Billing and Coding Compliance Flashcards
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Read the first 7 Billing and Coding Compliance flashcards as text
What is the National Provider Identifier (NPI)?
Answer: A unique 10-digit identification number issued to healthcare providers by CMS under HIPAA
The NPI is a unique 10-digit identification number issued by CMS to HIPAA-covered healthcare providers, used to identify providers in all standard electronic transactions.
What does 'incident to' billing allow under Medicare Part B?
Answer: Billing for services provided by non-physician practitioners under direct physician supervision at the physician's full reimbursement rate
'Incident to' billing allows services by non-physician practitioners (e.g., nurses, medical assistants) provided under direct physician supervision to be billed under the supervising physician's NPI at 100% of the Medicare fee schedule.
Under the False Claims Act, what is 'qui tam' litigation?
Answer: A whistleblower lawsuit filed by a private individual on behalf of the government
Qui tam provisions of the False Claims Act allow private individuals (relators/whistleblowers) to file lawsuits on behalf of the government against those who defraud federal programs and share in any monetary recovery.
What is a 'clean claim' in Medicare billing?
Answer: A claim that contains all required information and can be processed without requesting additional data
A clean claim contains no defects or improprieties and includes all required data elements, allowing the payer to adjudicate it without needing to request additional information.
What is 'phantom billing' in the context of healthcare fraud?
Answer: Billing for services, procedures, or supplies that were never actually provided to the patient
Phantom billing involves submitting claims for services or items that were never actually rendered to the patient, constituting outright fraud against Medicare, Medicaid, or other payers.
What is an Advance Beneficiary Notice (ABN) primarily used for?
Answer: To inform a Medicare beneficiary that Medicare may not cover a service and the patient may be financially responsible
An ABN is given to Medicare beneficiaries before receiving potentially non-covered services so they can make an informed decision about receiving the service and assume financial responsibility if Medicare denies payment.
What does 'coordination of benefits' (COB) mean in billing compliance?
Answer: The process that determines the order in which multiple insurance plans pay when a patient has more than one coverage
Coordination of benefits is the process used to determine which insurance plan is primary and which is secondary when a patient carries more than one health insurance policy, preventing duplicate payments.