Medicare & Medicaid Billing Flashcards

Under Medicare's Outpatient Prospective Payment System (OPPS), services are grouped into:

Answer: Ambulatory Payment Classifications (APCs)

OPPS assigns hospital outpatient services to APCs, which determine the Medicare payment rate for each visit or procedure.

The 'two-midnight rule' under Medicare determines:

Answer: When a hospital stay is expected to span two midnights and qualifies for inpatient admission

The two-midnight rule states that inpatient admission is appropriate when the physician expects the patient to require hospital care spanning at least two midnights.

Which of the following best describes 'crossover claims' in Medicare/Medicaid billing?

Answer: Claims automatically forwarded from Medicare to Medicaid for dual-eligible beneficiaries

Crossover claims are sent automatically by Medicare to Medicaid for dual-eligible beneficiaries, so Medicaid can pay the remaining cost-sharing amounts.

A provider receives a Medicaid overpayment notice for claims paid 18 months ago. Under federal law, what is the provider's obligation?

Answer: Report and return the overpayment within 60 days of identification

Federal law (ACA Section 6402) requires providers to report and return identified overpayments within 60 days, regardless of how old the claim is.

The Medicare Physician Fee Schedule (MPFS) calculates payments using three components of the Relative Value Unit (RVU). Which of the following is NOT one of those components?

Answer: Overhead Facility RVU

MPFS uses Work, Practice Expense, and Malpractice RVUs — there is no separate 'Overhead Facility RVU' component.

A hospital readmits a Medicare patient within 30 days for the same condition. Under the Hospital Readmissions Reduction Program (HRRP), what financial consequence may occur?

Answer: The hospital may face a reduction in its Medicare base payments

HRRP penalizes hospitals with excess readmissions by reducing their Medicare base DRG payments by up to 3% for all Medicare discharges.

When billing Medicaid for a service also covered by a third-party liability (TPL) insurer, the provider must:

Answer: Bill the third-party insurer first before submitting to Medicaid

Medicaid is always the payer of last resort; providers must bill all available third-party insurers first and submit to Medicaid only for any remaining balance.