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1. By contrast, statutes and regulations are written abstractly. Case law, also used interchangeably with common law, refers to the collection of precedents and authority set by previous judicial decisions on a particular issue or topic. In that sense, case law differs from one jurisdiction to another.
2. Civil law deals with the disputes between individuals, organizations, or between the two, in which compensation is awarded to the victim. Criminal law is the body of law that deals with crime and the legal punishment of criminal offenses.
3. A subpoena is a legal document that commands a person or entity to testify as a witness at a specified time and place (at a deposition, trial, or other hearing), and/or to produce documents or other tangible objects in a legal proceeding.
4. Subpoena duces tecum is a type ofsubpoenathat requires thewitness to produce documents, books, records, or otherevidence pertinent to a legalproceeding. This subpoena will have a designated time and place for compliance based on state and federal statutes. The most common manner for providing the evidence is usually by mailing or emailing the records.
5. Both depositions and interrogatories are used to obtain information and evidence that can be used as proof in a trial, but there are some notable differences. A deposition is a meeting where oral questions are asked, while an interrogatory is a written series of questions.
6. Qui tam is the abbreviation for the Latin phrase "qui tam pro domino rege quam pro se ipso in hac parte sequitur," meaning "Who sues on behalf of the King as well as for himself."A False Claims Act whistleblower can receive between 15 and 30 percent of the total recovery the U.S. gets from the defendant.
7. The Federal Registry is a daily gazette containing Presidential documents and new and amended Federal regulations. The Office publishes the complete set of Federal rules in the Code of Federal Regulations.
8. Program Transmittals often contains a summary section that provides a concise overview of the modifications or updates being introduced. This summary helps healthcare providers quickly grasp the key points without having to read the entire document.
9. A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
10. Records retention describes the methods and practices an organization will use to safeguard important records and maintain them for the required period of time until they need to be stored, redirected or otherwise disposed of.CMS requires that you retain the patient records for 10 years.
11. 6 years
12. 50 years
13. 5 titles
14. Title I protects health insurance coverage for individuals who lose or change jobs. It also prohibits group health plans from denying coverage to individuals with specific diseases and preexisting conditions and from setting lifetime coverage limits. Title II: HIPAA Administrative Simplification.
15. Establish national standards for processing electronic healthcare transactions. It also requires healthcare organizations to implement secure electronic access to health data and to remain incompliancewith privacy regulations set by HHS.
16. Committing Medicare fraud exposes individuals or entities to potential criminal, civil, and administrative liability, and may lead to imprisonment, fines, and penalties.
17. Violations are determined based on a tiered penalty structure. And up to $11,000 per violation
18. (a) Billing for services not rendered. (b) Billing for a non-covered service as a covered service. (c) Misrepresenting dates of service. (d) Misrepresenting locations of service. (e) Misrepresenting provider of service. (f) Waiving of deductibles and/or co-payments.
19. 1. a pattern of waiving cost-shares or deductibles 2. failure to maintain adequate medical or financial records, 3. a pattern of claims for services not medically necessary, 4. refusal to furnish or allow access to medical records, 5.improper billing practices, 6. Doctor Shopping, 7. Using Brand-Name Drugs
20. Compliance programs play a vital role in identifying potential risks early on through risk assessments and ongoing monitoring. They provide a framework for addressing areas where legal requirements may be overlooked, ensuring that organizations remain within the boundaries of the law.
21. 1. Guard your online information. 2. Monitor your accounts. 3. Business Email Compromise. 4. Shred sensitive documents. 5. Check your credit report. 6. Think twice about sharing your information. 7. Implement fraud detection tools. 8. Report suspicious activity.
22. Medical reviews identify errors through claims analysis and/or medical record review activities. Contractors use this information to help ensure they provide proper Medicare payments (and recover any improper payments if the claim was already paid).
23. Medicare Administrative Contractors (MACs) regionally manage policy and payment related to reimbursement and act as the fiscal intermediary for Medicare. MACs manage provider claims for payment and establish regional policy guidelines, called Local Coverage Determinations (LCDs).
24. The Deficit Reduction Act of 2005 created the Medicaid Integrity Program (MIP) in section 1936 of the Social Security Act (the Act), and dramatically increased the Federal government's role and responsibility in combating Medicaid fraud, waste and abuse.
25. The goal of the recovery audit program is to identify improper payments made on claims for services provided to Medicare beneficiaries.
26. DOJ and HHS OIG
27. The Medicare Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to give coordinated, high-quality care to their Medicare beneficiaries.
28. The Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and reduces improper coding, with the overall goal of reducing improper payments of Medicare Part B and Medicaid claims.
29. Improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care.
30. Invoice numbers. Record numbers. Combination of account number and entity number.
31. EDI, which stands for electronic data interchange, is the intercompany communication of business documents in a standard format. The simple definition of EDI is that it is a standard electronic format that replaces paper-based documents such as purchase orders or invoices.
32. Electronic Medical Record (EMR) and Electronic Health Record (EHR), Practice Management Software and Master Patient Index (MPI).
33. Protected health information (PHI) is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment.
34. Privacy is about controlling your personal data, confidentiality involves safeguarding information from unauthorized access, and security is the measures taken to protect data and systems from threats. Each of these concepts plays a major role in making sure that information remains protected.
35. A breach of confidentiality is when data or private information is disclosed to a third party without the data owner's consent.
36. A person who knowingly obtains or discloses individually identifiable health information in violation of the Privacy Rule may face a criminal penalty of up to $50,000 and up to one-year imprisonment.
37. Health Information Technology for Economic and Clinical Health ACT of 2009
38. It was intended to incentivize the use of electronic health records (EHRs) and expand protections of health information, through the intensification of HIPAA language and regulations, the lowering of financial barriers in the switch from paper to electronic records, and increased security measures to protect client.
39. A good Release of Information form should be clear, concise, and easy to understand. It should include all necessary information such as the patient's name, date of birth, and specific details about the information to be released. It should also specify who is authorized to receive the information and for what purpose.
40. Title III: Guidelines for pre-tax medical spending accounts

MAB Ch 12 NTQ

1. Which is more expensive, individual health insurance plan or group health insurance plan?
2. List 4 insurance plans under individual insurance plan.
3. Describe a group health insurance plan.
4. Can the employer limit access to certain health care options for members of a group health insurance plan?
5. List the items covered by an automobile insurance policy.
6. What does disability insurance pay for?
7. Under what conditions can an individual be found ineligible for disability benefits?
8. If a person is injured while on the job, which liability insurance pays for the medical cost of treating the patient?
9. List 4 conditions under which the commercial payer is the primary payer on a claim.
10. Describe the birthday rule.
11. When primary and secondary policies are from the same insurer, how many CMS-1500 forms are filed?
12. When the primary and secondary insurers are different, explain how the CMS-1500 claims are filed.

MAB Ch 13 NTQ 1. Explain the origin of BlueCross. 2. Explain the origin of Blue Shield. 3. Explain the development of BlueCross Blue Shield. 4. What is the difference between a nonprofit and a for profit corporation. 5. What are the responsibilities of participating providers? 6. What does BCBS agree to provide to their participating providers? 7. How much is a preferred provider network physician paid compared to a participating provider? 8. To whom does BCBS send payments when a BCBS patient is seen by a nonparticipating provider? 9. What services are covered under BCBS basic coverage? 10. What services are covered under BCBS major medical coverage? 11. What is a rider? 12. Describe the special accidental injury and the medical emergency care riders. 13. What allowances are made under BCBS indemnity coverage? 14. Describe the EPO plan. 15. Describe the HMO plan. 16. Describe the outpatient pretreatment authorization plan. 17. Describe the point of care plan. 18. What is the purpose of the second surgical opinion? 19. What is the purpose of the BCBS Federal Employee Program? 20. What is the purpose of BCBS Medigap plan? 21. List and describe 4 different healthcare anywhere BCBS plan. 22. Who submits claims for BCBS members? 23. All claims filed by PAR quality for assignment of benefits to the provider. What does this mean?

MAB Ch 14 Medicare 1. Who authorizes and who administers the Medicare Program? 2. What is the function of the Medicare Administrative contractors? 3. What does Medicare Part A cover? 4. What does Medicare Part B cover? 5. Describe Medicare Part C and Medicare Part D. 6. What is the purpose of Medigap insurance? 7. Which form is used to file Medicare Pat A and why? 8. What are the general Medicare eligibility requirements? 9. Which individuals under age 65 years old, qualify for Medicare? 10. Which part of the Medicare plan requires a premium? 11. To access eligibility information, what information about the provider must be verified? 12. In accessing eligibility information for the Medicare beneficiary, what information will be provided? 13. How does a person qualify for free Medicare Part A? 14. How can a person who has not paid into Medicare receive Medicare Part A? How much does it cost? 15. How are Medicare Part A premium determined? 16. When a person signs the Medicare card, what portion of the Medicare insurance plan are they agreeing to? Will they pay a premium? 17. If a person receives a Medicare card t does not want to pay a premium, what option do they have? 18. Which individuals don't not have to apply for Medicare Part A and B coverage? 19. Which individuals have to apply for Medicare Part A and Part B coverage? 20. What penalty is incurred if a person is eligible for Part B but did not participate at their time of eligibility? 21. Under what condition can a person delay participation in Medicare Part B without the penalty of increased premium? 22. What is the purpose of Medicare savings program? 23. Is hospitalization and medical care provided by a physician in the hospital, covered by Medicare Part A? 24. Does Medicare Part A (Medicare Hospital Insurance) cover the entire hospital charges while the patient is hospitalized? Explain. 25. What are lifetime reserve days and how often can they be used in a lifetime? 26. What is the cost to the patient on Medicare, for being in the hospital for: a. 1-60 days b. 61-90 days c. 91-150 days d. 150 + days 27. How many days is the lifetime reserve days for patients in a psychiatric ward? 28. What is the cost to the patient on Medicare for being in a skilled nursing facility for: a. 1-20 days b. 21-100 days c. 100+ days 29. If the doctor ordered/prescribed home health care for the patient with Medicare insurance, how much does the patient have to pay? 30. How much does a patient on prescribed home health care pay for durable medical equipment? 31. Define hospice. 32. How much does it cost for hospice care? 33. What is the cost to the patient, if he or she has to used Medicare Part B? 34. Can a provider choose to be kind to a patient with Medicare, by not collecting deductible and coinsurance from them?

35. What criteria are used to determine how much a physician is paid for services provided to patients with Medicare insurance? 36. What is the cost to a patient who has Medicare insurance, to use the ambulance services? 37. Describe Medicare Part C. 38. Who approves Medicare Part C, and who manages it? 39. What does Medicare Part C measure? 40. If you purchased Medicare Part C, do you also need to purchase Medicare Part D and Medigap insurance? 41. What are the different plan options available to patients enrolled in Medicare Part C? 42. How does private fee for service plans work for Medicare beneficiaries? 43. Is there a penalty for joining Medicare Part D later than the initial eligibility period? 44. What is the purpose of the Medicare Part D "donut hole"? 45. How did the Affordable Care Act assist with Medicare Part D? 46. What is the annual deduction for Medicare Part D? 47. What percentage of the drug cost does the patient pay during the coverage gap period? 48. At what point does the patient pay only a small copayment or coinsurance? 49. What is the goal of the PACE program? 50. What is the purpose of Medigap insurance? 51. What kind of program is Medicare Select? 52. What percentage of providers are Medicare participating providers (PARs)? 53. Does Medicare pay non-PARs more or less than the PARs? 54. Under the privacy act of 1974, what information cannot be disclosed to a Non-PAR? 55. If a patient is enrolled in Medicare Part B, who files the reimbursement claim, Medicare or the provider? 56. What is a Medicare Private Contract? 57. If a provider enters into a Medicare Private contract with one patient, is the provider able to bill for other Medicare patients, with whom no contractual agreement is made? 58. If a provider enters into a Medicare Private contract with one patient, under what condition is the provider able to bill for another Medicare patients? 59. Who provides an advance beneficiary notice of non-coverage and why? 60. Who is responsible for a non-covered service? 61. Why should the provider have the Medicare beneficiary sign an ABN prior to preventative service? 62. What is the difference between an ABN and a NEMB? 63. What is the hospital version of an ABN? 64. List the 4 modifiers that can be added to a procedure code that may be denied by Medicare. 65. Under what condition must a provider refund a patient for services rendered and paid for, out of pocket, by the patient? 66. Under what condition is Medicare the primary payer? 67. When is Medicare assigned a conditional primary payer status? 68. When is Medicare a secondary payer? 69. Under what condition would a provider need to file two CMS-1500 form of a given patient, during an encounter? 70. What modifier is used to indicate telemedicine services was provided?

MAB Ch 15 NTQ 1. Who mandates Medicaid? 2. Who administers Medicaid? 3. Give the variation of names for Medicaid used in California, Massachusetts and Tennessee. 4. Who is eligible for Medicaid? 5. Does the federal government provide 100% of the funds for Medicaid? Explain. 6. Who monitors, establishes requirements for delivery, funding, quality of service and eligibility for Medicaid? 7. What was the impact of the Affordable Care Act on Medicaid eligibility? 8. What is the effect of the June 2012 supreme court ruling concerning Medicaid? 9. What is the effect of modified gross income on Medicaid recipients? 10. Who are considered to be Categorically Needy groups for Medicaid? 11. Who qualify for the Medicaid Medically Needy Program? 12. List 9 different groups who qualify for Medicaid under the special group category? 13. What is the purpose of SCHIP-State Children Health Insurance Plan? 14. What services are included in the Program of All-inclusive Care for the elderly? 15. What is the purpose of the Spousal Improvement Protection Legislation 1989? 16. How often should you verify patient's Medicaid eligibility? 17. If a patient qualifies for retroactive eligibility, who is refunded and who is billed for the services rendered and paid for? 18. What services must be provided to the patient if the state receives federally matching funds for Medicaid? 19. When does a Medicaid beneficiary require preauthorization? 20. Who pays the providers for services rendered to Medicaid beneficiaries? 21. Which services are exempt form (Medicaid) copayment? 22. Which group of Medicaid beneficiaries are exempt from cost sharing requirements? 23. Under the Federal Medical Assistance Percentage program, how much does the federal government pay for the following entities: a. Wealthier States b. Indian Health Services c. Emergency services provided to undocumented aliens. 24. What services may be covered by Medicaid to Medicare beneficiaries with low income and limited resources? 25. Which patients have Medi-Medi coverage? 26. Medicaid is always a payer of last resort. Explain this statement. 27. Why is balanced billing illegal under Medicaid? 28. What percentage of Medicaid beneficiaries are also enrolled under Managed Care Organization? 29. Who pays for specialty care provided to Medicaid beneficiaries? 30. List the three electronic systems used to access the State's eligibility files for Medicaid beneficiaries. 31. To whom is a remittance advice sent? 32. What is the difference between adjusted claim and voided claim? 33. What is the purpose of the surveillance and utilization review subsystem? 34. When is a service considered to be medically necessary? 35. What information is needed for non-emergency hospitalization of Medicaid beneficiaries?

MAB CH 16 NTQ 1. Who is covered by Tricare? 2. Describe the CHAMPUS Reform Initiative. 3. What is the responsibility of Health Affairs? 4. What is the purpose of TAMP - Transitional Assistance Management Program? 5. Who determines eligibility for TAMP? 6. Where is TAMP eligibility documented? 7. Describe the Continued Health Care Benefit Program? 8. Who administers the TRICARE Program? 9. Who are TRICARE sponsors? 10. What is the role of the beneficiary service representative? 11. What is the role of the health care finder? 12. What is the difference between preauthorization and referral? 13. Who makes up the TRICARE civilian provider network and who files claims for services rendered to the patients? 14. What is the job of the Nurse Advisor? 15. What is a military treatment facility? 16. Differentiate between crucial pathways, practice guidelines and discharge planning. 17. What is the purpose of the program integrity office? 18. Under what condition can an authorized provider be excluded from the TRICARE program participation? 19. What is the purpose of the Health Administration Center? 20. What is the difference between CHAMPVA sponsor and CHAMPVA beneficiary? 21. What was the purpose of the Veterans Access, Choice and Accountability Act of 2014? Who qualified for this program? 22. Describe a primary care manager. 23. What are catchment areas? 24. Who makes arrangements with the military and civilian specialist on behalf of the TRICARE Prime beneficiary? 25. What happens when a TRICARE Prime beneficiary seeks medical care without prior approval? 26. What facility should the beneficiary go to, when there is a need for emergency care? 27. What is a benefit of the catastrophic cap benefit? 28. What are the requirements and benefits of TRICARE Extra? 29. What are the requirements and benefits of TRICARE standard? 30. What is the difference between TRICARE Reserve Select and TRICARE Retired Reserve? 31. Who qualifies for TRICARE for life (lifetime)? 32. What is the difference between US Family Health Plan and TRICARE Young Adult program? 33. Describe the dental care option under TRICARE. 34. What is the difference between a demonstration project and a clinical trial? 35. What are TRICARE supplemental plans? 36. What is the difference between a remittance advice and an explanation of benefits? 37. When is the deadline for filing TRICARE claims? 38. What period describe a government fiscal year? 39. How is TRICARE eligibility confirmed? 40. What is TRICARE's limiting charge for non-participating providers?

MAB Ch 17 NTQ 1. Who pays for and are required to maintain workers' compensation for employees? 2. What does worker's compensation insurance cover? 3. What benefits are included in the workers' compensation plan? 4. How do worker's compensation laws protect employers and employees? 5. What is the difference in the Federal workers' compensation and the State workers' compensation laws? 6. List 3 California laws that are related to workers' compensation? 7. Who administers workers' compensation? 8. What benefits are included in the Federal workers' compensation program? 9. List the four programs administered by the Office of Workers' Compensation Programs. 10. List 3 programs designed to prevent work related injuries and illnesses. 11. List 2 additional programs related to workers' compensation. 12. Who is compensated by the EEOICP? 13. Who is compensated by the Coal Mine Workers' Compensation Program? 14. When was the coal mine compensation program enacted? 15. What was the former name of the coal mine compensation program? 16. Who gets monthly checks from the Coal Mine Workers' Compensation Program? 17. When was FECA enacted and who receives benefits from FECA? 18. Who processes claims for FECA clients? 19. Who administers the Longshore and Harbor Workers' Compensation Program? 20. List the workers/type of employment covered by Longshore and Harbor Workers' Compensation. 21. What is the purpose of the Employee Compensation Appeal Board (ECAB)? 22. Who has final decision after the ECAB has made a determination? 23. Describe the composition of the ECAB. 24. Describe the composition of the Department of Labor Appeal Board. 25. Who develops and enforces safety and health rules that apply to all U.S. mines? 26. What is the purpose of OSHA? 27. What is an MSDS? 28. What special consideration does OSHA require for health care workers? 29. How long should vaccination records and accidental needle exposure records be kept? 30. What is the purpose of Federal Employment Liability Act? When was it made into law and by whom? 31. What is the purpose of the Jones Act? 32. What is the difference between a workers' compensation self-insurance plan and a commercial workers' compensation plan? 33. Who qualifies for workers' compensation benefits? 34. Under what condition can a worker lose the right to workers' compensation coverage for an injury on the job? 35. What is considered as an on-the-job injury? 36. Who determines the extent of the disability? 37. What are the 5 classifications for workers' compensation benefits? 38. What is the difference between temporary and permanent disability? 39. What is covered under vocational rehabilitation and survivor benefits? 40. Are providers allowed to make up their own fees when providing care for patients with workers' compensation cases? 41. If a patient is from State A and is injured in State B, who billing instructions do you follow in charging the patient for services rendered, State A or State B? 42. What are the benefits of employers and employees in incorporating managed care into workers' compensation?

43. Who files the first report of injury form and how many copies are completed? 44. Who receives a copy of the first report of injury form? 45. What is the time frame for filing the first report of injury form? 46. What patient information is required on the first report of injury form? 47. If the employer disputes the claim, what should you do with the first report of injury form? 48. What should be included in the patient's progress notes after the patient has been examined for the work-related injury? 49. Are you in violation of HIPAA or patient privacy, if you do not obtain the patient's signature before releasing the progress notes to the workers' compensation payer or the commission board? 50. What is the recourse for the patient, if a claim is denied? 51. What is a deposition? 52. What is the difference between workers' compensation fraud and workers' compensation abuse? 53. What is the difference between employer, employee and provider fraud? 54. Who is eligible for State and Federal workers' compensation benefits? 55. List 3 agencies that can pay for workers' compensation charges. 56. Who is the underwriter for workers' compensation? 57. Lis the forms used to file a workers' compensation claim? 58. For workers' compensation benefits to kick in, does the patient have to pay a premium, copayment, or deductible? 59. What two systems are used to determine fees charged for services provided to patients with workers' compensation insurance? 60. What happens if a patient with a work-related injury does not inform the provider that the injury was work related, and the provider files a claim against the patient's health insurance plan, but the patient later claims that the injury was work-related and want to file a workers' compensation claim instead? 61. On the CMS-1500 form, the patient's name and insured name are different, when filing workers' compensation claim. Explain why this is so. 62. How should you handle the patient signature line on the CMS-1500 form when filling a workers' compensation claim?

Why do employers provide group health plan coverage