Medicare & Medicaid Billing Flashcards

Under the Medicare Conditions of Participation (CoPs), a hospital must submit a Medicare claim within how many days of the date of service for timely filing?

Answer: 1 year (365 days)

Medicare requires claims to be filed within 1 calendar year (365 days) from the date of service or discharge to be considered timely.

Which National Correct Coding Initiative (NCCI) edit prevents billing two codes together when one is considered a component of the other?

Answer: Column 1/Column 2 Edit (Comprehensive/Component Edit)

Column 1/Column 2 edits (Comprehensive/Component edits) bundle a component code (Column 2) into a more comprehensive code (Column 1), preventing separate billing.

A Medicare patient is placed in 'observation status' for 72 hours before being formally admitted as an inpatient. How does this affect skilled nursing facility (SNF) coverage?

Answer: Observation hours do NOT count toward the 3-day qualifying inpatient stay

Observation status is outpatient care billed under Part B, so those hours do not count toward the 3-day inpatient hospital stay required to qualify for Part A SNF benefits.

Which federal law established the False Claims Act (FCA) liability for knowingly submitting false Medicare or Medicaid claims?

Answer: The False Claims Act (originally 1863, strengthened 1986)

The False Claims Act imposes civil liability, including treble damages and per-claim penalties, on any person or entity that knowingly submits false claims to federal healthcare programs.

A Medicaid managed care organization (MCO) pays a provider a fixed monthly amount per enrolled member, regardless of services rendered. This payment model is called:

Answer: Capitation

Capitation is a prospective per-member-per-month (PMPM) payment that the MCO pays the provider whether or not the member receives services.

Under the Medicare Secondary Payer (MSP) rules, which situation makes Medicare the PRIMARY payer?

Answer: The patient is retired and has retiree health coverage from a former employer

Retiree health coverage from a former employer is secondary to Medicare because the retiree is no longer an active employee, making Medicare primary.

The 'Clean Claim' standard under Medicare requires that a claim must be paid or denied within how many days of receipt?

Answer: 30 days

Medicare requires MACs to pay or deny clean claims within 30 days of receipt to avoid interest penalties under the Prompt Payment Act.