Chapter 1 CPMA Exam Prep Complete Questions & Answers.

12.1% - ANSWER # of improper Medicare Fee-For-Service claim payments, according to Federal Government. FFS - ANSWER Fee-For-Service Prepayment Review - ANSWER Review of claims prior to payment. Prepayment reviews result in an initial determination. Postpayment Review - ANSWER Review of claims after payment. May result in either no change to the initial determination or a revised determination, indicating an underpayment or overpayment. Underpayment - ANSWER A payment a provider receives under the amount due for services furnished under the Medicare statute and regulations. Overpayment - ANSWER A payment a provider receives over the amount due for services furnished under Medicare statutes and regulations 5 Common reasons for overpayment are: - ANSWER *Billing for excessive and subsequent payment of the same service or claim. *Duplicate submission and payment for same service or claim *Payment for excluded or Medically unnecessary services. *Payment for services in setting not appropriate to pt's needs or condition *Payment to an incorrect payee. MACs - ANSWER Medicare Administrative Contractors MAC Responsibilities - ANSWER Process claims from physicians, hospitals, and other health care professionals, and submit payment to those providers according to Medicare rules and regulations (including identifying under- and overpayments). ZPICs - ANSWER Zone Program Integrity Contractors PSCs - ANSWER Program Safeguard Contractor ZPICs/PSCs - ANSWER Perform investigations that are unique and tailored to specific circumstances and occur only in situations where there is potential fraud, and take appropriate corrective actions