Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key


Play button


Play button




Click to flip

16 Cards in this Set

  • Front
  • Back
  • 3rd side (hint)
Center for Medicare and Medicaid Services
Center for....
Explanation of Benefits
Explanation of Medicare Benefits
- the published explanations that accompany private payor Medicare payments or denials of health care benefits.
Explanation of...
Place of Service
-The place where a medical service is rendered can determine reimbursement and coding conventions applied to medical service codes, i.e In-patient or Out Patient
Place of...
National Correct Coding Initiative
- a database of CPT coding relationships identifying CPT services that are inherently bundled into other services.
National Correct...
National Committee for Quality Assurance
- A private not-for-profit organization that serves as a watchdog for the preservation of healthcare quality provided by Managed Care Organizations (MCO).
National Committee...
Primary Care Provider
-The physcian gatekeeper assisgned by a managed care system usually specializing in general practice, or in another non-specialized medical practice. This practioner manages the general overall care of the patient and referrals to specialists, laboratories and medical services or procedures.
Subrogation of Benefits
The process of identifying who is financially responsible for payment of an accident claim.
Golden Rule of Procedural Coding Compliance is...
If it is not documented it is not done and therefore, it is not billable
if it is not documented...
Civil Monetary Penalites
-fines attached to fraudulent claims
Two Type of Fraud under Federal False Claims Act:
Civil and Criminal
C & C
Operation Restore Trust
-the Clinton plan to reduce waste & overspending from the Medicare Trust Fund in an effort to preserve it's funding and longevity
PATH (Audits)
Physician at Teaching Hospital Audits
-teaching hospitals audit billing practices to see if 1) double-billing is being performed because services by residents are being billed as services by attendings which is billing fraud
Double billing
Prospective Audit
-pertains to auditing patient records against proposed billing information and is conducted on encounters yet to be billed & is an optimal device to check against accurary of chart/billing information
Opitmal process for...
Stark Law
Federal Law against kickbacks, a financial inducement for sending business between either a provider and a hospital or a provider and a DME supplier
Fraudulent billing for a service that was less than the service actually performed & misused as an incentive for patients to seek more frequent services
bill fraud
Upcoding (overcoding)
Fraudulent practice of billing for a service that is worth more than the lesser actual service provided
Billing Fraud