MA 1032 Medical Coding study notes
MA 1032 Medical Coding study notes MA 1032
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This 4 page Study Guide was uploaded by Megan on Thursday March 24, 2016. The Study Guide belongs to MA 1032 at University of Cincinnati taught by Judy Kronenberger in Fall 2016. Since its upload, it has received 29 views. For similar materials see Medical Coding in Medical Assisting at University of Cincinnati.
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Date Created: 03/24/16
MA 1032 OF M EDICAL B ILLING Chapter 1 study notes Medicare pays 80%; Beneficiary pays 20% as well as deductible, premiums, coinsurance, & 100% MA 1032 of Medical of noncovered services. Billing Chapter 1 study notes AOA – Administration on Aging ACL – Administration for Community Living NHE – National Health Expenditure DHHS – Department of Health and Human Services Who is eligible to enroll in Medicare: People ages 65 and over + those with disabilities CMS – Centers for Medicare and Medicaid Services MAC – Medicare Administrative Contractors DME – Durable Medical Equipment Medicare Part A: Hospital Insurance (covers rooms, meals, treatments, therapy) Medicare Part B: Supplementary Insurance (not automatically provided to beneficiaries when they are eligible; pays for medically necessary services, outpatient hospital services, and home health care; beneficiaries pay premium each month. Medicare Part C: Medicare Advantage Organization (set of health care options from which beneficiaries can choose their health care providers – HMO, PPO...) Medicare Part D: Prescription Drugs (Beneficiaries pay premium each month) HIPPA – Health Insurance Portability and Accountability Act of 1996. Governs health care portability, privacy, medical savings accounts, and longterm care insurance. EDI – Electronic Data Interchange. PHI – Protected Health Information. All PHI is included in privacy requirements. NPI – National Provider ID. 1 Federal Register – Official publication for all “Presidential Documents”, “Rules & Regulations,” “Proposed Rules,” & “Notices.” (www.gpo.gov/fdsys/.) – Hospitals look into October editions; Outpatient facilities look into Nov/Dec editions. RBRVS – ResourceBased Relative Value Scale: Decreases Medicare expenditures, redistribute physicians’ payments more equitably, ensure quality health care at a reasonable rate. QIO Providers – 1. Direct payment is made to provider 2. 5% higher fee schedule than for nonQIO providers 3. Faster claim processing 4. Provider’s name listed in QIO directory Non QIO Providers – 1. Payments goes to patient on all claims 2. 5% lower fee schedule than that for QIO providers 3. Slower processing of claims MSDRG – Medical SeverityDiagnosis Related Groups. MAAC – Maximum Allowable Charge that limits total amount nonQIO providers can charge. RVU – Relative Value Unit (Work, Overhead, Malpractice) Standing Approval – Assigns benefits to the provider and is kept on file in the medical office. OBI – Office of Benefits Integrity: Oversees Medicare’s payment safeguard program related to fraud, audit, and medical review. OIG – Office of Inspector General: Develops annual work plan to outline the ways the Medicare program is monitored to catch fraud. IOM – Internet Only Manual: Establishes regulations to follow to avoid fraud. Fraud – 1. Billing for services not provided. 2. Applying for duplicate payment. 3. Unbundling/exploding charges 4. Using another person’s Medicare card to obtain care. MCO – Managed Care Organization: Responsible for health care services offered to an enrolled group or person. 2 PPO – Preferred Provider Organization: group of providers who form a network and have agreed to provide services to enrollees at a discounted rate. HMO – Delivery System that allows enrollee access to all health care services. Enrollee is assigned a primary care physician who acts as Gatekeeper. IPA – Individual Practice Association: physician provides services for a set fee. EPO – Exclusive Provider Organization: providers of services are not prepaid. GPM – Group Practice Model: physicians make contracts with the HMO to provide services to enrollees of HMO. PACE – Program for AllInclusive Care for the elderly. 3
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