HIM 130 Billing and Reimbursement - Test 1 Review

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Insurance Handbook for the Medical Office, 12th edition (Fordney)

false (but may not interpret insurance policies or act as an attorney)

A claims assistance professional (CAP) acts as an informal representative of patients and helps patients interpret insurance contracts. (T/F)

true

In some states, giving an insured client advice on purchase or discontinuance of insurance policies is construed as being an insurance agent.

true

An insurance billing specialist uses general skills in following an employer's established policies when dealing with the health care contract. (T/F)

true

The best way for an insurance specialist to keep up to date in the profession is to read health care industry association publications, attend seminars on billing and coding, and participate in e-mail listserv discussions.

false (for the benefit of the patient)

The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the physician.

false (The American Medical Association adopted the Principles of Medical Ethics in 1980.)

The Centers for Medicare and Medicaid Services, formerly known as the Health Care Financing Administration, adopted the Principles of Medical Ethics in 1980. (T/F)

true

Illegal coding practices are subject to penalties, fines, and/or imprisonment.

false (Never make critical remarks about a physician to a patient or anyone else.)

At certain times medical office staff members are allowed to make critical remarks about a physician to a patient. (T/F)

true

It is illegal to report incorrect information to government-funded programs such as Medicare, Medicaid, and TRICARE.

true

The title used for medical billing personnel may depend on the region of the United States where they work. (T/F)

true

Medical billing employees should be able to perform a variety of administrative duties pertaining to the business office.

false (In some plans, it is the patient's obligation to submit claims.)

Insurance companies never require the patient to submit the claim form. (T/F)

true

It is commonplace to find administrative duties shared by a number of specialists in the physician's office.

true

The primary goal of an insurance claims assistance professional (CAP) is to assist the consumer in obtaining maximum benefits and to tell the patient what checks to write to providers to make sure there are no overpayments. (T/F)

false (front office duties have gained in importance)

In a medical practice, front office duties have lost importance. (T/F)

false (a high school diploma is required for entry into an insurance billing or coding program)

Generally, a high school diploma is not required for an insurance billing specialist. (T/F)

false (Operating a self-owned insurance billing business carries greater responsibilities.)

Working in a physician's office as an insurance billing specialist carries greater responsibilities than operating a self-owned insurance billing business. (T/F)

false

Electronic claims submissions are a format of the past.

false (Do not use first names until you know it is appropriate to do so.)

It is acceptable practice for medical office personnel to use a patient's first name when speaking to the patient about his or her insurance. (T/F)

false (however billers and coders can still be held personally responsible under the law for billing errors)

Physicians are legally responsible for any actions of their employees performed within the context of their employment; therefore, an employee cannot be sued or brought to trial.

true

Rules of etiquette for e-mail and cell telephone calls fall under the Health Insurance Portability and Accountability Act.

Multiskilled health professional

What does the abbreviation MSHP designate?

multiskilled health care practitioners

Cost pressures on health care providers are forcing employers to reduce personnel costs by hiring ________.

claims submission

Administrative medical office responsibilities include ________. (laboratory analyses, claims submission, taking x-rays, venipunctures)

works for the consumer and helps patients file insurance claims

A claims assistance professional ________ and ________.

the actual money available to a medical practice

What is "cash flow" in a medical practice?

diagnostic and procedure coding must be reviewed for its correctness and completeness

Front office medical duties have become increasingly important because

completion of an accredited program for coding certification

Which level of education is generally required for one who seeks employment as an insurance coder?

American Health Information Management Association (AHIMA)

Which organization published diagnostic and procedure coding competencies for outpatient services and diagnostic coding and reporting requirements for physician billing?

all of the above

The amount of money an insurance billing specialist earns is dependent on which of the following factors? (knowledge, experience, size of employing institution, all of the above)

all of the above

A billing specialist is entrusted with (holding patients' medical information in confidence, collecting monies, being a reliable resource for coworkers, all of the above)

moral principles or practices

Medical etiquette refers to

standards of conduct

Medical ethics include

Code of Hammurabi

The earliest written code of ethical principles for the medical profession is the ________.

The Principles of Medical Ethics

What is the name of the modern code of ethics that the American Medical Association (AMA) adopted in 1980?

notify your physician

What should you do if you discover that a patient of your physician employer is under the care of another physician for the same ailment?

unethical

Reporting incorrect information to private insurance carriers is considered ________.

the American Health Information Management Association (AHIMA) code of ethics

Which code of ethics is most appropriate for an insurance billing specialist who handles medical records?

diagnostic and procedure coding competencies for outpatient services and diagnostic coding and reporting requirements

18. AHIMA publishes (diagnostic and procedure coding competencies for outpatient services, diagnostic coding and reporting requirements, diagnostic medical terminology)

all of the above

A self-employed medical insurance biller who does independent contracting is responsible for (advertising, billing, accounting, all of the above)

the eHealth Code of Ethics

The Internet Healthcare Coalition has developed ________.

illegal

Reporting incorrect information to government-funded programs is ________.

all of the above

Insurance specialist certificate programs include (anatomy, diagnostic coding, computer technology, all of the above)

all of the above

The doctrine stating that physicians are legally responsible for both their own conduct and that of their employees is known as (respondeat superior, let the master answer, vicarious liability, all of the above)

all of the above

The AHIMA Code of Ethics is appropriate for (health information specialists, coders, insurance billing specialists, all of the above)

all of the above

Why are multiskilled health practitioners (MSHPs) in demand? (they are cross-trained to provide more than one function, they are often competent in more than one discipline, they offer more flexibility to their employer, all of the above)

illegal and unethical

Determine whether the following statement is illegal, unethical, or both illegal and unethical:
Using code numbers to increase payment when case documentation does not warrant it

illegal

Determine whether the following statement is illegal, unethical, or both illegal and unethical:
Reporting incorrect information to Medicare

illegal and unethical

Determine whether the following statement is illegal, unethical, or both illegal and unethical:
Coding services that were not performed for payment

illegal and unethical

Determine whether the following statement is illegal, unethical, or both illegal and unethical:
Unbundling services when an available single code includes all services

unethical

Determine whether the following statement is illegal, unethical, or both illegal and unethical:
Reporting incorrect information to a private insurance carrier

illegal and unethical

Determine whether the following statement is illegal, unethical, or both illegal and unethical:
Assigning a code without documentation from the provider

illegal and unethical

Determine whether the following statement is illegal, unethical, or both illegal and unethical:
Coding a condition as primary when the majority of the treatment is for a preexisting condition

true

Notes, papers, and memos regarding patient information should be disposed of using a shredding device. (T/F)

true

Confidentiality between the physician and the patient is automatically waived when the patient is being treated in a workers' compensation case. (T/F)

false (disclosure)

To give, release, or transfer information to another entity is called consent. (T/F)

true

A HIPAA compliance exception to the right of privacy and privileged communication is a patient's records pertaining to his or her industrial accident case. (T/F)

false (business associate)

Under HIPAA guidelines, an outside billing company that manages claims and accounts for a medical clinic is known as a covered entity. (T/F)

false (compliance)

The process of meeting regulations, recommendations, and expectations of federal and state agencies that pay for health care services and regulate the industry is known as eHealth information management. (T/F)

true

A patient has the right to obtain a copy of his or her confidential health information. (T/F)

true

The Correct Coding Initiative (CCI) detects improperly coded claims through the use of computer edits. (T/F)

false (reduce Medicare overpayments)

The goal of the Medicare Integrity Program (MIP) is to identify and reduce excessive Medicare costs. (T/F)

true

Baby Baker was born on February 4, 2005, at 9:20 AM, and the proper format for transmission is 200502040920.

true

Disclosing PHI as authorized by the laws relating to workers' compensation does not require a signed authorization. (T/F)

true

Privileged information is related to the treatment and progress of patients. (T/F)

all of the above

Confidential information includes (everything that is heard about a patient, everything that is read about a patient, everything that is seen regarding a patient, all of the above)

have the physician return the telephone call

What is the correct response when a relative calls asking about a patient?

city of residence

Nonprivileged information about a patient consists of the patient's (city of residence, diagnosis, illness, treatment)

gunshot wound cases

Exceptions to the right of privacy rule include

all of the above

Confidentiality is automatically waived in cases of (gunshot wounds, child abuse, extremely contagious diseases, all of the above)

he or she may be subject to fines and imprisonment

When an insurance billing specialist bills for a physician and completes a Medicare claim form with information that does not reflect the true situation,

The employee and the employer could be brought into litigation by the state or federal government.

What action could happen if an employee knowingly submits a fraudulent Medicare or Medicaid claim at the direction of the employer and subsequently the medical practice is audited?

abuse

To bill Medicare beneficiaries at a higher rate than other patients is considered ________.

all of the above

Electronic media refers to (leased telephone or dial-up telephone lines, the Internet, transmissions that are physically moved from one location to another, all of the above)

privacy and security rules

The Office of Civil Rights enforces

Use care in the choice of words when leaving the message.

What is the best response when telephoning a patient about an insurance matter and the patient's voice mail is reached?

SNOMED

A uniform lexicon system used for managing patient electronic health records, information, indexing, and billing laboratory problems is called ________.

HIPAA Title II Administrative Simplification

The focus on the health care practice setting and reducing administrative costs and burdens are the goals of ________.

privacy officer or privacy official

individual who is designated to help a provider remain in compliance by setting policies and procedures in place, train staff regarding HIPAA, and act as the contact person for questions and complaints

covered entity

a health care coverage carrier, clearinghouse, or physician who transmits health information in electronic form in connection with a transaction covered by HIPAA

health care provider

individual who renders medical services, furnishes bills, or is paid for health care in the normal course of business

clearinghouse

third-party administrator who receives insurance claims from the physician's office, performs edits, and redistributes the claims electronically to various insurance carriers

business associate

individual who is hired by a medical practice to process claims to a third-party payer

abuse

Determine whether the following statement is a case of insurance abuse or fraud:
Calling patients back for repeated and unnecessary follow-up visits

abuse

Determine whether the following statement is a case of insurance abuse or fraud:
Failure to make required refunds when services are not reasonable and necessary

fraud

Determine whether the following statement is a case of insurance abuse or fraud:
Altering medical records to generate more in payment

abuse

Determine whether the following statement is a case of insurance abuse or fraud:
Charging excessively for services and supplies

fraud

Determine whether the following statement is a case of insurance abuse or fraud:
Altering fees on an insurance claim form to obtain higher payment

fraud

Determine whether the following statement is a case of insurance abuse or fraud:
Forgiving the deductible or copayment for a Medicare patient

fraud

Determine whether the following statement is a case of insurance abuse or fraud:
Changing the date of service

fraud

Determine whether the following statement is a case of insurance abuse or fraud:
Unbundling or exploding charges

abuse

Determine whether the following statement is a case of insurance abuse or fraud:
Filing insurance claims for services not medically necessary

abuse

Determine whether the following statement is a case of insurance abuse or fraud:
Billing Medicare beneficiaries at a higher rate than other patients

abuse

Determine whether the following statement is a case of insurance abuse or fraud:
Failure to make a refund when services are not reasonable or necessary

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