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Chapter 5 Insurance

Question	Answer
Record retention is the storage of documentation for an established period of time, usually mandated by federal law and __________.	state law.
An attorney calls the physician's office and requests that a copy of a client's medical record be immediately faxed to the attorney's office. The insurance specialist should	instruct the attorney to obtain the patient's signed authorization.
An insurance company calls the office to request information about a claim. The insurance specialist confirms the patient's dates of service and the patient's negative HIV status. The insurance specialist	appropriately released the dates of service, but not the negative HIV status.
A patient's spouse comes to the office and requests diagnostic and treatment information about their wife. The spouse is the primary policyholder on a policy for which the wife is named as a dependent. The insurance specialist should	obtain a signed patient authorization from the wife before releasing patient information.
Which is considered Medicare fraud?	billing for services that were not furnished and misrepresenting diagnoses to justify payment
Which is considered Medicare abuse?	improper billing practices that result in Medicare payment when the claim is the legal responsibility of another third-party payer
Federal and state statutes are __________.	passed by legislative bodies.
Which term describes guidelines written by administrative agencies (such as CMS) that are based on laws passed by legislative bodies?	regulations
Case law is based on court decisions that establish precedent, and is also called __________ law.	common
Which term describes an individual's right to keep health care information from being disclosed to others?	privacy
The safekeeping of patient information by controlling access to hard-copy and computerized records is a form of __________.	security management
Information that is converted to a secure language format for electronic transmission is __________ data.	encrypted
Which federal legislation was enacted in 1995 to restrict the referral of patients to organizations in which providers have a financial interest?	Stark II laws
Testimony under oath taken outside the court (e.g., at the provider's office) is a(n) __________.	deposition
Which act of legislation requires Medicare administrative contractors to attempt the collection of overpayments made under the Medicare or Medicaid programs?	Federal Claims Collection Act
The recognized difference between fraud and abuse is the __________.	Intent
When a Medicare provider commits fraud, which entity conducts the investigation?	Office of the Inspector General
A provider or beneficiary can receive a waiver of recovery of overpayment in which situation?	The beneficiary was without fault with respect to the overpayment and recovery would cause financial hardship.
As part of the administrative simplification provision of HIPAA, which of the following unique identifiers is assigned to providers?	National Health Plan Identifier (HPID)
Federal Register is	a legal newspaper published every business day
CMS Transmittals	Contain new and changed Medicare policies and or procedures that are to be incorporated into a specific CMS Program
An Audit is	Objective evaluation to determine the accuracy of submitted financial statements
A compliance program,	contains internal policies and procedures that an organization follows to meet mandated requirements.
Medical Review (MR)	is defined by CMS as a review of claims to determine whether services provided are medically reasonable and necessary.
Recovery Audit Contractor (RAC)	Is a program mandated by the Medicare Prescription drug, to find and correct improper Medicare payments. (Part C & D)
National Correct Coding Initiative (NCCI)	Developed in 1996 by CMS to reduce Medicare program expenditure by detecting inappropriate codes submitted on claims.
HIPAA	Passed by Congress in 1996 for concerns about fraud
HIPAA will help:	Improve the portability and continuity of health insurance coverage Combat waste, fraud, and abuse Promote the use of medical savings accounts. Improve access to long-term care services and coverage. Create privacy standards for health information
HIPAA is categorized into 5 titles	Title 1, Title 1, Title 3, Title 4, & Title 5
Title 1	Health Care Access, Portability, and Renewability
Title 2	Preventing Health Care Fraud and Abuse, Administrative Simplification, and Medical Liability Reform
Title 3	Tax-Related Health Provisions
Title 4	Application and Enforcement of Group Health Plan Requirements
Title 5	Revenue Offsets
Electronic Data Interchange (EDI)	is the process of sending data from one party to another using computer linkages
UB-04 flat file	is a series of fixed-length records that is used to bill institutional services, such as services performed in hospitals
Release of information (ROI)	by a covered entity (e.g., provider’s office) about protected health information (PHI) requires the patient (or representative) to sign an authorization to release information, which is reviewed for authenticity
Record Retention	is the storage of documentation for an established period of time, usually mandated by federal and/or state law. HIPAA mandates the retention of health insurance claims for a minimum of 6 years, unless state law specifies a longer period.
HIPAA security rule	defines administrative, physical, and technical safeguards to protect the availability, confidentiality, and integrity of electronic protected health information (PHI).
HIPAA privacy rule	establishes standards for how PHI should be controlled by indicating authorized uses (e.g., continuity of care) and disclosures (e.g., third-party reimbursement) and patients’ rights with respect to their health information

Created by: vlw2861

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