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129 Cards in this Set
- Front
- Back
- 3rd side (hint)
Outcomes and assessment information set- C |
Core items for the comprehensive assessment of adult Home Care form the basis for measuring the patient outcomes for the purpose of outcome-based quality improvement |
Sayles 2013, 278 |
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Policy |
Describes General guidelines that direct Behavior or direct and constrain decision-making in the organization |
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Vital risk areas for the accuracy of the claims submission process |
Coding and billing , documentation, and medical necessity for tests and procedures. |
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Fraud |
Intentional deception or misrepresentation leading to some unauthorized benefit |
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Abuse |
Unnecessary costs or false representation or failure to disclose fact |
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Federal sentencing guidelines |
Corporate compliance programs became common after the adoption of this |
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Ability to subpoena audit trails |
A legal concern regarding the EHR |
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7 steps of ineffective program to prevent and detect violations of law |
These Federal sentencing guidelines have become the blueprint for an effective compliance program for healthcare organizations |
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Accreditation |
The act of granting approval to a healthcare organization |
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A compliance officer should Ensure |
A hotline to receive complaints and Adoption of procedures to protect whistleblowers from retaliation is in place |
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A comprehensive compliance program has |
7 elements as the minimum necessary outlined by the oig |
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Documentation education |
Part of a compliance education a focused effort should be made to provide documentation education to the medical staff |
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Ahrq |
Agency for healthcare research and quality, the agency most involved in Health Care Services Research |
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Ahrq |
Looks at issues related to the efficiency and effectiveness of healthcare delivery system common disease protocols and guidelines for improved disease outcomes. |
Sayles 2013,457 |
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Oig |
Office of the Inspector General |
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Office of the Inspector General |
Issues compliance program guidance for various types of healthcare organizations, posts documents that most Healthcare organizations need to develop Fraud and Abuse compliance plans. |
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Data security |
Includes ensuring that workstations are protected from unauthorized access |
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Log off automatically |
If a workstation is inactive for a period of time by the organisation it should do this |
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Automatic log off |
Helps prevent unauthorized users from accessing ephi when an authorized user walks away from the computer without logging out of the system |
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Retrospective utilization review |
Conducted after the patient has been discharged |
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Retrospective review |
Examines the medical necessity of services provided to the patient while in the hospital |
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Hie |
Health information Exchange |
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Identity management |
Used to provide access controls, authentication, and audit logging in health information Exchange |
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HITECH |
ARRA ESTABLISHED |
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Joint Commission |
Accrediting organization that has instituted continuous Improvement and Sentinel event monitoring and uses Tracer methodology |
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Middle managers |
Role of developing implementing and revising the organization's policies |
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Business associate agreements |
The Creator of health information should obtain a business associate agreement with the receiver |
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Staffing tools |
May be used to plan and manage staff resources. |
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Position descriptions |
Outline the work and qualifications required by the job |
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Middle managers |
Execute the organizational plans developed at the board and executive levels the operational information that Executives need to develop meaningful plans for organizations future |
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Performance standards |
Established expectations for how well the job will be done and how much work will be accomplished |
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Written policies and procedures |
Explaining Staffing requirements and scheduling assist the supervisor and being fair and objective and help the staff understand the rules |
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The Joint Commission |
Most visible organization responsible for accrediting healthcare organizations since the 1950s primary focus at this time is to determine whether organizations continually monitoring the quality of care they provide |
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Requirements of The Joint Commission |
Continual Improvement process being placed throughout the entire organization, from the governing body down all Department lines. |
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Deficit reduction Act of 2005 |
Made compliance programs mandatory |
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Policy |
He clearly stated and comprehensive statement that establishes the parameters for decision-making and action |
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Policies |
Developed at both the institutional and departmenttal levels. Should be consistent within the organization. They must be developed in accordance with applicable laws and reflect actual practice. |
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DRA of 2005 |
The mandatory Deficit reduction Act of 2005 was enacted in 2006. |
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UR |
utilization review is the process of determining whether the health care provided to a specific patient is necessary |
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Basis for utilization review |
Pre-established objective screening criteria according to time frames specified in the organization's plan |
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Utilization management |
What process is used to determine the appropriate of Medical Services during specific episodes of care |
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Types of utilization review |
Pre-admission Continued stay Discharge |
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Basic functions of the utilization review process |
Case management Discharge planning Utilization review |
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What are insufficient to determine whether the hospital is in compliance |
The medical record committee wants to determine if the hospital is in compliance with Joint Commission standards for medical record delinquency rates. The HIM director has compiled a report that shows that records are delinquent for an average of 29 days after discharge. Given this information what can the committee conclude? |
#238 |
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Business associate agreement |
The Creator should seek a business associate agreement with the receiver of the information |
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The Joint Commission |
The largest Healthcare standard-setting body in the world since 1952 |
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Physician offices |
Do not have to meet the standards in the conditions of participation for Medicare and Medicaid reimbursement |
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Data security program |
Auditing information system activity is an important part of this |
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Unauthorized access to a system |
An audit Trail may be used to detect this |
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Auditing information of the system |
Performed by examining and evaluating audit trails |
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Audit Trail |
Record of system and application activity by users |
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Elements of performance |
Specific performance expectations and or structures and processes that provide detailed information for each of the Joint Commission standards |
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EPs, or elements of performance |
Must be in place for an organization to provide safe high quality Care, treatment, and services. |
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Critical for HIM professionals working in an accredited facility |
Knowledge of EPs pertaining directly to the Health Care record and documentation in the record |
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Healthcare quality improvement Act |
The creation of the National Practitioner Data Bank was mandated by this |
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NPDB |
National Practitioner Data Bank |
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National Practitioner Data Bank |
Provide a Clearinghouse for information about medical practitioners who have a history of malpractice suits and other quality problems. |
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Hospitals are required to consult |
The NPDB national Practitioner Data Bank before granting medical staff privileges to healthcare practitioners |
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Bylaws |
Dictate how a medical staff operates |
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Considered legally binding |
Hospital bylaws spell out specific qualifications that Physicians must demonstrate before they can practice medicine in the hospital. Any changes must be approved by a vote of the medical staff and the hospital governing body |
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CEO |
Chief executive officer |
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Chief executive officer |
Primary responsibility is Implementing the policies and strategic direction of the hospital or Healthcare organization and building effective executive management team |
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License |
Medical school graduates must pass attached before they can practice medicine |
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State Medical boards |
Administer licensure test, passing scores vary by state. Most Physicians also complete several years of residency training in addition to medical school |
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Section 164 .524 of the Privacy Rule |
States that an individual has the right to access to inspect and obtain a copy of his or her own protected health information that is contained in a designated record set such as a health record. |
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Exceptions to Privacy Rule 164 .524 |
To what may be accessed: such as Psychotherapy notes, information compiled in reasonable and anticipation of a civil, criminal or administrative action or proceeding, or PHI subject to the Clinical Laboratory improvements are all exceptions |
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As long as state laws or regulations, Physicians do not state otherwise |
The HIPAA Privacy Rule provides patient with significant rights that allow them to have some measure of control over their health information |
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Fees for medical records |
HIPAA allows a reasonable cost based fee when an individual requests a copy of PHI or agrees to accept a summary or explanatory information |
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Reasonable cost based fee includes |
Cost of copying including supplies and labor, postage. Retrieval fees are not permitted to be charged to patients |
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Automatic data controls to preserve confidentiality and integrity |
Edit check Audit trails Password management |
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Security awareness program |
Is not an automatic control |
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Access to information |
Within the context of an electric health records protecting data privacy means defending or safeguarding |
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Protecting data privacy |
Means safeguarding access to information within the context of data security. |
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Data privacy |
Only those who need to know information should be authorized to access it |
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Data security |
Protection measures and tools for safeguarding information and information systems |
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The HIPAA Privacy Rule intent |
Allow individual to obtain copies of records for a fee that is reasonable enough for an individual to pay for it |
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The Privacy Rule requires |
The copy fee for the individual be reasonable and cost-based |
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Risk management |
Conducts analysis, identify threats, determines likeliness threats may occur, and estimates the impact of events for an electronic health record |
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A written contingency plan |
To handle an emergency response in the event of an Untoward event. |
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Administrative safeguards |
Include policies and procedures that address the management of Computer Resources |
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Employees |
Biggest threat to the security of healthcare data |
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Once a year |
To ensure revelancy, security policies and procedures should be reviewed |
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Good forms design |
Needed within an EHR to create ease-of-use. The use of a selection box allows the user to select a value a predefined list. |
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Radio buttons |
Are used for singles elections within the EHR |
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Minimize keystrokes |
By using pop-up menus, good electronic forms design |
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Completeness check |
Performed for all required data, good electronic forms design |
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Text box |
To enter text , good electronic forms design |
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Clinical forms committee |
oversees the development and approval of new forms for the health record |
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Clinical forms committee |
Provides oversight for the development review and control of all enterprise-wide information capture tools including paper forms and design of computer screens |
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Physical control |
Placing blocks on computer room doors |
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EDMS |
Electronic data management system |
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24 pound paper for double sided forms |
Recommended for design of forms for an electronic data management system |
Sayles 2013, 364 |
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Physical access controls |
Safeguards that protect physical equipment Media or facilities |
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20 - 24 pound paper is recommended for use in copiers, scanners and fax machines |
In an electronic data management system paper forms are added to the electronic health record using a scanner so the weight of the paper is important |
Sayles 2013, 356 |
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Before action is taken |
The HIM supervisor should determine if a breach has occurred via the audit Trail |
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Coding policies |
Ahima code of ethics Ahima standards of ethical coding Official coding guidelines Applicable federal and state regulations Internal Documentation policies requiring the presence of a physician documentation to support all coded diagnosis and procedure code assignments |
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Public Law 113 - 36 |
Mandated the establishment of Fraud and Abuse control programs to battle Health Care Fraud and Abuse |
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Access to ePHI controls |
User-based access Role-based access Context based access |
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Reign based Access Control |
Does decisions are based on the rules individual users have as a part of an organization. Each user is given various privileges to perform their role or function. |
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Review of record by the patient is permitted |
After the authorization for use and disclosure is verified. Usually Hospital Personnel should be present during on site reviews to assist with the requester |
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As long as state laws or regulations or the position does not State otherwise |
Competent adult patients have the right to access their record. |
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State laws on the issue of minors |
HIPAA the first two state laws, applicable state laws should be consulted regarding appropriate authorization. |
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Medicare definition of fraud |
Intentional representation than an individual knows to be false or does not believe to be true but makes knowing that the representation could result in some unauthorized benefit |
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Medicare conditions of participation |
Rules set forth by CMS |
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Nationwide expansion OF RAC |
Was fully implemented and operational by January 2010 |
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Single sign-on |
Allow sign on to multiple related but independent software Systems |
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Physical access controls |
Safeguards that protect physical equipment Media or facilities |
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Access control |
Means being able to identify which employees should have access to what data |
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Steps in medical necessity and utilization review |
Initial clinical review peer clinical review appeals consideration |
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OIG WORK PLAN |
Can be used to discover current hot areas of compliance |
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Common forms of fraud |
Services not rendered but billed Misrepresenting the diagnosis to justify the payment Unbundling or exploding charges |
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Control to access services |
One aspect of managed care that has the greatest impact on Healthcare organizations |
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Managed Care Systems control cost |
Primarily by presetting payment amounts and restricting patient access to Healthcare Services through pre-certification and utilization review processes |
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Coding compliance plan |
Should include a physician query process, coding diagnosis not supported by health documentation, upcoding, correct use of encoder software, unbundling ,coding health records with incomplete documentation, assignment of discharge destination codes, and complete process for using scrubber software |
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Evidence based practice guideline |
Explicit statement that directs clinical decision-making. Evidence-based clinical practice guidelines are Foundation of members care for specific clinical conditions |
Casto and Forrestal 2013, 107 |
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Cost control |
The gatekeeper role of the primary care provider. They determined the appropriateness of Health Care Service, the level of Health Care personnel, and the setting in the Continuum of Care |
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Safe harbors |
Exceptions to the federal anti-kickback statute that allows legitimate business Arrangements and are not subject to prosecution |
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Fair market value compensation |
Common theme runs through safe harbors and that is the intent to protect certain Arrangements which is commercially reasonable items or services are exchanged for |
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Twice |
Times each year Health Care Facilities required to practice emergency preparedness plans |
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Commission on accreditation of rehab facilities |
Private not for profit organization committed to developing and maintaining practical customer-focused standards to help organizations measure and improve the quality value and outcomes of Behavioral Health and Medical Rehab programs |
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CARF |
Commission on accreditation of Rehabilitation Facilities |
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Deemed status |
Accrediting bodies such as Joint Commission can survey facilities for compliance with Medicare conditions of participation instead of the government |
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Tracer methodology |
Evaluation that follows Hospital experiences of past or current patients |
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PFP |
Priority Focus review follows the experience of care through the organization's entire Healthcare process and allows the surveyor to identify performance issues |
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Standard of care for health condition |
Likely to be considered medically necessary |
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Goals of case management |
Continuity of Care, cost-effectiveness, Quality and appropriate utilization |
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ABN |
When a service is not considered medically necessary based on the reason for the encounter the patient should be provided with this indicating Medicare might not pay and the patient might be responsible for the entire charge |
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Demand letter |
Document sent to the provider notifying them of an incorrect payment determination the Medicare recovery audit contractor |
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Medical |
Type of identity theft occurring after a patient uses another person's name and insurance information to receive Healthcare benefits |
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