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33 Cards in this Set
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represents the Avg or maximum amt the third party payer will reimburse providers for the service.
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Allowable Fee - pg 6
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Type of Episode-of-Care
Reimbursement. A method of pmt for health service in which the 3rd party payer reimburses providers a fixed, per capita amt for a period. |
Capitated payment method
pg 8 |
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Method of pmt for health services in which the 3rd party reimburses providers a fixed per capita amt for a period.
Characteristic of HMOs Per capita means per head or per person. |
Capitation
pg 8 |
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Annual amt of money that the policyholder must incur (and pay) before the health insurance will assume liability for the remaining charges or covered expenses.
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Deductible
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Health care pmt method in which providers receive one lump sum for all services they provide related to a condition or disease.
One or more healthcare services given by a provider during a specific period of relatively continuous care in relation to a particular health or medical problem or situation. In home health, the episode of care is all home care services and nonroutine medical supplies delivered to the patient during a 60-day period. In the home health prospective pmt system (HHPPS), the episode of care is the unit of pmt. |
Episode-of-care reimbursement
pg 8 |
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Predetermined list of fees that the 3rd party payer allows for pmt for all healthcare services.
Third party payer's predetermined list of fees for each healthcare service. |
Fee Schedule
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Beneficial to a person they make all of their Health decision they get to decide the Hosp, Dr .
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Healthcare pmt method in which providers receive pmt for each service rendered.
Fee attached to the service, it is a set fee Very common method *Type of unit of payment. -Self-Pay - -Traditional Retrospective Pmt -Manage Care |
Fee-for-service reimbursement
(FFS) pg 5 |
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Type of episode-of-care reimbursement
Pmt rates for healthcare services are established in advanced for a specific time period. Pre established rates regardless of the costs they acctually incur. The predetermined rates are based on avgerages. ____represents 2 situations per-diem payment (per day) case-based payment. |
Prospective pmt method
pg 9 |
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Physician, clinic, hospital, nursing home, or other healthcare entity (second party) rendering the care.
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Provider
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Compensation or repayment for healthcare services already rendered.
U get pd 4 something U did. |
Reimbursement
pg 3 |
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Type of retrospective fee-for-service pmt method
Classifies health services in terms of effort, practice expense (overhead), and malpractice insurance. Uses a pmt method to reduce fees also known as discounted fee-for-service |
RBRVS
Resource based relative scale |
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Type of fee-for-service reimbursement
Method of reimbursement pays providers after the services have been rendered. |
Retrospective pmt method
pg 6 |
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Unkowing or unintentional submission of an inaccurate claim for pmt.
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Abuse
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Hospital outpatient prospective pmt system (HOPPS). The classification is a resource-based reimbursement system. The pmt unit is the ambulatory pmt classification group (APC group)
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Ambulatory payment classification (APC)
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The process of comparing performance
to a preestablished standard or performance of another facility or group. |
Benchmarking
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Providers receive a fixed, preestablished pmt for ea. case. (Cases r partients, residents or clients who receive Health svc for a condition or disease.
3rd party payers reimburse providers for ea cast rather than for ea. svc. Single number that compares the overall complexity of the healthcare organization's patients to the complexity of the avg of all hospitals. Typically, the CMI is for a specific period and is derived from the sum of all diagnosis related roup (DRG) weights, divided by the number of Medicare cases. |
Case Mix Index (CMI) pg 38
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A component of an HIM compliance plan or a corporate compliance plan that focuses on the unique regulations and guideline with which coding professionals must comply.
Component of the HIM Dept Compliance Plan •The Core areas -Policies and procedures -Education and training -Auditing and monitoring |
Coding Compliance plan
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Managing a coding or billing dept according to the laws, regulations and guidelines that govern it.
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Compliance
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Designated individual who monitors the compliance process at a healthcare facility.
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Compliance Officer
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•Prohibits knowingly filing a false or fraudulent claim for payment to the government
•Knowingly using a false record or statement to obtain payment on a false or fraudulent claim paid by the government •Conspiring to defraud the government by getting a false or fraudulent claim allowed or paid Legislation passed during the Civil War that prohibits contractors from making a false claim to a governmental program; used to reinforce healthcare fraud and abuse. |
False Claims Act
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Intentionally making a claim for pmt that one knows to be false.
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Fraud
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The use of electronic devices and media to collect, store & retrieve healthcare information.
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Health Information technology (HIT)
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Reimbursement & medical necessity policies established by regional fiscal intermediaries. New format for Local Medical Review Policies (LMRPs). LCDs and LMRPs vary from state to state.
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Local Medical Review Policy (LMRP)
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Organization that developed the clinical modification to the International Classification of Diseases, 9th Revision (ICD-9); responsible for maintaining and updating the diagnosis portion of the International Classification of Diseases, 9th revision, Clinical Modifiction (ICD-9-CM)
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Nat'L Center for health Statistice (NCHS)
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A set of coding regulations to prevent fraud and abuse in physician and hospital outpatient coding; specifically addresses unbundling and mutually exclusive procedures.
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Nat'l Correct Coding Initiative (NCCI)
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A division of the Dept of Health & Human Services (DHHS)
that investigates issues of noncompliance in the Medicare & Medicaid programs such as fraud & abuse. |
Office of Inspector General (OIG)
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a benchmarking database
maintained by the Texas Medical Foundation that supplies individual QIOs with hospital data to determine state benchmarks and monitor hospital compliance. |
Program for Evaluation Pmt Patterns Electronic Report (PEPPER)
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Electronic Report (PEPPER)
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Medicare contractor that is responsible for carrying a specified scope of work during a three-year period; monitors and assists healthcare facilities with quality, payment,treatment denial, & health information technology issues.
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Quality Improvement Organization (QIO)
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The result of successful demonstration project required by the MMA of 2003. RACs ensure correct pmts are made by Medicare for part A & B claims.
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Recover Audit Contractor (RAC)
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The contract specifications for quality improvement organizations (QIOs) to complete during their three-yr contract period.
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Scope of Work/Statement of Work
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The practice of using a code that results in higher payment to the provider than the code that actually reflects the service or item provided.
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Upcoding
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The practice of using multiple codes that describe individual steps of a procedure rather than an appropriate single code that describes all the steps of the comprehensive procedure performed.
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Unbundling
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