Billing and Coding

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The health care plan that reimburses providers for individual health care services provided is a

fee for service plan

What Organization is responsible for the health of a group of enrollees and can be a health plan, hospital physician group, or health system

Managed Car Organization (MCO)

Managed care plan enrollees received care from

Their Primary Care Provider (PCP)

A method of controlling health care costs and quality of care by reviewing the appropriateness and neccessity of care provided to patients prior to the adminstration of care is

Utilization management

Prior to scheduling elective surgery managed care plans often require

Second Surgical Opinion

Which of the following would be considered an example of a managed care plan

Point of service plan

What organization is owned by hospital(s) and physician groups that obtain managed care plan contracts?

Physician hospital organization

A network of physicians and hospitals that have joined together to contract with insurance companies to provide health care to subscribers for a discounted fee is a

Prefered provider organization (PPO)

A plan offered either by a single insurance plan or as a joint venture by two or more insurance carriers and which provides subscribers or employees with a choice of MO, PPO, or triditional health plan is a

1. Triple option 2. cafeteria plan 3. flexible benefit plan
All 3 insurance plan offer this.

This is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees, health status, age sex, and occupation.

Risk Pool

Voluntary process that a health care facility or organization (e.g hospital or managed care plan undergoes to demonstrate that it has met standards beyond those required by law

Accreditation

When the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium, what type of consumer-directed health plan would this be

Customized subcapitation plan (CSCP)

Consumer - Directed health plans provide incentives for controlling health care expenses and give individuals a (an) ______ to traditional health insurance and managed care coverage

Alternative

Health insurance is available to

1. Individuals who participate in individual (personal) health plans.
2. of a prepaid health plan
3. individuals who participate in group ( employer - sponsored ) health plans

A contract that protects the insured form loss. It guarantees payment to the insured for an unforeseen event in return for the payment of premiums

Insurance

Indentification of disease and the provision of care and treatment such as that provided by members of the health care team to persons who are sick, injured, or concerned about their health

Medical Care

A contract between a policy holder and a third-arty payer or government program to reimburse the policy holder for all or a portion of the cost of medically necessary treatment.

Health Insurance

The most common form of Medicare fraud is

1. Billing for services not provided
2. Misrepresenting the diagosis to justify payment
3. Soliciting offering, or receiving a kick back.
All of the above

Not an Example of Abuse

Falsifying Certificates of Medical Necessity plans of treatment

The development of an _______ begins when the patient contacts a health care provider's office and schedules an appointment.

Patient File

The CMS 1500 Claim form is used to report

1. Professional Services
2. Technical Services

The CMS 1500 Claim form requires responses to standard questions pertaining to whether the patient's condition is related to

1. Auto Accident
2. Secondary Insurance
3. Employment

The check in procedure for a patient who is ____ to the provider's office is more extensive thatn for a ___ patient.

New and Returning

The ________ is the person responsible for paying the charges

Guarantor

Health Insurance information that is needed so the claim can be processed includes

1. Name and Phone of the third party payer
2. Name of policy holder

Copayments are to be paid

At the time of the visit

Before scheduling an appointment with a specialist, a managed care patient must obtain a

Referral from the PCP or Case manager

Generate a deparate __record and ____ for each patient to maintain each type of information

Financial and Medical

Contracts with participation providers and accepts whatever the plan pays for services performed

Participating Providers - PAR

Upon the patients arrival at the physician's office, the health information specialist should have the patient complete a

Patient Registration Form

______is the insurance plan responsible for paying health care insurance claims first.

Primary Insurance

The _____is/are the financial record source document (s) used by health care providers to record services and diagnoses rendered during the visit.

1. Encounter form
2. Superbill

Actions inconsistent with accepted practices

Abuse

Intentional deception or misrepresentation

Fraud

The practice of reporting multiple codes for a service when a single code should be assigned

Unbundling

Notes used in providers office to document patient visits

SOAP Notes

Computerized record of all financial transactions between patient and practice, also known as the Patient Ledge is know as the

Patient account record

Fathers plan is always primary when child is covered by both parents

Gender Rule

Chronological summary of all transactions posted on a specific day

Day Sheet

Physician does not contract with the insurance plan

Non - Par

Clearinghouse that involves vendors, like banks, in the processing of claims

Value add Network (VAN)

Supporting documentation associated wit a health care claim or patient encounter

Claim Attachment

Hospital Financial record source document

Charge Master

Reported on claims to provide clarification about procedures and services performed

Modifers

Maximum amount the payer will allow for a procedure or service

Allowed Charges

Clearinghouse claims processing format

Electronic Flat File

Employees and dependents who join a managed care plan

Enrollees

Pre-established payments for health care services

Capitation

Primary Care Provider (PCP)

Gatekeeper

Development of patient care plans

Case Management

Prevents providers from discussing all treatment options

Gag Clauses

Encouragement to reduce or limit services

Physician Incentivies

Physician or health care provider under contract to manage care plan

Network Provider

Nonprofit organization that contracts with and acquires the clinical and business assets of physician practices

Medical Foundation

Provides health care to enrolled members on prepaid basis

HMO

Patients may use HMO providers or self-refer to non-HMO providers

Point of service Plan

Physicians and Hospitals joined together to contract with insurance companies for a discounted fee

PPO

Subscriber or employee may coose beween HMO, PPO, or traditional health insurance plan

Triple option Plan

People grouped for insurance purposes, cost determined by employee's health status, age, sex, and occupation

Risk Pool

Health Care Accreditation

The Joint Commission

Provides practice management services to individual physician practices

MSO(Management Service Organization)

Identification of disease and provision of care

Medical Care

Contract that protects from loss

Insurance

The most common form of Medicare fraud is

1. Billing for services not provided
2. Misrepresenting the diagnosis to justify payment
3. Solicitng, offering, or receiving a kickback
All of these are common forms of fraud

Which of the following is not an example of abuse

Falsifying Certificates of medical necessity plans of treatment

The development of a __________begins when the patient contacts a heath care provider's office and schedules an appointment

Patient File

The CMS - 1500 claim form is used to report

1. Professional Services
2. Technical Services

The CMS - 1500 Claim form requires responses to standard questions petaining to whether the patient's condition

1. An auto accident
2. secondary insurance
3. employment
All of these are common forms of fraud

The _______is the person responsible for paying the charges

Guarantor

Health insurance information that is needed so the claim can be processed includes

1. Name, phone number of the third-party payer
2. Name of policyholder

Copayments are to be paid

At the time of the visit

A _____ contracts with a third-payer and accepts whatever the plan pays for procedures or services performed

Participation Provider

Before scheduling an appointment with a specialist, a managed care patient must obtain a

Referral from the PCP or case manager

Generate a separate _____ record and ____record for each patient to maintain each type of information

Financial and Medical

_________is the insurance plan responsible for paying health care insurance claims first

Primary Insurance

When children are covered by the insurance policies of both parents, the _____states that the parent whose birth month and day occure eariler in the calendar year holds the primary policy

Birthday Rule

Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions?

Truth in Lending Act

Which protects information collected y consumer reporting agencies

Fair Credit Reporting Act

Which is the best way to preven delinquent claims

Verify health plan indentification information onlall patients

Which is a characteristic of delinquent commercial claims awaiting ayer reimbursement

The delinquent claims are resolved directly with the payer

Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider

Common data file

Which is the fixed amount patients pay each time they receive healthcare services

Co - Payment

An elecronic claim is submitted using _____as its transmission media

Magnetic Tape

A claim that is rejected because of an error or omission is considered a

Open Claim

Contracted network of healthcare providers that provide care to subscribers for a discounted fee

PPO

Organization of affiliated providers sites that offer joint healthcare services to subscribers.

IDS

Provides benefits to subscribers who are required to receive services from network providers

HMO

Provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis

EPO

Patients are free to use the managed care panel of providers or self-refer to non-managed care providers

POS

Arranging appropriate healthcare services for discharged patients

Discharge planning

Review for medical necessity of inpatient care prior to admission

pre-admission review

Review for medical necessity of test/procedures ordered during ordered during inpatient hospitalization

concurrent review

Grants prior approval for reimbursement of a healthcare service.

preauthoration

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