Revenue Cycle and Compliance Flashcards

What is the 'clean claim' in the context of the revenue cycle?

Answer: A claim submitted without errors that requires no additional information for payment

A clean claim is one submitted free of errors, with all required information, allowing the payer to process and pay it without requesting additional information.

Which federal law establishes criminal penalties for healthcare fraud and abuse, including upcoding and unbundling?

Answer: False Claims Act (FCA)

The False Claims Act prohibits knowingly submitting false or fraudulent claims to federal healthcare programs, with penalties including treble damages and fines.

What is 'upcoding' in medical billing?

Answer: Reporting a higher-level code than the documented service to increase reimbursement

Upcoding is the fraudulent practice of billing for a more expensive service than what was actually provided to receive higher reimbursement.

The Correct Coding Initiative (CCI) edits are designed to prevent:

Answer: Improper unbundling of procedures that should be billed as one code

CCI edits (National Correct Coding Initiative) are claim edits that prevent inappropriate unbundling of services that should be reported with a single comprehensive code.

What does the STARK Law (Physician Self-Referral Law) prohibit?

Answer: Physicians referring patients to entities where they have a financial interest for designated health services

The Stark Law prohibits physicians from referring Medicare/Medicaid patients to entities in which the physician or an immediate family member has a financial relationship, for designated health services.

An 'Advance Beneficiary Notice' (ABN) is required when:

Answer: Medicare may not cover a service due to medical necessity concerns

An ABN must be given to a Medicare beneficiary before services are provided when the provider believes Medicare may deny payment for lack of medical necessity.