code of conduct
hospital establish compliance standards
Purpose of OIG work plan?
communicate issues that will be reviewed during the year for compliance with Medicare regulations
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code of conduct - ANSWER- hospital establish compliance standards
Purpose of OIG work plan? - ANSWER- communicate issues that will be reviewed
during the year for compliance with Medicare regulations
Medicare pt. admitted on Friday, what services fall within the three day window
rule? - ANSWER- Dx services and related charges provided on the W,R, and F
before adm.
What does modifier allow a provider to do? - ANSWER- Report a specific
circumstance that affected a procedure or service without changing the code or
its definition
Out pt. dx services provided within 3 days of adm. of a medicare benef. to an
IPPS hospt, what must happen to these charges - ANSWER- combined with the in
pt. bill and paid under the MS-DRG system
Why is OIG pursuing the medicare Secondary Payer - ANSWER- reviews
medicare payments for beneficiaries who have other insurance and assesses the
effect. of procedures in preventing inappro. medcare payments for benef. with
other ins. coverage
Recurring or series registration? - ANSWER- one reg. record is created for multi
days of service
Nonemergency pt. who comes for service w/out prior notif. to the provider called?
- ANSWER- unscheduled pt.
stmnts apply to observ. pt. type - ANSWER- used to evaluate the need for an in pt.
adm.
, which services are hospice programs required to provide on an around the clock
basis - ANSWER- physician, nursing, pharmacy
purpose of initial step in put pt. testing scheduling process - ANSWER-
identifying the correct pt. in the providers database or add the pt. to the database
scheduler instructions are used to prompt the scheduler to do what? - ANSWER-
complete the scheduling process correctly based on service requested
medicare guidelines require that when a test is ordered for which an LCD or NCD
exists, the info provided on the order must include which of the following? -
ANSWER- documentation of the medical necessity for the test
advantage of pre reg. program? - ANSWER- reduces processing times at the time
of serivce
what data are required to est. a new MPI entry? - ANSWER- pts. name, DOB, sex
Which HIPAA trans. set provides electronic processing of ins, verif requests and
responses? - ANSWER- the 270-271 set
a mother and father both cover their 16 yo child as a dep. on their health ins,
plans, which both follow the bday rule. mothers dob is 1-19-68 and fathers dob is
7-19-67; whose plan is primary - ANSWER- mothers
true about third party payers? - ANSWER- payments received by the provider
from the payer respon. for reimbursing the provider for the pts. covered services
co-payment? - ANSWER- fixed amt. that is due for a specific service
pts annual out of pocket limitation is 3000, excluding deduct. to date this cal. year
the pt has satisfied the 500 deduct. and has paid 2300 in co insurance to various
providers. max amount of coinsurance the pt will owe - ANSWER- 700
type of plan that allows the subscriber to pay lower premium costs in return for a
higher deductible? - ANSWER- consumer directed health plan
characteristic of a managed care contracted methodology - ANSWER-
prospectively set rates for in pt. and out pt. services
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