What are Medical Ethics? - Correct answer-Standards of conduct based on moral
principle. They are generally accepted as a guide for behavior towards
... [Show More] pt's, dr's, coworkers, the gov, and ins co's.
What does acting within ethical behavior boundaries mean? - Correct answer-carrying
out one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, &
trust.
Legal Aspects of of Medical Billing & Coding: - Correct answer-...
Compliance regulations: - Correct answer-Most billing-related cases are based on
HIPPA and False Claims Act
Health Insurance Portability & Accountability Act (HIPPA) - Correct answer-Enacted in
1996, created by the Health Care Fraud & Abuse Control Program-enacted to check for
fraud and abuse in the Medicare/Medicaid Programs and private payers
What are the 2 provisions of HIPPA? - Correct answer-Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA? - Correct answer-Insurance Reform-primary purpose is to
provide continuous ins coverage for worker & their dependents when they change or
lose jobs. Also *Limits the use of preexisting conditions exclusions *Prohibits
discrimination from past or present poor health *Guarantees certain employees/indv the
right to purchase new health ins coverage after losing job *Allows renewal of health ins
cov regardless of an indv's health cond. that is covered under the particular policy.
What is Title II of HIPPA? - Correct answer-Administrative Simplification-goal is to focus
on the health care practice setting to reduce administrative cost & burdens. Has 2 parts1) development and implementation of standardized health-related financial &
administrative activities electronically 2) Implementation of privacy & security
procedures to prevent the misuse of health info by ensuring confidentiality
What is the False Claims Act (FCA)? - Correct answer-Federal law that prohibits
submitting a fraudulent claim or making a false statement or representation in
connection w/ a claim. Also protects & rewards whistle-blowers.
CBCS Exam with 100% Correct Answers
2023 Version Graded A+
What is the National Correct Coding Initiative (NCCI)? - Correct answer-Developed by
CMS to promote the national correct coding methodologies & to control improper coding
that lead to inappropriate payment of Part B health ins claims.
How many edits does NCCI include? - Correct answer-2: 1)Column 1/Column 2 (prev
called Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Column 1/Column 2 edits (NCCI) - Correct answer-Identifies code pairs that should not
be billed together b/c 1 code (Column 1) includes all the services described by another
code (Column 2)
Mutually Exclusive Edits (NCCI) - Correct answer-ID's code pairs that, for clinical
reasons, are unlikely to be performed on the same pt on the same day
What are the possible consequences of inaccurate coding and incorrect billing? -
Correct answer-*delayed processing & payment of claims *reduced payments, denied
claims *fine and/or imprisonment *exclusion from payer's programs, loss of dr's license
to practice med
Who has the task of investigate and prosecuting health care fraud & abuse? - Correct
answer-The Office of Inspector General (OIG)
Fraud - Correct answer-knowingly & intentionally deceiving or misrepresenting info that
may result in unauthorized benefits. It is a felony and can result in fines and/or prison.
Who audits claims? - Correct answer-State & federal agencies as well as private ins
co's
What are common forms of fraud? - Correct answer-billing for services not furnished,
unbundling, & misrepresenting diagnosis to justify payment
Abuse - Correct answer-incidences or practices, not usually considered fraudulent, that
are inconsistent w/ the accepted medical business or fiscal practices in the industry.
What are examples of Abuse? - Correct answer-submitting a claim for
services/procedures performed that is not medically necessary, and excessive charges
for services, equipment or supplies.
What is a method use to minimize danger, hazards, & liabilities associated w/ abuse? -
Correct answer-Risk Management
Patient Confidentiality - Correct answer-All pt's have right to privacy & all info should
remain privileged. Only discuss pt info when necessary to do job. Obtain a signed
consent form to release medical info to ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization
under the HIPPA Privacy Rule? - Correct answer-When using for TPO, Treatment
(primarily for the purpose of discussion of pt's case w/ other dr's) Payment (providers
submit claims on behalf of pt's) & Operations (for purposes such as training staff &
quality improvement)
What is Employer Liability? - Correct answer-Means physicians are legally responsible
for their own conduct and any actions of their employees (designee) performed w/in the
context of their employment. Referred to as "vicarious liability. A.K.A "respondent
superior"-"let the master answer". Means employee can be sued & brought to trial
What is Employee Liability? - Correct answer-"Errors & Omissions Insurance"-protection
against loss of monies caused by failure through error or unintentional omission on the
part of the indv or service submitting the claim. ****Some dr's contract w/ a billing
service (clearinghouse) to handle claims submission, & some agreements contain a
clause stating that the dr will hold the co harmless from "liability resulting from claims
submitted by the service for any account", means dr is responsible for mistakes mad [Show Less]