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16 Cards in this Set
- Front
- Back
- 3rd side (hint)
CMS
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Center for Medicare and Medicaid Services
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Center for....
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EOB/EMOB
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Explanation of Benefits
Explanation of Medicare Benefits - the published explanations that accompany private payor Medicare payments or denials of health care benefits. |
Explanation of...
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POS
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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...
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NCCI
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National Correct Coding Initiative
- a database of CPT coding relationships identifying CPT services that are inherently bundled into other services. |
National Correct...
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NCQA
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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...
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PCP
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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. |
Primary...
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Subrogation of Benefits
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The process of identifying who is financially responsible for payment of an accident claim.
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Sub...
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Golden Rule of Procedural Coding Compliance is...
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If it is not documented it is not done and therefore, it is not billable
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if it is not documented...
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CMP
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Civil Monetary Penalites
-fines attached to fraudulent claims |
Civil...
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Two Type of Fraud under Federal False Claims Act:
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Civil and Criminal
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C & C
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ORT
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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 |
Operation...
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PATH (Audits)
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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
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Prospective Audit
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-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
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Opitmal process for...
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Stark Law
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Federal Law against kickbacks, a financial inducement for sending business between either a provider and a hospital or a provider and a DME supplier
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Kickback
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Undercoding
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Fraudulent billing for a service that was less than the service actually performed & misused as an incentive for patients to seek more frequent services
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bill fraud
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Upcoding (overcoding)
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Fraudulent practice of billing for a service that is worth more than the lesser actual service provided
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Billing Fraud
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