Revenue Cycle and Compliance Flashcards

What is the timely filing limit for Medicare Part B claims?

Answer: One calendar year from the date of service

Medicare Part B requires claims to be filed within one calendar year (12 months) from the date of service to be eligible for reimbursement.

Which term describes billing for services NOT actually rendered?

Answer: Phantom billing (fraud)

Phantom billing is the fraudulent practice of submitting claims for services never actually provided to the patient.

A provider routinely waives patient copayments and deductibles without hardship assessment. This is considered:

Answer: Fraudulent — it misrepresents the actual charge and can induce overutilization

Routine waiver of copayments/deductibles is considered fraud because it misrepresents the true amount charged and can induce overuse of services billed to federal programs.

What is 'downcoding' in the context of medical billing?

Answer: Assigning a lower-level code than documented to avoid audit risk or scrutiny

Downcoding occurs when a provider or coder assigns a lower-level (less complex) code than the documentation supports, resulting in lower reimbursement.

Which federal program monitors healthcare claims for fraud, waste, and abuse through data analysis and audits?

Answer: Recovery Audit Contractor (RAC) Program

Recovery Audit Contractors (RACs) identify and recover improper Medicare payments through post-payment claim audits and data analysis.

Under the Anti-Kickback Statute (AKS), which of the following is prohibited?

Answer: Offering or accepting remuneration to induce referrals for services covered by federal healthcare programs

The Anti-Kickback Statute prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce referrals for items or services covered by federal healthcare programs.