Reimbursement & Claims Processing Flashcards
7 cards from real CMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Reimbursement & Claims Processing flashcards as text
Which federal law established the fraud and abuse provisions that include the Anti-Kickback Statute and the False Claims Act?
Answer: The Social Security Act
The Social Security Act contains the Anti-Kickback Statute (Section 1128B) and other fraud and abuse provisions, while the False Claims Act is a separate but related civil statute.
A physician bills for 99215 (high complexity E/M) but the documentation only supports 99213. This is an example of:
Answer: Upcoding
Upcoding is billing for a higher-level service than was actually documented or performed, which constitutes fraud and can result in significant penalties.
Under Medicare's Prospective Payment System (PPS) for inpatient hospital care, payment is primarily determined by:
Answer: The patient's Diagnosis-Related Group (DRG)
Inpatient PPS pays hospitals a predetermined amount based on the patient's DRG, which groups diagnoses with similar clinical characteristics and resource use.
What is the function of a Medicare Administrative Contractor (MAC)?
Answer: Processing Medicare claims and performing audits on behalf of CMS
MACs are private companies that contract with CMS to process Medicare fee-for-service claims, make coverage decisions, and conduct provider education.
A provider receives a postpayment audit and is asked to repay an overpayment. Under Medicare, if the provider disagrees, what is the first level of the appeals process?
Answer: Redetermination by the Medicare Administrative Contractor (MAC)
The first level of the Medicare claims appeal process is a redetermination, which is reviewed by the same MAC that made the original claim determination.
Which modifier indicates that a procedure was performed on the right side of the body?
Answer: Modifier RT
Modifier RT (Right Side) is used to indicate the procedure was performed on the right side, while LT indicates the left side.
What does the term 'capitation' mean in managed care reimbursement?
Answer: A fixed per-member per-month payment regardless of services rendered
Capitation is a payment model in which a provider receives a fixed monthly payment per enrolled patient regardless of the number or type of services provided.