required facilities to identify and reduce improper Medicare payments and, specifically, the Medicare payment error rate. The conduct, aims, or qualities that characterize a professional person. commonly referred to as HCPCS level II codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT (e.g., J-codes are used to assign drugs administered. Understanding Health Insurance: A Guide to Billing and Reimbursement - 2020: Author: Michelle Green: Edition: 15: Publisher: Cengage Learning, 2020: ISBN: 0357478177, 9780357478172: Length: … surveillance and utilization review subsystem (SURS), safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services. includes all outpatient procedures and services (e.g., same-day surgery, x-rays laboratory tests, and so on) provided during one day to the same patient. an arrangement among providers to provide capitated (fixed, prepaid basis) health care services to Medicare beneficiaries. review for medical necessity of inpatient care prior to the patient's admission. managed care. This provides lower-cost commercial liability insurance to its members. managed care plan that provides benefits to subscribers if they receive services from network providers. Bundle: Understanding Health Insurance: A Guide to Billing and Reimbursement, 13th + Premium Web Site, 2 terms (12 months) Printed Access Card + Cengage EncoderPro.com Demo Printed Access Card + ICD-10-CM Professional for Physicians 2017 + CPT Standard 2017{{ studentProduct.buyingOptions.platform_0_bundleOptions_0_15. Employee Retirement Income Security Act of 1974 (FRIBA). sent to the provider; serves as an explanation of benefits from Medicaid and contains the current status of all claims (including adjusted and voided claims). flat-file format used to bill provider and noninstitutional services, such as services reported by a general practitioner on a CMS-1500 claim. Discover the essential tool to prepare for a career in medical insurance billing -- UNDERSTANDING HEALTH INSURANCE, 13E. system by which payers deposit funds to the provider's account electronically. associated with how an insurance plan is billed—the insurance plan responsible for paying health care insurance claims first is considered primary. begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days. documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment. a registered nurse licensed by the state in which services are provided, has a master's degree in a defined clinical area of nursing from an accredited educational institution, and is certified. Understanding Health Insurance, 12th Edition, is the tool students need when preparing for a career in medical insurance billing. Bundle: Understanding Health Insurance: A Guide to Billing and Reimbursement, 13th +Premium Web Site, 2 terms (12 months) Printed Access Card + … for MindTap Medical Insurance & Coding, 2 ter Paperback. organization of affiliated provider sites (e.g., hospitals, ambulatory surgical centers, or physician groups) that offer joint health care services to subscribers. Prepare for a career in health information management and medical billing and insurance processing with Green's UNDERSTANDING HEALTH INSURANCE, 14E. review of patient records and CMS-1500 (or UB-04) claims to assess coding accuracy and whether documentation is complete. recipient eligibility verification system (REVS). document that provides official instruction, such as the customized document that gives covered entities permission to use specified protected health information (PHI) for specified purposes or to disclose PHI to a third party specified by the individual, Nonpublished code edits, which were discontinued in 2000, Unauthorized release of patient information to a third party, also called common law; based on a court decision that establishes a precedent, One-digit character, alphabetic or numeric, used to verify the validity of a unique identifier, Also called case law, is based on a court decision that establishes a precedent, Restricting patient information access to those with proper authorization and maintaining the security of patient information, Public law governed by statute or ordinance that deals with crimes and their prosecution, to decode an encoded computer file so that it can be viewed. A type of liability insurance that covers physicians and other health care professionals for liability relating to claims arising from patient treatment. check made out to both patient and provider. created physician quality reporting initiative (PQRI) system that establishes a financial incentive for eligible professionals who participate in a voluntary quality reporting program. performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries. Is employed by a third-party payer and reviews health-related claims to determine whether the charges are reasonable and for medical necessity. employed by the IPO, and other health care organizations (e.g., an ambulatory surgery clinic and a nursing facility). involves assessing the revenue cycle to ensure financial viability and stability using metrics (standards of measurement). Hospital Inpatient Quality Reporting (Hospital IQR) program, developed to equip consumers with quality of care information so they can make more informed decisions about health care options; requires hospitals to submit specific quality measures data about health conditions common among Medicare beneficiaries and that typically result in hospitalization; eligible hospitals that do not participate in the hospital IQR program will receive an annual basket market update with a 2% point reduction (The Hospital IQR was previously called The Reporting Hospital Quality Data for Annual Payment Update Program), Hospital Payment Monitoring Program (HPMP). formerly called local medical review policy (LMRP); Medicare administrative contractors create edits for national coverage determination rules that are called LCDs. [Ruth M Burke; Lynette M Williamson; Michelle A Green; Jo Ann C Rowell] Find helpful customer reviews and review ratings for Understanding Health Insurance: A Guide to Billing and Reimbursement at Amazon.com. What is a risk retention or risk purchasing group? prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services. sometimes called recipient eligibility verification system or REVS; allows providers to electronically access the state's eligibility file through point-of-sale device, computer software, and automated voice response. description of amount commonly charged for a particular medical service by providers within a particular geographic region; used for establishing allowable rates. funds that a provider or beneficiary has received in excess of amounts due and payable under Medicare and Medicaid statutes and regulations, number of dollars paid in error out of total dollars paid for inpatient prospective payment system services. charitable, educational, civic, or humanitarian organization whose profits are returned to the program of the corporation rather than distributed to shareholders and officers of the corporation. autonomous, centrally administered program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients and their families. $100.00 $65.00. Defense Enrollment Eligibility Reporting System (DEERS). classifies patients according to long- term (acute) care DRGs, which are based on patients' clinical characteristics and expected resource needs; replaced the reasonable cost-based payment system. Understanding Health Insurance: A Guide to Billing and Reimbursement (with Premium Web Site, 2 terms (12 months) Printed Access Card and Cengage EncoderPro.com Demo … payment components consisting of physician work, practice expense, and malpractice expense. financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. software that edits outpatient claims submitted by hospitals, community mental health centers, comprehensive outpatient rehabilitation facilities, and home health agencies; the software reviews submissions for coding validity (e.g. qualified disabled working individual (QDWI), program that helps individuals who receive Social Security and Medicare because of disability, but who lost their Social Security benefits and free Medicare Part A because they returned to work and their earnings exceeded the limit allowed; states are required to pay their Medicare Part A premiums. covers the medical expenses of individuals groups; premiums and benefits vary according to the type of plan offered. BlueCross BlueShield (BCBS) coverage for the following services: hospitalization, diagnostic laboratory services, x-rays, surgical fees, assistant surgeon fees, obstetric care, intensive care, newborn care, and chemotherapy for cancer. protects TRICARE beneficiaries from devastating financial loss due to serious illness or long-term treatment by establishing limits over which payment is not required. Understanding Health Insurance: A Guide to Billing and Reimbursement (with Premium Website, 2 assesses and measures improper Medicare fee-for-service payments (based on reviewing selected claims and associated medical record documentation). measures, monitors, and reduces the incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals. Prepare for a successful career in medical billing and insurance processing or revenue management with Green's UNDERSTANDING HEALTH INSURANCE: A GUIDE TO BILLING AND REIMBURSEMENT, 2020 Edition. MindTap: Powered by You. reimburses health care services to Americans over the age of 65. requires implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, faster Medicare appeals decisions, and more. Get all of the chapters for Test Bank for Understanding Health Insurance A Guide to Billing and Reimbursement, 10th Edition: Green . Health Maintenance Organization (HMO) Assistance Act of 1973, authorized grants and loans to develop HMOs under private sponsorship; defined a federally qualified HMO as one that has applied for, and met, federal standards established in the HMO Act of 1973; required most employers with more than 25 employees to offer HMO, Healthcare Effectiveness Data and Information Set (HEDIS). This comprehensive, inviting book presents the latest code sets and guidelines. Protection mandated by state law that covers employees and their dependents against injury and death occurring during the course of employment. uniformed service personnel who are either active duty, retired, or deceased, health care program for active duty members of the military and their qualified family members, TRICARE-eligible retirees and their qualified family members, and eligible survivors of members of the uniformed services, beneficiary counseling and assistance coordinator (BCAC). serves as a federal health care team created to work with regional military treatment facility commanders, uniformed service headquarters' staffs, and Health Affairs (HA) to support the mission of the Military Health Services System (MHSS). legal action to recover a debt; usually a last resort for a medical practice. documents health care services provided to a patient. enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients; as well as protect medical assistants' right to practice. organizes diagnosis-related groups (DRGs) into mutually exclusive categories, which are loosely based on body systems (e.g., nervous system). claim Medicaid should not have originally paid, resulting in a deduction from the lump-sum payment made to the provider. ROI by a covered entity (e.g., provider's office) about protected health information (PHI) requires the patient (or representative) to sign an authorization to release information, which is reviewed for authenticity (e.g., comparing signature on authorization forms to documents signed in the patient record) and processed within a HIPAA mandated 60 day time limit, request for ROI include those from patient, physicians, and other health care providers, third-party payers, Social Security Disability Attorneys; and so on. implemented as a result of the BBA of 1997; utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs. includes the identification of disease and the provision of care and treatment as provided by members of the health care team to persons who are sick, injured, or concerned about their health status. It is a provision of the False. Students cover the latest code sets, coding guidelines, and health plan claims completion instructions. centralized health care plan adopted by some Western nations (e.g., Canada, Great Britain) and funded by taxes. organization that accredits clearinghouses. uses a device (e.g., scanner) to convert printed or handwritten characters into text that can be viewed by an optical character reader. More items to explore. Understanding Health Insurance, Tenth Edition is fully updated to the latest code sets, guidelines, and claim forms to provide you with the most essential and up-to-date knowledge on billing and reimbursement. cost-sharing program between the federal and state governments to provide health care services to low- income Americans; originally administered by the Social and Rehabilitation Service (SRS). The print version of this textbook is ISBN: 9781305437142, 1305437144. an organization (e.g., third-party payer) that contracts with CMS to process claims and perform program integrity tasks for Medicare Part A and Part B and DMEPOS; each contractor makes program coverage decisions and publishes a newsletter, which is sent to providers who receive Medicare reimbursement. mandated reporting and disclosure requirements for group life and health plans (including managed care plans), permitted large employers to self-insure employee health care benefits, and exempted large employers from taxes on health insurance premiums. Examine today's most important topics, such as managed care, legal and regulatory issues, coding systems and compliance, reimbursement methods, clinical … classification system used to collect data for statistical purposes. A clause that protects patients from being billed for amounts not reimbursed by payers except for copayments, coinsurance amounts, and deductibles.

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