate?	The payer, the payee, patient name, dos, service performed, total charges, allowed amount, amount patient is responsible for, contractual adjustments, a brief explanation why claim was denied if denied.
If a patient has a secondary insurance generally, what do they pay?	Generally they only pay the amount the primary EOB says was the members responsibility.
What is the role of EOB's in identifying healthcare fraud and abuse?	Payers will notify pts of what providers claims were submitted on their behalf. This informs them of their patient responsibility and also lets them know if they might have received services that were not medically necessary, experimental, or cosmetic.
For Medicare, if a covered service was furnished to a Medicare beneficiary, is it required to submit a claim for the services provided?	Yes, the provider must submit the claim to Medicare
Can a provider charge a beneficiary for completing or filing claims with Medicare?	No
What is the penalty if he provider does not comply with filing a claim to Medicare if it is mandatory?	It can result in civil monetary penalty being imposed of up to $10,000 per violation that occurs.
What are the exceptions to the mandatory filing rule?	Medicare is listed as secondary payer, payment from the primary insurance sent directly to beneficiary, beneficiary. Not provide the primary insurance information, services were provided outside of United States, services excluded for Medicare, beneficiary signed. An ABN for services in indicated that they didn't want Medicare to be billed, the provider opted out of the Medicare program in. Contract with the beneficiary, the provider has been barred or excluded from the Medicare program.
What is the timely filing for Medicare claims?	365 days For outpatients, the date is determined on the line items and for inpatient claim should have a span of dates and they use the "from" date to determine timely filing.
If timely filing is not meant, is the provider able to build the patient?	No, the claim must be written off
What is a late charge for facility billing?	Typically mean those charges that are posted after the DOS, after leg days have passed, or after the bill has dropped.
What are some reasons late charges occur?	Timeliness of charge and entry, credit of unused medications, system processing issues
How are late charges handled?	Late charges often have to be rebuild, causing delays and account resolution. Sometimes the late charges will just be credited from the account or written off instead of being rebuild.
Our late charges costly?	Yes
What is the 3-day payment window rule?	A Medicare regulation that requires all diagnostic and clinically related non-diagnostic outpatient services provided within 3 days of inpatient admission to be combined to the inpatient claim when they are provided by entity wholly owned or operated by the inpatient hospital.
What is the one day payment window rule?	Similar to the 3 day payment window rule but for inpt psych hospitals, inpt rehab facilities,, long term care facilities, and children's and cancer hospitals.
How can electronic claims be generated?	a variety of resources, such as in -house computer system, stand-alone billing system, or intermediary provider software.
What are the benefits of electronic billing?	Faster entry into payer system, less paper, faster sub to payer, proof of receipt, less clerical intervention, greater interest, fewer staffing resources, more reports, better follow-up capabilities.
What are some problems with electronic billing?	Challenges with payer acceptance, inability to send attachments, inflexible vendor reporting, upload and download issues, challenges with backward integration.
What are some Medicare edits?	NCCI, Outpatient Code Editor, Medicare Code Editor, MUE
What does NCCI stand for?	National Correct Coding Initiative
What are NCCI edits?	Identify mutually exclusive CPT-4 and HCPCS codes or those that should not be billed together.
What does NCCI edits promote?	It promotes correct coding methodologies and strives to eliminate improper coding.
Why were NCCI edits introduced?	Establish standards of medical billing, identify codes that may be potential for fraud and abuse, identify codes that are components of another code, and should not be unbundled and billed on the same encounter by the same provider.
When do NCCI reviews happen?	Before the claim is paid. The processing system tests every pair of codes reported on the same DOS, for the same pt, and same provider.
What can prevent a NCCI edit from triggering.	An appropriate modifier.
What does OCE stand for?	Outpatient Code Editor
What is the OCE edits	Similar to the NCCI edits but apply to hospital outpatient services under the hospital OPPS.
OCE edits determine?	- Determine whether a specific code is payable under the hospital OPPS - Include many of the CCI edits - Determine if the ASC limit applies to each bill
What is Medicare Code Editor (MCE)?	It is software that can detect incorrect billing data that is being submitted.
What are the 3 things that the MCE address to support the assignment of an MS-DRG.	Code edits - examine a record for the correct use of ICD-10 codes. Coverage edits - exam type of pt and the proce performed to determine if the service was covered. Clinical edits - exam the clinical consistency of procedural and dx info to determine if resonable.
What does MUE stand for?	Medically Unlikely Edits
When are MUE reviewed?	prepayment
What is a MUE?	A unit of service edit for HCPCS/CPT codes for services rendered by a provider to a single pt on the same DOS.
What are MUEs designed to do?	To reduce errors due to clerical entries and incorrect coding based on anatomic considerations.
Can MUEs be overridden with a modifier.	Sometimes
Can MUEs be appealed.	Not in most cases.
If a provider disagrees with a MUE who should they contact?	Correct Coding Solutions, the contractor who developed the program.
What is a "clean" claim?	A claim that does not require the carrier or MAC to investigate. Basically everything is good with the claim and it is processed and paid the first time with no issues.
What are "non-standard claims"?	Claims that have extraneous attachments in lieu of data entered correctly in the claim form.
What is an "incomplete" claim?	A claim with required information missing (for example, no NPI).
What is an "invalid" claim"	A claim that contains complete and necessary information; however, the info is illogical or incorrect ( for example, an incorrect NPI).
What happens if a claim is found to be incomplete or invalid?	It is returned to the provider (RTP).
What is an Unprocessable Claim?	Any claim that is considered incomplete or invalid.
How many days does Medicare allow for invalid or incomplete claims to be corrected?	45 days
What is the most important compliance function for claim billing?	To stay current on requirements and submitting accurate claims.
What could happen if errors go uncorrected and claims are paid inappropriately?	The provider could be subject to severe penalties up to and including exclusion from Medicare.
What are the 7 elements of a a compliance plan?	1. Written policies and procedures 2. Have a Compliance officer and committee 3. Training and education 4. Lines of communication 5. Enforced standards and disciplinary procedures 6. Auditing and monitoring. 7. Responding to offenses and developing corrective action plans.

Created by: PRO Teacher larae711

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