Buck's Step-by-Step Unit 1: Reimbursement

Match the Medicare part(s) with the correct phrase(s) below.

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Automatic coverage under Social Security

Part A

Match the Medicare part(s) with the correct phrase(s) below.

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Optional coverage under Social Security

Part B, C, D

Match the Medicare part(s) with the correct phrase(s) below.

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Hospice care coverage

Part A

Match the Medicare part(s) with the correct phrase(s) below.

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Prescription drug coverage

Part D

Match the Medicare part(s) with the correct phrase(s) below.

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Physician visit coverage

Part B

Match the Medicare part(s) with the correct phrase(s) below.

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Beneficiary pays premium for coverage

Part B, C, D

Match the Medicare part(s) with the correct phrase(s) below.

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Codes assigned for payment using diagnoses; CPT; and HCPCS

Part A, B, C

The major third-party payer in the United States is the ______.

government

The Medicare program was established in what year?

1965

Hospital Insurance is Medicare Part ____.

A

Supplemental Medical Insurance is Medicare Part ____.

B

Which edition of the Federal Register is of special interest to hospital facilities?

October

Which edition of the Federal Register is of special interest to outpatient facilities?

November or December

The Medicare Economic Index is published in what publication?

Federal Register

In 1989, a major change took place in Medicare with the enactment of ________.

Omnibus Budget Reconciliation Act (OBRA)

This term is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes knowing that the deception could result in unauthorized benefit.

fraud

This organization develops a work plan to identify areas of the Medicare program that will be monitored.

Office of the Inspector General (OIG)

The physician responsible for controlling and managing the health care of an HMO enrollee is the _____.

gatekeeper

What does the abbreviation PACE stand for?

Program for All-Inclusive Care for the Elderly

Two insurance programs were established in 1965 by amendments to the Social Security Act known as Part ____ and Part ____.

A, B

The Secretary of DHHS has delegated responsibility for Medicare to which department?

Centers for Medicare and Medicaid Services (CMS)

Who administers funds for Medicare?

Social Security Administration

Who is eligible for Medicare? (select all that apply)

a. permanent kidney failure

b. 65 and over

c. 60 and over

d. disability benefits

e. chronic conditions

a. permanent kidney failure

d. disability benefits

Three components of the relative value unit are work, overhead (or practice expense), and __________.

malpractice

What does RBRVS stand for?

Resource-Based Relative Value Scale

What is the fastest growing segment of our population today?

Elderly (60+)

What is the name given to groups that handle the daily operations of the Medicare program?

Centers for Medicare and Medicaid Services (CMS)

Intentional deception or misrepresentation is known as

fraud

Quality Improvement Organizations were previously termed:

Peer Review Organizations (PROs)

MS-DRG assignment reports __________ services.

Part A

October editions of the Federal Register are of the special interest to:

hospital facilities

OBRA 1990 contained modifications and clarifications regarding the

physician fee schedule

What services are paid by Medicare Part A?

Hospital

What services are paid by Medicare Part B?

Physician

What services are paid by Medicare Part D?

Prescription Drugs

The Privacy Rule standards address the use and disclosure of individuals’ health information called:

Protected Health Information

Updates of special interest to hospital facilities are published in which month in the Federal Register?

October

In the RBRVS system, payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into what three components?

1. Physician work

2. Overhead (practice expense)

3. Malpractice

Who is responsible for developing an annual work plan to identify fraud?

Office of the Inspector General (OIG)

The purpose of managed health care is to provide ________ services and theoretically to _________ the health care services provided to the enrollee.

cost-effective, improve

A list of allowable charges for Medicare services.

Medicare Fee Schedule (MFS)

National network of consumers, physicians, hospitals, and other caregivers, who work to refine care delivery systems at the state level, striving to improve the quality, timing, and cost of care for Medicare patients.

Quality Improvement Organization (QIO)

An entity that manages the process claims for CMS.

Medicare Administrative Contractor (MAC)

A group of providers who form a network to provide services to enrollees at a discounted rate.

Preferred Provider Organization (PPO)

An official publication of all government “Rules and Regulations” and “Proposed Rules.”

Federal Register