health services billing
What are the two types of forms used for health services billing?
CMS 1501 and CMS 1450
CMS 1100 and CMS 1450
UB-05 and UB-1450
Describe how Medicaid payments to providers are limited by the federal government.
The payments to providers are not limited by the federal government but rather by state agencies that have predetermind estimates.
The law requires that Medicaid payments to qualified hospitals, nursing facilities, ICF/MRs, and clinics not exceed a reasonable estimate of the amount that Medicare would pay for equivalent services in the aggregate within state-owned or operated, non-state-owned or operated, and private facilities.
CMS reviews state payment methodologies and supporting documentation to ensure that the state plan methodology may be audited and is comprehensively described and that payment rates are economic, efficient, and sufficient to attract willing and qualified providers.
All of the statements are correct.
None of the statements are correct
What is charge explosion?
When charges increase dramatically over a set period of time
When the set of charges is explained in line item fashion on a master bill
When a uniform set of supplies is utilized for a services or procedure
When charge masters are delivered to a large group all at once
How does the False Claims Act (FCA) impact providers of health care services?
Under the FCA, health care providers who knowingly make false or fraudulent claims to the government are fined $5,500 to $11,000 per claim plus up to three times the amount of the damages caused to the federal program.
Under the FCA, health care providers who knowingly make false or fraudulent claims to the government are fined $1,500 to $110,000 per claim plus up to three times the amount of the damages caused to the federal program.
Under the FCA, health care providers who knowingly make false or fraudulent claims to the government are fined $5,500 to $11,000 per claim plus up to five times the amount of the damages caused to the federal program.
Under the FCA, health care providers who knowingly make false or fraudulent claims to the government are fined $5,500 to $10,000 per claim plus up to 10 times the amount of the damages caused to the federal program.
What are the elements that should be present, at a minimum, in all charge masters?
The six elements are: charge code, item description, department number, charge (price), revenue code, and CPT/HCPCS code.
Only three are required. Those are charge code, item description, and charge (price).
The five elements are charge code, item description, department number, charge (price), and CPT/HCPCS code.
The six elements are: charge code, item description, physician, charge (price), revenue code, and CPT/HCPCS code.
Prosecution under the FCA requires that specific intent to defraud the government was present.
What is the objective in a managed-care environment that often leads to conflict between hospitals and doctors?
Increase in patient load
Empty hospital beds
Increase specialist referrals
Increased emphasis on which of the following by both Medicare and Medicaid have also provided a strong incentive for hospitals and nursing homes to either merge or establish affiliation arrangements?
What factors contribute to the complexity of the revenue cycle in health care?
Nature and importance of services provided and regulation
Size of the industry (amount of money involved)
Cost of care and third-party payer system (most of the payments for services are not directly from the recipient of those goods and services)
“Diversity and complexity of patients, providers, payers, payment methods, and care settings; and nonstandardization of care”
What type of physician alignment is most appealing to physicians because their control is maximized in this type of organizational setting?
Alignment with hospitals
Alignment with health plans
Alignment with other physicians
Alignment with other medical groups
Most of the major coverage provisions of the Affordable Care Act went into effect in what year and gave millions of people coverage under the law?
Governmental healthcare organizations are able to raise funds through equity investments.
What piece of legislation prohibits a person from receiving income from a pattern of activity, including committing an enumerated act (such as mail or wire fraud), at least twice in 10 years?
Stark Physical Self-Referral Law
Patient Protection and Affordable Care Act
Racketeer Influenced and Corrupt Organizations Act
The financial manager’s main responsibility is to acquire and use funds so as to maximize the firm s value. Their main functions may include: forecasting and planning, making major investment financing decisions, coordinating and controlling, dealing with the financial markets, and managing public opinion.
For what reason is physician expenditures increasing?
Increased use of physician services
Reduced accessibility to adequate health care
Increased regulation for physician practices
Decreased number of specialist referrals
__________ is often referred to as the antidumping law because it prohibits hospitals from transferring an emergency patient to another hospital simply because of the patient’s inability to pay.
The earnings of an investor-owned corporation can be subject to double taxation.
Providing medically unnecessary care to a patient and then billing Medicare for it is an example of Medicare fraud.
What are primary uses of financial information?
Financial statements report on a company’s income, cash flow and equity. The primary uses of financial information are to: assessment the financial condition of the organization, estimate the stewardship of the organization, review the efficiency and usefulness of operations, and establish the level of compliance with directions.
Should hospitals and physicians undercode Medicare patient stays and patient visits in order to reduce the possibility of being charged under the False Claims Act?
No. Coding experts believe any inaccurate coding is bad coding.
Yes. For multiple reasons, coding experts believe that this is an acceptable practice used to keep the hospital/physician practice in business and away from government scrunity.
Neither answer listed is correct.
Both answers listed are correct.
In order for integration with other physicians to be successful, what person is needed to arrange the financing of capital needs and to provide administrative leadership?
FCA charges against providers can be brought by individuals under a qui tam action.
One of the advantages of a nonprofit organization compared with an investor-owned company is that the investor-owned company is subject to federal income taxes.
EMTALA allows a hospital to transfer an emergency patient to another hospital because of the patient’s inability to pay.
What are the six stages of the revenue cycle?
Submission of the bill or claim to the respective payer
The provision of services to the patient
Generation of charges for services
Preparation of a bill or claim
Collection of payment
Documentation of services
What is the difference in ownership between a sole proprietorship, a partnership, and a corporation?
A sole proprietorship is a business owned by one individual.
A partnership exists when two or more persons associate to conduct a business.
A corporation is a legal entity created by a state. The corporation is separate and distinct from its owners and managers.
All of the statements are correct.
How does the Stark Law impact physicians?
The Stark Law prohibits a physician from referring a patient for certain designated health services to an entity with which the physician has a financial relationship.
A provider may not bill Medicare for a claim based on a prohibited referral.
Unlike antikickback statutes, the Stark Law does not include an intent requirement. In addition, the Stark Law applies only to referrals made by physicians.
The Stark law does not impact physicans at all and is mainly directed towards outside entites that may develop financial relationships with Medicare directly.
All of the statements are correct.
None of the statements are correct.
Hospital emergency room personnel are permitted to query the patient regarding his or her financial or insurance status at any time as long as the patient initiates such a discussion.
Which of the following covers nearly 100% of hospital service charges but is subject to a 20% coinsurance payment for most physician services?
Assume that an ambulance brought Cindy Roe to the emergency department of Grace Medical Center. She decides to leave the hospital without receiving treatment. The attending physician and the hospital staff offer Cindy medical examination and treatment within the hospital before she leaves. Cindy refuses treatment and refuses to sign an informed consent, and they let her go. The physician/hospital most likely has violated EMTALA.