Medicare fraud Study guides, Class notes & Summaries

CSPR - Certified Specialist Payment Rep (HFMA) Questions and Answers 2023 Steps used to control costs of managed care include: Bundled codes Capitation Payer and Provider to agree on reasonable payment DRG is used to classify Inpatient admissions for the purpose of reimbursing hospitals for each case in a given category w/a negotiated fixed fee, regardless of the actual costs incurred Identify the various types of private health plan coverage HMO Conventional PPO and POS H...

UNITED HEALTHCARE (UHC) – ETHICS AND COMPLIANCE LATEST 2023-2024 EXAM| ACTUAL QUESTIONS AND VERIFIED ANSWERS |A+ GRADE Q: Agent Jacob learns that Emily, the consumer with whom he is meeting, is the authorized legal representative for her father. What must Jacob explain to Emily when completing an Enrollment Application for her father? Answer: Jacob must explain that Emily will sign the Enrollment Application and must be able to provide documentation upon request by the Plan that indic...

AHIP TRAINING Medicare Fraud, Waste, and Abuse Training EXAM 50+ QUESTIONS AND VERIFIED CORRECT ANSWERS 2023. AHIP TRAINING Medicare Fraud, Waste, and Abuse Training 1. Medicare plan means: A MA plan, MA-PD plan or PDP 2. Subcontractor means: **An individual or entity that provides services on behalf of a Medicare plan sponsor. This includes individuals and organizations with DIRECT relationship with the plan sponsor or individuals or organizations with INDIRECT relationship, such as ...

Medicare Fraud, Waste, & Abuse (2022/2023) (Certified Answers) Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job, you use a process to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain individuals. What should you do? a.Do what your immediate supervisor asked you to do and adjust or add risk diagnosis co...

Does Medicare pay for all tests ordered by Providers? - No, they need to determine if it's covered and medically necessary. For larger physician practices, how often does the OIG suggest reporting compliance activities to the board of directors? - Regularly According to the OIG, medically unnecessary services can be billed to Medicare for what purpose? - To receive a denial so a claim can be submitted to a secondary payer. Which component of the OIG has a duty of operating the OIG hotline...

National Coverage Determination (NCD) - Which of the following Medicare policies determines if a particular item or service is covered by Medicare? Adjudication - Which of the following is considered the final determination of the issues involving settlement of an insurance claim? Encounter Form - A form that contains charges, DOS, CPT codes, ICD codes, fees and copayment information Admitting clerk - A patient comes to the hospital for an inpatient procedure. Which of the following hospi...

Steps used to control costs of managed care include: - ANSWER-Bundled codes Capitation Payer and Provider to agree on reasonable payment DRG is used to classify - ANSWER-Inpatient admissions for the purpose of reimbursing hospitals for each case in a given category w/a negotiated fixed fee, regardless of the actual costs incurred Identify the various types of private health plan coverage - ANSWER-HMO Conventional PPO and POS HDHP/SO plans - high-deductible health plans with a savings...

UNITED HEALTHCARE (UHC) – ETHICS AND COMPLIANCE LATEST 2023-2024 EXAM| ACTUAL QUESTIONS AND VERIFIED ANSWERS Version 2 |A+ GRADE Q: John has Power of Attorney to act on behalf of his mother. What does that mean when it comes to his mother enrolling in a Medicare Advantage Plan? Answer: John may sign the Enrollment Application and must be able to provide documentation upon request by the Plan that indicates his authority under state law to enroll his mother. Q: In which of the...

True or False: The ACA requires that all providers adopt a compliance plan as a condition of enrollment with Medicare, Medicaid, and Children's Health Insurance Program (CHIP). - Answer- True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) - Answer- 1.Protect our programs 2.Protect your patients 3.Protect the Provider At which level of the Medicare Part A or Part B appeals process is the app...

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