Physician Advisor Role In HCQM – Complete Study
Guide
What are the roles of physician advisor? Right Ans - Regulatory
oversight, cost containment, Medicare audits and denials, commercial
insurance denials, length of stay management, clinical documentation
improvement, and ICD-10 implementation. Done with concurrent reviews,
daily MDR rounds, patient quality and safety initiatives, compliance,
coding, CDI and physician education.
PSROs- Professional standards review organizations Right Ans - Created
to review the quality, quantity, and cost of hospital care provided through
Medicare and Medicaid 1972
Regulatory payer Right Ans - CMS- governed by government policies
and guidelines
Medicare coverage database (MCD) Right Ans - used by Medicare
administrative contractors, providers, and other health care industry
professionals to determine whether a procedure or service is reasonable
and necessary for the diagnosis or treatment of an illness or injury;
contains national coverage determinations (NCDs), including draft policies
and proposed decisions; local coverage determinations (LCDs), including
policy articles; and national coverage analyses (NCAs), coding analyses for
labs (CALs), Medicare Evidence Development & Coverage Advisory
Committee (MedCAC) proceedings, and Medicare coverage guidance
documents.
MAC Right Ans - Medicare Administrative Contractors. Develop payment
policies to education providers on how to submit accurate claims for
reimbursement
RAC (RA) Right Ans - Recovery Audit Contractor
CERT Right Ans - Comprehensive Error Rate Testing
QIO (Quality Improvement Organization) Right Ans - A private
organization composed of practicing physicians and other health care
, professionals in each state that is paid by the Centers for Medicare &
Medicaid Services under contract to review the care provided to Medicare
beneficiaries.
ZPIC Right Ans - Zone Program Integrity Contractor
Zone Program Integrity Contractor (ZPIC) Right Ans - program
implemented in 2009 by CMS to review billing trends and patterns,
focusing on providers whose billings for Medicare services are higher than
the majority of providers in the community. ZPICs are assigned to the
Medicare administrative contractor (MAC) jurisdictions, replacing the
Program Safeguard Contracts (PSCs).
Supplemental Medical Review Contractors Right Ans - SMRC
MIC Right Ans - Medicaid Integrity Contractors; review, audit, and
educate providers to combat fraud and abuse.
Prospective Review Right Ans - reviewing appropriateness and
necessity of care provided to patients prior to administration of care.
concurrent review Right Ans - review for medical necessity of tests and
procedures ordered during an inpatient hospitalization
Retrospective review Right Ans - reviewing appropriateness and
necessity of care provided to patients after the administration of care
MAC (Medicare Administrative Contractor) Right Ans - Pay part A and B
claims. They must be paid within 30 days.
QIO (Quality Improvement Organization) Right Ans - Evaluates quality
of first admission of readmission that occurs within 30 days after
discharge. May require admissions to be bundled together if felt discharge
was too early or poor discharge planning. Settles appeals if patient does
not want discharge. Reviews short stay inpatient claims.
Recovery Audit Contractor (RAC) Right Ans - To retrospective reviews
claims for billing errors. Has 4 regional contractors. Now only reviews
Guide
What are the roles of physician advisor? Right Ans - Regulatory
oversight, cost containment, Medicare audits and denials, commercial
insurance denials, length of stay management, clinical documentation
improvement, and ICD-10 implementation. Done with concurrent reviews,
daily MDR rounds, patient quality and safety initiatives, compliance,
coding, CDI and physician education.
PSROs- Professional standards review organizations Right Ans - Created
to review the quality, quantity, and cost of hospital care provided through
Medicare and Medicaid 1972
Regulatory payer Right Ans - CMS- governed by government policies
and guidelines
Medicare coverage database (MCD) Right Ans - used by Medicare
administrative contractors, providers, and other health care industry
professionals to determine whether a procedure or service is reasonable
and necessary for the diagnosis or treatment of an illness or injury;
contains national coverage determinations (NCDs), including draft policies
and proposed decisions; local coverage determinations (LCDs), including
policy articles; and national coverage analyses (NCAs), coding analyses for
labs (CALs), Medicare Evidence Development & Coverage Advisory
Committee (MedCAC) proceedings, and Medicare coverage guidance
documents.
MAC Right Ans - Medicare Administrative Contractors. Develop payment
policies to education providers on how to submit accurate claims for
reimbursement
RAC (RA) Right Ans - Recovery Audit Contractor
CERT Right Ans - Comprehensive Error Rate Testing
QIO (Quality Improvement Organization) Right Ans - A private
organization composed of practicing physicians and other health care
, professionals in each state that is paid by the Centers for Medicare &
Medicaid Services under contract to review the care provided to Medicare
beneficiaries.
ZPIC Right Ans - Zone Program Integrity Contractor
Zone Program Integrity Contractor (ZPIC) Right Ans - program
implemented in 2009 by CMS to review billing trends and patterns,
focusing on providers whose billings for Medicare services are higher than
the majority of providers in the community. ZPICs are assigned to the
Medicare administrative contractor (MAC) jurisdictions, replacing the
Program Safeguard Contracts (PSCs).
Supplemental Medical Review Contractors Right Ans - SMRC
MIC Right Ans - Medicaid Integrity Contractors; review, audit, and
educate providers to combat fraud and abuse.
Prospective Review Right Ans - reviewing appropriateness and
necessity of care provided to patients prior to administration of care.
concurrent review Right Ans - review for medical necessity of tests and
procedures ordered during an inpatient hospitalization
Retrospective review Right Ans - reviewing appropriateness and
necessity of care provided to patients after the administration of care
MAC (Medicare Administrative Contractor) Right Ans - Pay part A and B
claims. They must be paid within 30 days.
QIO (Quality Improvement Organization) Right Ans - Evaluates quality
of first admission of readmission that occurs within 30 days after
discharge. May require admissions to be bundled together if felt discharge
was too early or poor discharge planning. Settles appeals if patient does
not want discharge. Reviews short stay inpatient claims.
Recovery Audit Contractor (RAC) Right Ans - To retrospective reviews
claims for billing errors. Has 4 regional contractors. Now only reviews
