CPB Exam 2023 with complete solution question s and answers

Abuse An action that results in unnecessary costs to a federal healthcare program, directly or indirectly. Anti-kickback Knowingly and willfully offering or accepting rewards or remuneration for services that are billable to a federal healthcare plan. Benefiiciary An individual that is eligible for Medicare or Medicaid benefits based on the CMS guidelines. Conditions of Participation (CoP) Conditions that healthcare organizations must meet in order to participate with the plan or program. Covered Entity Clearinghouse and providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards. Criminal Healthcare Fraud Act Scheme to willingly defraud any healthcare benefit program. False Claims Act Federal statute setting criminal and civil penalties for falsely billing the government; over representing the amount of a delivered product, or under stating an obligation to the government. Fraud Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal HC program. HIPAA-Health Insurance Portability and Accountability Act of 1996 Federal law in which the primary goal is to make it easier for people to keep insurance, protect the confidentiality and security of HC info and help control administration costs. PPO-Preferred Provider Organization Managed care organization of Drs, hospitals and other providers who agree with insurer to provide HC at reduced rates to their clients. PHI-Protected Health informaion Individually identifiable health information, reasonably used to identify an individual. Qui Tam Action A lawsuit brought by a private citizen against a person or company who is believed to have violated the law in the performance contact with the government of in violation of government regulation. Stark Law A federal law that places limitations of certain physician referrals. Truth in Lending Act An act which requires lenders to inform borrowers of all direct, indirect and true costs of credit. ACO-Accountable Care Organizations HC organization characterized by a payment and care delivery model rust seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. Capitation Fixed payment remitted at regular intervals to a medical provider by a managed care organization for an enrolled patient. Carve-out Service not covered in an insurance contract, usually reimbursed according to a different arrangement or rate formula. CDHP-Consumer Driven Health Plans Third tier insurance plans giving members more control over their heath budgets. CSC-Customized Sub-capitation Managed care plan in which HC expenses are funded by insurance coverage, individual selects one of each type of provider to create customized premium. DEERS-Defense Enrollment Eligibility Reporting System Database of all uniformed service members, their spouses and family members and others who are eligible for Tricare. Employer's Liability Insurance Protects an employer from damages from a lawsuit resulting from an injury due to the employer's negligence. EPO- Exclusive Provider Organization Organization that has entered into contracts with medical care providers or groups of medical care providers to provide HC services to members. FSA-Flexible Spending Account Tax advantaged HC account an individual contributes money into that is used to pay for certain out of pocket HC costs. Gatekeeper Physician, usually PCP, who is responsible for determining a patient's primary services and coordinating care for patient. GPWW-Group Practice Without Walls Medical practice formed to share economic risk, expenses and marketing effort. HMO-Health Maintenance Organization Organization that provides comprehensive HC with limited referral to outside specialists that is financed by fixed periodic payments determined in advance. HSA-Health Savings Account Savings account used in conjunction with a high deductible policy that allows users to save money tax free for medical expenses. HRA-Healthcare Reimbursement Account Employer funded plan that reimburses employees for incurred medical expenses that are not covered by the company's standard insurance plan. IDS-Integrated Delivery System Network of affiliated facilities and providers working together to offer joint HC services. IPO-Integrated Provider Organization Corporate umbrella for the management of diversified HC delivery system. MCO-Managed Care Organization Organization that combines the functions of inurance MSO-Management Service Organization Business providing nonclinical services to providers, like practice management service, to individual physicians practices. NPI-National Provider Identifier Unique 10 digit ID number required by HIPAA. PHO-Physician-Hospital Organization Organization that is owned by hospitals and physician groups working cooperatively to develop improved methods of HC delivery,oversee integration of physicians and hospitals into health delivery networks, assist in voluntary group formation, and collect, analyze and disseminate information. Privileging Assesses the physician's expertise in a specific practice based on documented competence in the specialty in which privileges are requested. Triple Options Plan Allows an insurer to administer three different HC plans so that members may select the benefit options they want; straight indemnity insurance, HMO or PPO. Indemnity Plan Allows patient to choose any physician and facility of their choosing. Group Model HMO HMO that contracts with multi-specialty group that provides care to members. Staff Model HMO (Closed Panel HMO) HMO that employs the physicians on salary to provide care to the members in the clinics and other facilities owned by the HMO. Physicians contracted to provide care to only the HMO patients. Network Model HMO HMO that contracts with more than one multi-specialty group, individual practice groups and individual physicians. IPA-Individual Practice Association HMO that contracts with independent physicians who maintain their offices and provide services to HMO and non-HMO patients for which they receive a fixed amount per patient. Mixed Model HMO HMO that combines features of the IPO and group models together. COBRA Created under the Consolidated Omnibus Reconciliation Act. It allows an employee who leaves a company to continue to be covered under the company's health plan for a certain time period and under certain conditions. Medicare Secondary Payer (MSP) Form Medicare Secondary Payer Form is used to determine if Medicare is secondary to another insurance. Patient Ledger Computerized permanent record of all financial transactions between the patient and the practice; patient account record. Acute Condition with rapid or short course. Chronic Condition that develops slowly and lasts a long time. Combination Code Single code used to classify two diagnoses. External Code Code used to identify how and where an injury occurred. Etiology Cause of the disease. Eponym Disease or syndrome named after a person. Essential Modifiers Subterms that are listed below the main term in alphabetical order that are indented. Excludes1 Note to indicate the terms listed are to be reported with a code from another category. Excludes2 Note indicates that the condition excluded is not part of the condition represented by the code. A patient may have both conditions at the same time. It is acceptable to use both the code and the excluded code together. Includes Note under the three digit category title to define further or to give an example of the contents of the category. NEC Not elsewhere classifiable. Nonessential Modifiers Subterms that follow the main term and are enclosed in parentheses. Clarify diagnosis but are not required. NOS Not otherwise specified. Sequela An inactive, residual effect or condition produced after the acute portion of an injury or illness has passed. Tabular List Diagnosis codes organized in numerical order. Z Codes Codes used to describe circumstances or conditions that could influence patient care. Current Procedural Terminology (CPT) A code set copyrighted and maintained by the American Medical Association (AMA). Global Surgery Status Indicator An assigned indicator, which determines classification for a minor or major surgery, based on relative value unit (RVU) calculations. Major Surgery Global period is one day prior to surgery to 90 days after. Minor Surgery Global period is day of surgery and 0-10 days after. National Correct Coding Initiative (NCCI) Used by professional billers to determine codes considered by CMS to be bundled codes for procedures and services deemed necessary to accomplish a major procedure. Advanced Beneficiary Notice (ABN) Standardized form that explains to patients why Medicare may deny the particular service or procedure. Healthcare Common Procedure Coding System (HCPCS) Level II National procedure code set for HC practitioners, providers and medical equipment suppliers when filing claims for devices, transportation and other items and services. Locum Tenens Substitute physician who takes over the professional practice of a physician who is absent for a reason such as illness, pregnancy, vacation or continuing medical evaluation. Regular physician submits claim with modifier Q6 to all services. Medicare Administrative Contractor (MAC) Company under contract with the federal government to handle claims processing for Medicare services. Medical Unlikely Edits (MUE) Part of NCCI edits that places limits on the frequency that individual codes can be billed on a single date of service by a single provider. Outpatient Code Editor (OCE) Software that edits outpatient hospital claims to detect incorrect billing data and determine if the Ambulatory Surgery Center (ASC) limit should apply to each claim and reviews all codes for validity and coverage. Electronic Data Interchange (EDI) Computer to computer exchange of business documents in a standard format, between business partners. Birthday Rule The health plan of the parent whose birthday is first in the calendar year is designated as primary. Chargemaster Hospital specific electronic list that includes all procedures, services, supplies and drugs that are billed to payers. Synonymous with charge description master (CDM). Clean Claim Claim with all the elements necessary to adjudicate the claim. CPT-Current Procedural Terminology Five digit code used to describe medical, surgical, radiology, laboratory, anesthesia and E/M services. Electronic Data Interchange (EDI) Describes the process of transferring data electronically between providers and insurances. Fee Schedule List of fees the physician establishes is the fair price for the services they provide. Subrogation When an insurance company attempts to recoup expenses for a paid claim when another payer should have been responsible. Bad Debt A/R that will likely remain uncollected and will be written off. Fair Debt Collection Policy Act (FDCPA) States that third party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred for personal, family or household purposes. Fair Credit Reporting Act Protects information collected by the consumer reporting agencies. Fee For Service (FFS) Payment model where payment is made to a provider for each individual service. Ledger Card Am accounting of service descriptions, charges, payments, adjustments and where current balances are posted. Prompt Payment Act Federal law that ensures that federal agencies pay their bills within 30 days of receipt and acceptance of materials and/or services. Resource Based Relative Value Scale (RBRVS) Payment system that takes into account the work done by physicians, malpractice insurance and practice expenses. Practice expenses include overhead, supplies, equipment and staff salaries.