Medical Insurance Procedures

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The first step that the medical office specialist is respnsible for befor submitting a madical claim is:

obtaining correct & complete patient information forms.

THe individual at the insurance carriers who verifies the medical necessity of the providers' reported procedures is called the:

medical rewiew examiner

A complaint can be made to the state insurance commissioner if:

a claim has been downcoded, appealed, & not reconsidered

When providers determine that fees to be use by considering what other providers charge for similar services, the structure is considered:

charge based

The 3 cost elemnts considered in developing the resource-based relative value scale (RBPVS) system are:

work, practice, & malpractice expense.

The portion of the physician's work payment under the resource-based relative value scale(RBRVS) system, adjusted for location, is:

25%

The provider's usual charge for a procedure or service can be:

higher than, lower than, or equal to the allowed charge.

The types of payments an insured is required to meet includes all of the following:

charges over the allowed amount for non-participating provider, charges for excluded services, & deductibles.

The section of an explanation of benefits (EOB) that indicates who was paid, how much, & when is called the:

benefit payment information

The difference between the billed amount & the allowed amount for a PAR provider is:

written off by the provider

The deductible under most insurance plans applies to each individual each:

calendar year

Coinsurance refers to:

a percentage of allowable charges a patient must pay

The set amount a patient must pay for each serviceis referred to as:

a copay

If a physician's office provides care for services excluded form an insurance policy, the:

patient must pay 100% of the cost

The section of an explanation of benefits (EOB) that summarizes the total deduction, charges not covered by the plan, & the amount the patient may owe the provider is called the:

coverage determination

A provider that is able to balance-bill a patient for the amount over the allowed charge is referred to as a:

nonparticipating provider

Under Medicare Part B, reimbursement to a PAR provider is based on:

80% payment by Medicare, & 20% by the patient after the deductible

Under the 80/20 plan, if a participating provider's usual charge is $200.00 for a procedure & the allowed amount is $150.00, the provider can collect:

$120.00 from the insurance carrier, & $30.00 from the patient

Uner an 80/20 plan, if the nonparticipating provider's charge is $200.00 for a procedure & the allowed amount is $150.00, the provider can collect:

$120.00 from the insurance carrier, & $80.00 from the patient

Under a capitation arrangement, a provider is paid per member, per month (PMPM) for all enrolled members:

whether or not they are seen that month.

The amount of money not paid to providers during a contract year but kept to offset any additional cost incurred for refferals or other services under a plan are called a:

withhold

The nationally uniform relative values are adjusted by:

geographical locations

The value unit used to shoe the cost element for a specific geographical location is referred to as the:

geographic practice cost index

The Medicare conversion factor is determined & updated annually by:

the Centers for Medicare & Medicaid Services (CMS).

The cost of Physician Malpractice insurance is highest for which of the following specialties?

obstetrics & gynecology

An allowed amount includes the amount that will be paid by:

the insurance company & the patient

The largest cost element in determining the resource-based value scale (RBRVS) is:

professional liability insurance

When developing the resource-based relative value scale (RBRVS), the overhead of the physician;s office is called the:

practice expense

The time it takes to perform a service when determining the resource-based relative value scale (RBRVS) is considered in the:

provider's work

In determining the resource-based relative value scale (RBRVS), the techincal skill of the provider is considered in the:

provider's work

In determining the resource-based relative value scale (RBRBS), the risk to the patient in performing the services is considered in the:

professional liability insurance

Resource-based fee structures consider all of the following factors:

provider's location

No matter what a provider charges, a third party payer will establish the amount to reimburse based on what is considered:

usual, customary, & reasonable

When a third-party payer determines reimbursement, they consider UCR, which means:

usual, customary, & reasonable

Prior to the Omnibus Budget Reconciliation Act (OBRA) of 1989, Medicare payment to providers were based on:

resource used to perform the procedure or services

The RBRVS fee schedule is known as the:

resource-based relative value scale

When a claim has been reduced by the insurance carrier, the medical office assistant can ask for reconsideration by filing:

an appeal

The elaected offical that has regulatory control over insurance carriers & can assist with complaints or disputes is the:

state insurance commissioner

If a claim is denied due to lack of medical necessity, the provider should:

refund any payment made by the patient

When a claim is processed, an explaination of benefits is sent to:

both the patient & provider

If no payment is made by the company because a patient has not satisfied a deductible:

an EOB is sent to both the patient and the provider

The 2 main methods for determining providers' fees are called the:

charge-based & resource-based fee structures.

A claim that is removed from a payer's automated processing system for additional review is sent for:

a manual review

If a claim is determined to not be medically necessary at the level reported, the claim will be:

downcoded

If an insurance carrier downcodes a claim, the medical office assistant should:

send a request for reconsideration & appeal to the insurance carrier

If an insurance carrier does not reconsider a downcoded claim that has been appealed by the physician's office, the medical office assistant can:

complain to the state insurance commissioner

The notification sent from the insurance carrier to the patient & healthcare provider after a claim has been sent is known as a:

explanation of benefits

During the patient's care, ll procedures & tests are documented on a:

encounter form

The insurance carrier's decsion reguarding whether or not to pay a claim is known as:

adjudication

When a treatment is determined to be apporiate for the diagnosis, the care is considered:

medically necessary

The submission of additional clinical information to a insurance company to overturn a claim denial is known as a:

appeal

If a claim is denied because required authorization was not obtained by the physician, the medical office specialist should:

appeal to the insurance carrier to explain the reasons for the claims denial

If a physician requests a peer review the results in confirmation that services were not medically necessary:

the physician must pay for the review

In SOAP documentation, the evaluation & management (E/M) examination that the physician provides is considered:

objective

When appealing disallowances resulting from low maximum allowable fees, the medical office assistant should include information:

about payment from other carriers

ERISA stands for the:

Employee Retirement Income Security Act

Qualified independent contractors must process a reconsideration within:

30 days

If a denial is upheald under a self-funded plan, the medical office assistant should appeal to the:

Department of Labor

If a denialis upheld when regulatory information was included, the medical office assistant should appeal to the:

carrier legal counsel

In general, Medicaid can request refunds for overpayments to providers for up to:

5 years

The statue of limitations for refunds where no contract language is stated is:

4 years

Wrongful maintance of an overpayment by a provider is called:

conversions

Medicare carriers must process a redetermination within:

30 days

Physicians must file an appeal an administrative law judge, within

60 days

In order to appeal a claim to an administrative law judge, the claim must be for a minimum of:

$100.00

According to Medicare Part B, the number 1 reason that an appeal is returned is for not:

having a valid signature

If a carrier misquotes benefits that were subsequently provided to a patient, the:

medical office assistant should appeal the denial

Statics show that the presentage of claims typically overturned on the first appeal is:

25%

According to the waiting period for an ERISA claim, a plan must respound to the status of the claim within:

90 days

a decision on a claim appealed through the employss Retirement Income Security Act ERISA) must be made within:

120 days

To appeal a claim under the Employee Retirement Income Security Act (ERISA), a provider is given at least:

60 days

The 1st level of Medicare appeals is a request for:

redetermination by the carrier

The 2nd level of Medicare appeals is a request for:

review by qualified independent contractors

The 3rd level of Medicare appeals is a request for:

review by an administrative law judge

When appealing denials resulting from not medically necessary services, the medical office assistant should include information:

from the patient medical records

All of the following claims can be appealed by telephone:

the carrier requested information from the patientwas not received

A claim can be appealed by telephone if:

a modifier was used to indicate multiple procedures that the carrier bundled.

A formal appeal must be made in writing if:

a billing error was made by the medical office assistant

Benefit plans not covered by the Employee Retirement Income Security Act (ERISA), include:

church plans

The law that protects the interests of the participants who depend on benefits from private employss benefit plans is known as:

ERISA

In SOAP documentation, the diagnosis made by the doctor is considered:

part of the assessment

In SOAP documentation, the recommended treatment by the doctor is considered:

part of the plan

In SOAP documentation, the documentation of vital signs, height, weight, & blood pressure is considered:

objective findings

In SOAP documentation, the physician's medical decsion making is considered:

part of the assessment

The medical office specialist can learn about an insurance carrier's appeal process though:

newsletters from the carrier, an administrative manual, phones calls to the carrier.

In SOAP documentation, medications ordered for the patient is considered:

part of the plan

Appeals can be made to the state insurance commissioner by:

patients, physicians, & insurance carriers

The chronological recdording of pertinent facts & observations requarding a patient's health statusis known as:

documentation

From the insurance carrier's perspective, if a service is not documented in the medical record, the:

service was not done

In medical record documentation, SOAP means:

subjective, objective, assesment plan

In SOAP documentation, the information the patient tells the doctor is considered:

subjective

In SOAP documentation, the evaluation & management (E/M) history that the physician takes is considered:

subjective

If a claim is denied because the physician provided services before the patients health insurance contract went into effect, the medical office specialist should:

bill the patient

The patient is responsible to pay a denied claim in all of the following cases:

services were provided after coverage was canceled, services provided before the policy-effeftive date, & a pre-existing condition

If a patient is upset about nonpayment of a claim, the medical office specialist should so all of the following:

explain the policy more than once, if necessary, explain in simple language why the insurance carried denied payment, & use respect & care when explaining policy benefits.

When an objective, unbiased group of physicians determines what payment is adequate for services provided, the process is called:

peer review

Many insurance carriers will consider rebilling by the physicians office:

a duplicate claim, fraudulent billing, & a notice that payment is delinquent

Reasons to rebill an insurance claim include all of the following:

some of the services on the claim were over looked by the provider's office, charges on the orginal claim were not detailed, & the medical office specialist made a mistake on the claim.

An examination & verification of claims submitted by a physician is known as a:

audit

If a claim is denied as a noncovered benefit, the medical office specialist should:

appeal to the insurance carrier

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