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Medicare Terminology and Concepts, Exams of Advanced Education

A comprehensive overview of key medicare terminology and concepts, including important terms related to coverage, billing, and regulations. It covers a wide range of topics such as advance beneficiary notices, coordination of benefits, diagnosis-related groups, medicare advantage plans, medigap, modifiers, and more. The detailed explanations and definitions can be valuable for healthcare professionals, medicare beneficiaries, and anyone interested in understanding the complexities of the medicare system. The document serves as a useful reference guide, covering essential medicare-related knowledge that can be applied in various healthcare settings and administrative contexts.

Typology: Exams

2023/2024

Available from 08/12/2024

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Download Medicare Terminology and Concepts and more Exams Advanced Education in PDF only on Docsity! AAHAM Certified Revenue Cycle Professional (CRCP) Terms - 2024 (KD) 3-Day Rule - Answer- a requirement that all diagnostic or outpatient services furnished in connection with the principle admitting diagnosis within three days prior to the hospital admission are bundled with the inpatient services for Medicare billing 837I - Answer- the American National Standards Institute transaction for an institutional claim; as a result of HIPAA, it is replacing the electronic UB-04. 837P - Answer- a former American National Standards Institute transaction for a professional claim (the electronic equivalent of the CMS 15000), since replaced by the 5010A1 838 - Answer- quarterly Medicare Credit Balance Report CMS 1450 - Answer- another name for the UB-04 Uniform Bill form. CMS 1500 - Answer- the billing form used to submit physician and professional service claims to Medicare. ABN - Answer- Advance Beneficiary Notice of Noncoverage; a form given to a Medicare beneficiary before services are furnished when a service does not meet or is not expected to meet medical necessity. Abuse - Answer- the misuse of a person, substance, service, or financial matter such that harm is caused; some forms of healthcare abuse include excessive or unwarranted use of technology, pharmaceuticles, and services; abuse of authority; and abuse of privacy, confidentiality, or duty to care; it also includes improper biling practices (like billing Medicare instead of primary insurur),increasing charges to Medicare beneficiaries but not to other patients, unbundling of servies, and unnecessary transfers of patients. Accounts Receivable (AR) Days Outstanding - Answer- an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable. Accrual - Answer- a method of accounting in which income is recognized at the time it is earned, even if not yet collected, and expenses are booked as they are incurred, even if not yet paid. ADA - Answer- Americans with Disabilities Act; a law passed in 1990 that requires employers to make reasonable adjustments to the work site to accommodate a disabled employee's ability to perform the job and requires buildings to be accessible to those with disabilities. ADC - Answer- Average Daily Census; the average number of inpatients maintained in the hospital each day for a specific period of time. ALOS - Answer- Average length of Stay; a metric calculated by dividing the total number of patient days by the number of discharges. Ambulatory Payment Classification - Answer- a payment methodology that places outpatient services into groups based on similar procedures and resource use. Americans with Disabilities Act - Answer- a law passed in 1990 that requires employers to make reasonable adjustments to the work site to accommodate a disabled employee's ability to perform the job and requires buildings to be accessible to those with disabilities. Anticipated value of AR - Answer- AR balance less the average deduction from revenue, based on the historical deduction from revenue rate. Anti-Kickback Statute - Answer- a law that prohibits offering free or discounted services to a physician associated with, or who refers patients to, another healthcare facility. APC - Answer- Ambulatory Payment Classification; a payment methodology in which services paid under the prospective payment system are classified into groups that are similar clinically and in terms of the resources they require; a payment rate is established for each APC. AR - Answer- accounts receivable. AR Days - Answer- Days a measure of how long, on average, it takes to collect revenue from the date of discharge. Asset - Answer- control procedures to protect assets from theft. Assets, those things a business owns that have a value. Assignment of benefits - Answer- a written authorization, signed by the policyholder (or the patient, in the absence of the policyholder) to an insurance company, to pay benefits direcly to the provider; when assignment is not accepted, the payment wil be sent to the patient and the provider will have to collect it. CMHC - Answer- community mental health center. CMS - Answer- Centers for Medicare and Medicaid Services; formerly the Health Care Financing Administration (HCFA), was established in 1977 to administer the two national healthcare programs, the mission of CMS is to ensure effective, up-to-date healthcare coverage and promote quality care for beneficiaries. COB - Answer- Coordination of Benefits; the determination of which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits. Coinsurance - Answer- the percentage of allowable charges which the patient must pay after paying his or her deductible. / The insured pays a share of the payment made against a claim. Commercial insurance - Answer- health insurance that covers individuals; most often obtained as a benefit of employment, individual policies can be purchased by people who do not get insurance through an employer. Complex - Answer- a type review in which RAC requests medical records and makes its determination from them. Conditional Payment - Answer- a payment made when another payer is responsible, but the claim is not expected to be paid promptly (usually within 120 days from receipt of the claim); it prevents the beneficiary from having to pay out of pocket; Medicare then has the right to recover any payments that should have been made by another payer. Conflict of interest - Answer- a situation where one or more parties to an arrangement have an opportunity to exploit their position for personal or business advantage. Conservator - Answer- an individual appointed by a court to handle the affairs of another person who is incapable of caring for him- or herself. coordination of benefits - Answer- the process of determining which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits. Cost to Collect - Answer- the percentage of total costs to the total dollar amount received. courtesy discharge - Answer- a type of discharge in which a patient's financial considerations have been met so he or she is allowed to leave the hospital without going through the usual formalities; the patient is billed at a later date. Coverage percentage - Answer- the percentage at which a payer will reimburse the provider; also called the reimbursement rate. CPT - Answer- Current Procedural Terminology; a system of terms and five-digit numeric codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare prof essionals. Critical Access Hospital (CAH) - Answer- a non-profit hospital located in a state that has established a Medicare Rural Hospital Flexibility Program; it must have 25 or fewer beds and an ALOS of 96 hours or less, be located a certain minimum distance from other hospitals, and furnish 24-hour emergency care services; Medicare pays CAH's for most inpatient and outpatient services on the basis of reasonable cost. Current liabilities - Answer- those things that a business owes and are expected to be settled in cash within one year, such as wages, taxes, and accounts payable. CWF - Answer- Common Working File data mailer - Answer- a system-generated, free-form statement that is used to communicate the status of a patient's account and/or to bill the patient for an unpaid amount remaining on the account. Days Cash on Hand - Answer- a calculation to indicate how long an entity could keep paying bills if money stopped coming in. Debits and credits - Answer- entries that increase or decrease the balance of various accounts. Deductible - Answer- an amount that a patient must pay for healthcare before the payer begins to pay. Diagnosis-Related Group - Answer- a group of services that has a payment weight assigned to it, based on the average resources used to treat Medicare Discharge of Debtor - Answer- a potential outcome of bankruptcy that releases the gaurantor / patient from financial responsibility of any and all account balances listed on the bankruptcy petition; the account balance is to be written off to the appropriate transaction code. discharged not final billed - Answer- an account where the patient has completed treatment but, for various reasons, has not had a claim produced. Dismissal - Answer- a court ruling whereby a bankruptcy is rejected by the court; the most common reason for dismissal is the failure of the debtor to follow through on the filing process and on payment to the attorney, and failure to provide requested documentation; upon dismissal of a bankruptcy, a creditor can bill the debtor directly, refer the account to a collection agency, or pursue litigation. DME - Answer- Durable Medical Equipment; medical equipment that can withstand repeated use, such as wheelchairs, hospital beds, oxygen and walkers. DMEPOS - Answer- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. DNFB - Answer- Discharged not Final Billed; an account for a patient who has completed treatment but has not had a claim produced, Or, accounts that are not yet billed at the time of discharge DNR - Answer- Do Not Resuscitate; a document that states that the patient does not wish to have CPR or similar interventions performed in the event of a medical emergency. DRG - Answer- Diagnosis-related group; Is a system to classify hospital cases / A group of services that has a payment weight assigned to it, based on the average resources used to treat Medicare patients. Durable Power of Attorney for Healthcare - Answer- also known as Healthcare Power of Attorney; a document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient's behalf if he/she is unable to do so. E&M - Answer- Evaluation and Management; both the process of and the charge for examining a patient and formulating a treatment plan. ED - Answer- Emergency department. EHR - Answer- electronic health record. Emancipation - Answer- a process by which a minor is freed from parental control based on specific criteria (the minor no longer requires parental guidance or financial support, fathered or gave birth to a child, or has reached the age of majority) EMR - Answer- electronic medical record. Emergency Medical Treatment and Active Labor Act (EMTALA) - Answer- also known as the Federal Anti-Dumping Statute; legislation enacted in 1986 in response to concerns that hospitals were refusing to treat patients without insurance and even transferring them to other facilities and leaving them there, sometimes without notifying the receiving facility. Equity - Answer- what a business is worth, as determined by the difference between assets and liabilities. ER - Answer- Emergency Room. ESRD - Answer- end stage renal disease. I-Bill - Answer- another name for an itemized statement. ICD - Answer- International Classification of Diseases; a standard transaction set used for 1) chief complaints or diagnosis for professional services and inpatient procedures, and 2) for diagnosis and procedure codes for professional and technical services for both inpatient & outpatient procedures. IEQ - Answer- Initial Enrollment Questionnaire; a questionnaire mailed about three months before patients become entitled to Medicare, asking about any other healthcare coverage that may be primary to Medicare. imprest - Answer- petty cash. Implied consent - by law - Answer- consent that occurs in a situation where the patient is unconscious and is taken to the emergency room; the law allows treating the patient. Implied consent - in fact - Answer- consent by silence; the patient implies consent to the treatment by not objecting. Important Message from Medicare - Answer- a notice issued within two days of admission and again within two days of discharge that explains to inpatients what to do if they feel they are being discharged too soon. Income (or loss) - Answer- the result of subtracting expenses from revenue. Income Statement - Answer- a financial statement that is a record over a set period of time and used to evaluate an organization's ability to pay present and future debts, and to earn revenue that exceeds expenses;also called Profit and Loss Statement. Initial Preventive Physical Examination - Answer- the "Welcome to Medicare Physical Exam" that is offered to each beneficiary once in a lifetime. also known as IPPE Initiation - Answer- the beginning of the treatment for a new encounter or a new plan of care; one of the times when a "triggering event" for an ABN can occur. IPPE - Answer- initial preventive physical examination; the "Welcome to Medicare Physical Exam" allowed once in a lifetime. Judgement - Answer- a legally verified claim against a debtor ; a legal right to collect a debt that can be used to obtain a lien. LCD - Answer- Local Coverage Determination; policies developed by Medicare area contractors that specify criteria for services and show under what clinical circumstances an item or service is considered to be reasonable, necessary and appropriate. Lien - Answer- a recorded claim against real or personal property; if the property is sold, the creditor must be paid out of the proceeds of that sale. Liability Insurance - Answer- coverage for a non-work-related accident through property and casualty or auto insurance. lifetime reserve - Answer- 60 days of inpatient hospital services that a beneficiary can opt to use after having used 90 days of inpatient hospital services in a benefit period; it comes with a high coinsurance and can be used only once in the beneficiary's lifetime, but can be split among multiple hospital stays. Living Will - Answer- a document that specifies what treatments a patient does and does not wish to receive; it means that difficult decisions about future care are made while the person is alert; patients can choose the circumstances under which they will die; and patients desire regarding organ donation are made known. Locum Tenens - Answer- a temporary substitute, especially for a doctor or member of the clergy. Long Term Care - Answer- care generally provided to the chronically ill or disabled in a nursing facility or rest home; among the services provided by nursing facilities are 24- hour nursing care; rehabilitative services such as physical, occupational, and speech therapy; and assistance with daily activities like eating, bathing and dressing. LTC - Answer- Long Term Care; a form of acute care for patients who are expected to stay more than 25 days; also sometimes refers to custodial care that is offered in nursing homes. LTR - Answer- Lifetime Reserve; 60 days of inpatient hospital services that a beneficiary can opt to use after having used 90 days of inpatient hospital services in a benefit period; it comes with a high coinsurance and can be used only once in the beneficiary's lifetime, but can be split among multiple hospital stays. MDC - Answer- Major Diagnostic Category; one of 25 groups of DRGs. (diagnosis- related groups) Meaningful use - Answer- MU; providers are using certified EHR technology to achieve health and efficiency goals including reducing errors; making records and data available; generating reminders and alerts; supporting clinical decisions; and automating e-prescribing/refills. Medicaid - Answer- a health insurance program for certain low-income people; it is funded and administered through a state-federal partnership; also known as Title XIX. ; States have authority to: Establish eligibility standards, Determine what benefits and services to cover & Set payment rates. MUE - Answer- Medically Unlikely Edit; an automated edit for HCPCS/CPT codes for services rendered by a provider to a single beneficiary on the same date of service; it helps to prevent inappropriate payments due to clerical entries and incorrect coding based on anatomic considerations. Medicare - Answer- a health insurance program for the elderly (age 65 or older) and those under age 65 who have permanent disabilities or end stage renal disease (ESRD); also known as Title XVIII. Medicare Advantage Plan - Answer- another name for Medicare Part C; managed care coverage provided by private insurance companies approved by Medicare and must follow Medicare rules; There are 5 types of Advantage Plans - HMOs, PPOs, Private Fee-for-Service Plans, Special Needs Plans and Medicare Medical Savings Accounts. Medicare Credit Balance Report - Answer- quarterly report (also called the 838 report) of credit balances; the report is required even if there are no credit balances; failure to file the 838 will cause Medicare to start withholding payments. MSN - Answer- Medicare Summary Notice; a remittance advice; formerly called the Explanation of Benefits (EOB) Medigap - Answer- also known as Medicare supplemental insurance; health insurance sold by private insurance companies to fill in the "gaps" in coverage (like deductibles, coinsurance and copayments) under the Original Medicare Plan; some policies also cover benefits that Medicare doesn't cover, like emergency healthcare while traveling outside the U.S. Modifier - Answer- a code that indicates that a service or procedure was altered by some circumstance that increases or decreases its value; it can also clarify the anatomic site of a procedure or help avoid the appearance of duplicate billing. MSN - Answer- Medicare Summary Notice; a remittance advice; formerly known as the Medicare Explanation of Benefits (EOB). MSP - Answer- Medicare Secondary Payer; laws that shifted costs from the Medicare program to other sources of payment; MSP information is gathered from each beneficiary to determine the proper coordination of benefits. MU - Answer- Meaningful Use; providers are using certified EHR technology to achieve health and efficiency goals including reducing errors; making records and data available; generating reminders and alerts; supporting clinical decisions; and automating e-prescribing/ refills. Navigators - Answer- Individuals who help consumers fill out applications for health coverage through the Marketplace; they help determine if consumers qualify for programs to help lower their costs. POA - Answer- Power of Attorney. POA indicator - Answer- Present on Admission indicator; a type of indicator paired with each diagnosis code in the medical record of an inpatient claim to help identify non- payable complications such as hospital acquired infections, sponges left in patients, and so on. POS - Answer- point of service; as related to financial policies, POS collections are the only cost-effective method of collecting small-dollar copayments. Preadmission - Answer- the process of gathering patient information and taking care of as many items as possible prior to the actual date of service. Preauthorization - Answer- the process of obtaining advance insurance approval in order for payment to be secured later; also called precertification. Pre-certification - Answer- the process of obtaining authorization from an insurance company review organization approving the medical necessity of a hospitalization. Pregnancy Discrimination Act - Answer- a law enacted in 1978 to prohibit discrimination against employees and applicants on the basis of pregnancy, childbirth, and related medical conditions. Preregistration - Answer- the process of gathering patient information and taking care of as many items as possible prior to the actual date of service. Present on Admission - Answer- a type of indicator paired with each diagnosis code in the medical record of an inpatient claim to help identify non payable complications such as hospital-acquired infections, sponges left in patients, and so on. Preventive service - Answer- services intended to preserve good health and/ or detect disease at an early stage; under PPACA, most insurance plans must cover these services at 100%, not subject to deductible or coinsurance. Progressive disciplinary action - Answer- the process of documenting performance and behavior prior to, during, and after the entire disciplinary process; the documentation should reflect progression, success, or continued regression, and inability to perform satisfactorily. propensity to pay - Answer- a score based on an assessment of a patient's ability and willingness to pay Provider Self-Disclosure Protocol - Answer- a protocol published by the OIG to promote voluntary disclosure of potential claim violations: RAC - Answer- Recovery Audit Contractor; a private firm charged with identifying under- and overpayments in Medicare and earning a contingency fee for denial of previously paid claims. RBRVS - Answer- Resource Based Relative Value Scale; a payment reform provision comprising three major elements: a fee schedule for payment of physician services, based on the relative value unit (RVU); the Medicare Volume Performance Standard (MVPS) for the rates of increase in Medicare expenditures for physician services; and limits on the amount non-participating physicians can charge beneficiaries, referred to as the limiting charge. Recovery Audit Contractor - Answer- a private firm charged with identifying under and overpayments in Medicare and earning a contingency fee for denial of previously paid claims. Recurring - Answer- a type of outpatient who will be coming regularly for repetitive types of treatment. Reduction - Answer- a decrease in the frequency or duration of care; one of the "triggering events" for a provider to issue an ABN. Regulation Z - Answer- another name for Title I of the Consumer Credit Protection Act, or the Truth in Lending Act; it requires disclosure of information before credit is extended. Relative Value Unit - Answer- one of the elements of the RBRVS; the base value of a procedure in comparison to other procedures, consisting of three components: physician work, practice expense (overhead), and professional malpractice liability premiums. Resource Utilization Group - Answer- the system to determine the payment rate for most skilled nursing care; the provider completes the Minimum Data Set as part of the federally required process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes; the MDS then determines the RUG and hence the payment; the patient is re-evaluated at intervals during his or her stay and the RUG rate may be changed. Resource-Based Relative Value Scale - Answer- a scale used by Medicare to determine the value of practitioner services. respite care - Answer- short-term, temporary custodial care that allows a family member or other unpaid caregiver to get relief from caring for a physically frail or dependant person at home. Revenue - Answer- the dollars generated when a business provides it services and generates a charge. RFP - Answer- Request for Proposal; a document that defines a job to be done, asks for specific pricing, asks responders to explain what makes them the best choice, and asks for references. Roster billing - Answer- a simplified billing process for mass immunizers to submit one claim form with a list of immunized beneficiaries. RUG - Answer- Resource Utilization Group; a system to determine the payment rate for most skilled nursing care; the provider completes the Minimum Data Set as part of the federally required process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes; the MDS then determines the RUG and hence the payment; the patient is re-evaluated at intervals during his or her stay and the RUG rate may be changed. RVU - Answer- Relative Value Unit; the basis for the fee schedule for payment of physician services that is one of the elements of the Resource Based Relative Value Scale (RBRVS). Self-insurance - Answer- a type of insurance in which a company does not purchase group insurance, but rather puts premium payments into a fund and pays a third party to administer benefits from the fund. Self-pay - Answer- the common term for patients who have no insurance. Series - Answer- a type of outpatient who will be coming regularly for repetitive types of treatment. Skilled Nursing Facility - Answer- an institution or a distinct part of an institution which provides skilled nursing care and services for residents who require medical or nursing care, or services for the rehabilitation of injured, disabled, or sick persons. Skip-tracing - Answer- efforts to locate correct information when an address or telephone number in an account turns out to be incorrect. SNF - Answer- Skilled Nursing Facility; a separate wing of the hospital, a nursing home, or a freestanding facility; to qualify for SNF coverage, Medicare requires a person to have been a hospital inpatient for at least three consecutive days (not including the day of dscharge). SNF PPS - Answer- Skilled Nursing Facility Prospective Payment System. TCPA - Answer- Telephone Consumer Protection Act of 1991; a law that restricts telephone solicitations (in other words, telemarketing) and the use of automated telephone equipment. able to make recommendations about coverage and may only sell plans from specific health insurance companies. AHA - Answer- the American Hospital Association AHRQ - Answer- Agency for Healthcare Research and Quality; one of the DHHS Operating Divisions ancillary services - Answer- services other than routine room and board charges that are incidental to the hospital stay; they include operating room; anesthesia; blood administration; pharmacy; radiology; laboratory; medical, surgical, and centeral supplies; physical, occupational, speach pathology, and inhalation therapies; and other diagnostic services. ANSI - Answer- the American National Standards Institute ACL - Answer- Administration for Community Living; one of the DHHS Operating Divisions. APR - Answer- Annual Percentage Rate; one of the elements of disclosure required by the Truth in Lending Act. ATB - Answer- Aged Trial Balance; a resource for internal collection efforts. ATSDR - Answer- Agency for Toxic Substances and Disease Registry; one of the DHHS Operating Divisions. Average Daily Revenue - Answer- the average amount of revenue or charges generated each day over a specified period of time. Average Days of Revenue in Accounts Receivable - Answer- also known as Accounts Receivable (AR) Days Outstanding; an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable. Beneficiary - Answer- a person who has healthcare insurance through Medicare Birthday Rule - Answer- a rule to determine coordination for benefits for a child covered by both parents; it dictates that the parent with the first birthday in the calendar year will provide the primary coverage; if both parents happen to have the same birthday, the plan that has covered a parent longer pays first. Black Lung Benefits Act - Answer- legislation which provides for medical treatments for coal miners totally disabled from black lung disease. Bressers - Answer- a cross-reference directory used in skip tracing. Brokers - Answer- Individuals who help consumers and small businesses complete the application process and enroll in healthcare coverage through the Marketplace; they are able to make recommendations about coverage and may only sell plans from specific health insurance companies. Call Centers - Answer- an option for consumers to ask questions about health coverage options and obtain assistance with the Marketplace application process. Case Management - Answer- also known as Utilization Review (UR); an area that performs critical tasks during registration and a patients stay, such as reducing unnecessary admissions; managing the approved length of stay; ensuring an appropriate level of care for the patient's condition; serving as liaison with primary and specialty physicians; serving as liaison with the insurance carrier; obtaining approvals, when clinically necessary, for pre-certification/re-certification; advising the patient of discharge; and assisting with appeals for denials, when applicable. CDC - Answer- Centers for Disease Control and Prevention; one of the DHHS Operating Divisions. CDM - Answer- Charge Description Master; the chargemaster or master pricing list that includes services, supplies, devices, and medication charges for inpatient or outpatient servies by a healthcare facility. CERT - Answer- Comprehensive Error Rate Testing Certified Application Counselors - Answer- individuals (staff members or volunteers) who fulfill some of the same roles as Navigators and non-Navigators; they are not responsible for outreach and education but they do provide free information to consumers about insurance programs, they assist them in applying for coverage, and they help to facilitate the enrollment in health coverage. CHAMPUS - Answer- Civilian Health and Medical Programs of the Uniformed Services; the programs replaced by Tricare to cover healthcare for active duty and retired members of the uniformed services, their families, and survivors. Chapter 11 - Answer- a type of bankruptcy frequently referred to as a "reorganization"; it gives a distressed business a reprieve from creditor claims while it continues to function and work out a repayment plan. Chapter 12 - Answer- a type of bankruptcy for a family farmer with "regular annual income". Charity Care - Answer- service provided that is never expected to result in cash flow. CMP - Answer- Civil Monetray Penalty Title XVIII - Answer- another name for Medicare: Title XVIII (18), established in 1977 Title XIX - Answer- another name for Medicaid; Title XIX (19), established by CMS in 1977. CO - Answer- Compliance Officer CWF - Answer- Common Working File; a CMS file that contains Medicare patient eligibility and utilization data. Consumer assistance Programs - Answer- a resource to help address consumers' problems or questions about health coverage. Consumer Credit Protection Act - Answer- The first general federal consumer protection legislation; its provisions include the Truth in Lending Act, the Fair Credit Billing Act, the Fair Credit Reporting Act, and the Fair Debt Collection Practices Act. DHHS - Answer- Department of Health and Human Services; located in Washington D.C.; is the government's principle agency for protecting the health of all Americans and providing essential human services; it includes more than 300 programs (like Medicare, Medicaid), and some 11 Operating Divisions (like CDC, IHS, CMS). Coordination of Benefits Contractor - Answer- a contracted entity that assists with the collection, management, and reporting of other health coverage; COB Contractors do not process claims for the provider; they gather and disseminate coordination of benefits information to ensure that Medicare is not making primary payment for a service in error. CPU - Answer- Central Processing Unit. CRA - Answer- Credit reporting agency. Criminal Health Care Fraud Statute - Answer- a statute that prohibits willfully or knowingly executing a scheme to obtain any money or property owned by or in control of any healthcare benefit program or defrauding any healthcare benefit program. Custodial Care - Answer- care that is primarily for the purpose of meeting personal needs; persons without professional training may provide custodial care; it is not covered by Medicare. Definitive LCD/NCD - Answer- a policy that discusses and lists specific diagnosis codes, ICD procedure codes, and possibly signs and symptoms to support the need for the item or service being given. MAAC - Answer- Maximum allowable actual charge. MCE - Answer- Medicare Code Editor; software that edits claims to detect incorrect billing data that is being submitted. MDS - Answer- Minumum Date Set; part of the federally required process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes; the MDS then determines the Resource Utilization Group (RUG) and hence the payment. Medicare Participating Physician Program - Answer- a program that enables providers to accept assignment of benefits. MIC - Answer- Medicaid Integrity Contractors; review, audit and educate providers to combat fraud and abuse. Midnight Census - Answer- the number of patients in the hospital at midnight census; determind from the census count for the previous midnight, minus any discharges, plus any admissions, plus/minus any status changes. MSP Questionnaire - Answer- a questionnaire completed on an ongoing basis to help determine if Medicare is primary or secondary; it asks about employment, accidents and several other relevant subjects. MTF - Answer- Military Treatment Facility; established for the purpose of furnishing medical and/or dental care to eligible individuals. MVPS - Answer- Medicare Volume Performance Standard; the element of the Resource Based Relative Value Scale (RBRVS) for the rates of increase in Medicare expenditures for physician services. NAS - Answer- Non-Availability Statement; a requirement before any non-emergent inpatient services may by provided to Tricare Extra or Standard eligible beneficiary by a non-Military Treatment Facility (MTF). Privacy Act of 1974 - Answer- governs patient confidentiality; safeguards against an invasion of privacy through the misuse of records by federal agencies; it also allows a citizen to learn how records are collected, maintained, used and disseminated by the federal government. NIH - Answer- National Institute of Health; one of the DHHS Operating Divisions. non-definitive LCD/NCD - Answer- a policy that provides potential coverage circumstances, but most likely does not provide specific diagnoses, signs, symptoms, or ICD-9-CM codes that will be covered or non-covered; when the Medicare contractor considers or utilizes factors and information other than that in the LCD/NCD when making a coverage determination. non-Navigators - Answer- individuals who perform the same functions as Navigators but only in a state-based Marketplace or state partnership Marketplace. non-standard claim - Answer- a claim with extraneous attachments in lieu of data entered correctly in the claim form. notifier - Answer- CMS' name for an entity that issues ABNs. NPP - Answer- non physician practitioner. NUBC - Answer- National Uniform Billing Committee; the entity that determined the data elements used in the UB-04 final format as a cooperative effort with the American Hospital Association (AHA). Obamacare - Answer- one of the common names for the Patient Protection and Affordable Care Act, PPACA. OBRA - Answer- Omnibus Budget Reconciliation Act of 1989; it provided for the Resource Based Relative Value Scale (RBRVS) as a payment reform provision. observation - Answer- services furnished on a hospital premises, including use of a bed and periodic monitoring by a hospital's nursing staff; services should be reasonable and necessary to evaluate an outpatient condition to assess the need for admission to the hospital; observation services usually do not exceed 24 hours; however, there is no hourly limit on the extent to which they may be used (CMS has indicated that instances would be rare that a patient would remain in observation for more than 48 hours). office - Answer- care provided in a practitioner's place of business; a practitioner may be a medical doctor, podiatrist, chiropractor, dentist, advanced practice nurse, registered dietitian, physical therapist, psychologist or one of many other professions. ordering physician - Answer- a physician who orders non physician services for a patient, such as diagnostic x-rays. outpatient - Answer- treatment received at a hospital, clinic or dispensary by someone who is not hospitalized; emergency room patients, ambulatory patients, clinic patients and same-day surgery patients are all examples of the outpatient classification. PAT - Answer- pre-admission testing; the diagnostic medical screening of patients in advance of surgical or invasive procedures to determine hospitalization and/or surgical suitablility. Patient Bill of Rights - Answer- a development by the American Medical Association that guarantees a patient the right to receive courteous, considerate, respectful treatment in a clean/safe environment; appropriate healthcare; information about his/her health treatment plan in a way that he or she understands; continuity of care; confidentiality; privacy; participation in planning care treatment; refusal of care; use of grievance mechanisms; treatment without discrimination; an itemized bill and explanation of all charges; and review of the medical records and/or a copy at a reasonable fee. PCP - Answer- Primary care Physician per diem - Answer- Latin for "for each day"; a payment methodology in which providers are paid a predetermind amount for each day an inpatient is in the facility, regardless of actual charges or costs incurred. PPO - Answer- Preferred Provider Organization; one of the 5 types of Medicare Advantage Plans; similar to HMOs but members can see any doctor or provider that accepts Medicare and they do not need a referral to see a specialist. Private Fee-for-service Plans - Answer- one of the 5 Medicare Advantage Plans; which allow members to go to any provider that accepts the plan's terms. The private company decides how much it will pay and how much members pay for services. Special Needs Plans - Answer- one of the 5 Medicare Advantage 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. Medicare Medical Savings Accounts - Answer- one of the 5 Medicare Advantage Plans; This plan has two parts: One part is a Medicare Advantage Plan with a high deductible and the other part is a Medical Savings Account into which Medicare deposits money that people can use to pay healthcare cost. PPACA - Answer- Patient Protection and Affordable Care Act; commonly called "Obamacare" or the Federal Health Care Law; aimed primarily at decreasing the number of uninsured Americans and reducing the overall costs of healthcare; requires insurance companies to cover all applicants and offer the same rates regardless of pre- existing conditions or gender. percentage of occupancy - Answer- the ratio of actual patient days to the maximum patient days as determined by bed capacity; a low percentage of occupancy indicates inefficiency while a percentage that is too high will mean difficulty finding available beds, long hold times in ER, ect. physician extender - Answer- physician assistant, nurse practitioner, ect. PPS - Answer- prospective payment system PSA - Answer- Physician Scarcity Area what established HSAs (formerly known as MSAs)? - Answer- HIPAA Which Act prohibits harassment, abuse and use of false or misleading information? - Answer- Fair Debt Collection Practices Act which Act protects consumers from inaccurate or unfair practices by issuers of open- ended credit? - Answer- Fair Credit Billing Act what is also known as the Federal Anti-Dumping Statute? - Answer- EMTALA which program regulates laboratory licensing? - Answer- CLIA which Act requires providers to make available information on advance directives? - Answer- Patient Self Determination Act. What are the two main governing bodies affecting healthcare change? - Answer- DHHS and CMS what Act applies to agencies subject to FOIA? - Answer- Privacy Act which Act prohibits submission of false/fraudulent claims? - Answer- False Claims Act Who is the principle agency for protecting health of all Americans and providing essential human services? - Answer- DHHS what is also known as Title VI of the Consumer Credit Protection Act? - Answer- Fair Credit Reporting Act which Act applies to personal information maintained by agencies in the executive branch? - Answer- Privacy Act which Act deals with disclosure of information before credit is extended? - Answer- Truth in Lending Act which governing body administers Medicare and Medicaid? - Answer- CMS what is also known as Title VIII of the Consumer Credit Protection Act? - Answer- Fair Debt Collection Practices Act which Act or Statute restricts transfers until stabilization? - Answer- EMTALA what is the federal govenment's largest grant-making agency? - Answer- DHHS How often can a qualified Medicare beneficiary receive a screening for diabetes, if diagnosed with pre-diabetes? - Answer- Two per year How often can a qualified Medicare beneficiary receive a PSA test? - Answer- Once every 12 months How often can a qualified Medicare beneficiary receive a flu shot? - Answer- Once a year, in the fall or winter What are some services NOT covered by Medicare for qualified beneficiaries? - Answer- Cosmetic surgery, Routine eye care and most eyeglasses & Hearing aids. What is the "birthday rule" for parents who have been divorced or separated? - Answer- the plan of the parent who has custody pays first. The plan of a new spouse of the parent with custody pays second. and finally the plan of the parent who does not have custody pays last.