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Health Insurance Chapter 5

Involves actions that are inconsistent with accepted, sound, medical, business, or fiscal practices abuse
A legan newspaper published every business day by the national archives and records administration (NARA) federal register
An intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment fraud
An organization that contracts with CMS to process health care claims and perform program integrity tasks for both Medicare part A and part B medicare administative contractor
Is assigned to third-party payers, has 10 numeric positions, including a check digit as the tenth national health plan id (planID)
Is assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position national provider identifier (npi)
Funds a provider or beneficiary receives in excess amounts due and payable under medicare and medicaid statutes and regulations overpayment
Document published by medicare that contains new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual program transmittal
The storage of documentation for an established period of time, usually mandated by federal and/or state law record retention
What is the main difference between fraud and abuse? intent
Name an example of fraud: billing services not provided, unbundling codes
Name an example of abuse: overcharging for services, submits claims for services not medically necessary
Name an example of medicare abuse: improper billing practices that result in medicare payment when the claim is the legal responsibility of another third-party payer
What is the name of the document served to a physician ordering him to bring a patient's medical records to a court hearing? subpoena duces tecum
The type of law passed by legislative bodies is known as_________law. statutory
Which civil case document contains a list of questions that must be answered in writing? interrogatory
Which federal law has regulated the conduct of any contractor submitting claims for payment to the federal government since 1863? false claims act
The federal claims collection act requires medicare administrative contractors to: attempt to recover any reimbursement funds sent as over payment to providers and beneficiaries
Since the creation of the Occupational Safety and Health Administration in 1971, workplace fatalities have decreased by: 50 percent
The Physicians at Teaching Hospitals Hospitals (PATH) legislation was passed to: monitor Medicare rule compliance for payment of part B services and proper coding and billing practices
An individual can conduct a comprehensive review of a practitioner's past actions by referring to the: healthcare integrity and protection data bank
One of the provisions of HIPPA designed to improve protability and continuity of health care coverage is: providing credit for prior health coverage
Which department of Health and Human Services agency is responsible for investigating a Medicare provider who is suspected of committing fraud? office of inspector general
In additional to civil, criminal,and administrative penalties, those who commit health care fraud can also be tried for: mail and wire fraud
The first step a physician practice can take to identify areas in the practice that are vulnerable to fraud and abuse is to: perform periodic audits to internally monitor billing processes
An example of overpayment is: duplicate processing of claim
Unless the case involves fraud, administrative contractors are prohibited from seeking overpayment recovery when the: overpayment is not reopened within 48 months after payment
Code combinations that cannot be reported on the same claim are called: edit pairs
The most controversial of the proposed unique identifiers in the administrative simplification provision of HIPAA is the: national individual identifier
Claims that are considered appropriate for electronic data interchange (EDI) are_______ claims computer tape
Assigning passwords to users who are authorized to access patient records is a form of: security
What special handling is required to release medical information for a patient who is HIV-positive? patient must sign an additional authorization statement for release of information
Created by: kduvall20