CFO Insurance & Billing Flashcards

Which federal anti-kickback provision prohibits offering or receiving remuneration to induce referrals for Medicare-covered orthotics?

Answer: The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))

The Anti-Kickback Statute (AKS) prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce or reward referrals of Medicare/Medicaid business.

A patient's secondary insurance is billed after the primary insurer pays. This process is known as:

Answer: Coordination of Benefits (COB)

Coordination of Benefits (COB) is the process of determining which payer is primary and which is secondary, then billing appropriately to avoid duplicate payments.

For Medicare Durable Medical Equipment (DME) billing, which form is used to submit professional claims for orthotic devices?

Answer: CMS-1500

The CMS-1500 form is the standard claim form used by non-institutional providers and suppliers, including orthotics suppliers, to bill Medicare Part B.

What is the purpose of an Advance Beneficiary Notice of Non-coverage (ABN) in orthotics practice?

Answer: To notify the patient that Medicare may not cover the item and they may be responsible for payment

An ABN informs the beneficiary in advance that Medicare may deny coverage for a specific item or service, allowing the patient to decide whether to proceed and accept financial responsibility.

Which entity audits Medicare DME suppliers and can demand repayment for improperly billed orthotic claims?

Answer: Recovery Audit Contractor (RAC)

Recovery Audit Contractors (RACs) are authorized by CMS to identify and recover improper Medicare payments through post-payment audits of supplier claims.

When verifying a patient's insurance eligibility for orthotics, which information is most critical to confirm upfront?

Answer: Coverage for DMEPOS, deductible status, and prior authorization requirements

Confirming DMEPOS coverage, remaining deductible, co-insurance amounts, and any prior authorization requirements prevents claim denials and ensures accurate patient cost estimates.