Ch 1 Flashcards
(16 cards)
Medicare part A
Covers inpatient hospital care, care provided in skilled nursing facilities, hospice, and home healthcare.
Medicare part B
Covers medically necessary physician services, outpatient care, & other medical services not covered by part A. An optional benefit with a premium.
Medicare part C
AKA Medicare advantage, combines benefits of parts A, B, and sometimes D. Managed by private insurers.
Medicare part D
A prescription drug program available to all Medicare beneficiaries.
Medical necessity
Refers to whether a procedure/service is appropriate. Generally the least radical service/procedure that allows for effective treatment.
Medicaid
Health insurance assistance program for some low-income people sponsored by federal and state governments.
Advance Beneficiary Notice (ABN)
Standardized form explaining to the patient why Medicare may deny the service/procedure. Provider must present the patient a cost estimate within $100 or 25% of the actual cost. Should be signed if service isn’t expected to be covered.
PHI
Protected Health Information
HIPAA
The Health Insurance Portability and Accountability Act of 1996. Provides federal protections for protected health info when held by covered entities.
HIPAA covered entities
Doctors, clinics, psychologists, dentists, chiropractors, nursing homes, pharmacies. DOES NOT COVER WORKERS COMP
Minimum Necessary Requirement
Only the minimum necessary protected health info should be shared to satisfy a particular response. If info isn’t required, it should be withheld.
HITECH
The Health Information Technology for Economic and Clinical Health act. Strengthens parts of HIPAA regarding electronic transmission of health info.
Fraud
To purposely bill for services that were never given, or to bill for a service that has a higher reimbursement than the service provided.
Abuse
Payment for items or services that are billed by providers in error that should not be paid for by Medicare.
OIG Compliance program
Designates a compliance officer/contract(s) to monitor compliance efforts and enforce standards, conduct training/monitoring, responds to violations through investigation, opens lines of communication, and enforces disciplinary standards.
OIG Work Plan
Sets forth a plan for the year specially pertaining to healthcare and providers, outlining priorities and projects. Announces potential problem areas and receives special scrutiny.
