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121 terms

Marcy's Insurance Final

Insurance Final
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When a Medicare beneficiary has employer supplemental coverage, Medicare refers to these plans as
MSP.
The time limit within which a TRICARE inpatient claim must be filed is within
1 year from a patient's discharge from an inpatient facility
What is the protocol to follow on receiving a request for an attending physician's statement from an insurance company on a patient who has applied for health insurance?
Request a fee from the insurance company before sending the attending physician's statement.
What level of education is generally required for one who seeks employment as an insurance coder?
Completion of an accredited program for coding certification
The medically needy aged
require help in meeting costs of medical care
What does bundling mean
Grouping codes that are related to a procedure
The most important function of a practice management system is
accounts receivable.
An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an
preferred provider organization (PPO).
Confidential information includes
everything that is heard about a patient.
B) everything that is read about a patient.
C) everything that is seen regarding a patient
A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as
CC.
An insurance claim form that contains no staples or highlighted areas and on which the bar code area has not been deformed is called
a physically clean claim.
The average amount of accounts receivable should be
1.5 to 2 times the charges for 1 month of services
The largest section in the CPT book is the
surgery section.
The Part B Medicare annual deductible is
135
The letters preceding the number on the patient's Medicare identification card indicate
railroad retiree
Basic Maternal and Child Health Program (MCHP) provisions offered in all states include
children with handicap needs who require orthopedic treatment or plastic surgery
When a physician sees a patient more than is medically necessary, it is called
churning.
Privileged information is related to the treatment and progress of patients.
true
Office visits may be grouped on the insurance claim form if each visit
is consecutive, uses the same procedure code, and results in the same fee
In a bankruptcy case, most medical bills are considered
unsecured debt.
What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care?
Foundation for medical care
The official American Hospital Association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the"
final diagnosis.
B) operative notes.
C) discharge summaries
Exceptions to the right of privacy rule include
gunshot wound cases
What is the name of the federal act that prohibits discrimination in all areas of granting credit?
Equal Credit Opportunity Act
How should blocks be treated on an OCR CMS-1500 claim form that do not need any information
Leave the block blank
Medicaid is administered by the
state government with partial federal funding
The diagnosis listed first in submitting insurance claims for patients seen in a physician's office is the
primary diagnosis
When a remittance advice (RA) is received from Medicare, the insurance billing specialist should
post each patient's name and the amount of payment on the day sheet and the patient's ledger card
The physician who is responsible for coordinating and managing all of the health care for the TRICARE Prime patient is referred to as a/an
PCM.
What is the best response when telephoning a patient about an insurance matter and the patient's voice mail is reached?
Use care in the choice of words when leaving the message
Who may accept a subpoena?
The prospective witness
B) An authorized person
The Medicaid program was a direct result of
a law passed by Congress in 1950.
Part B of Medicare covers
diagnostic tests.
In the Medicare program, there is mandatory assignment for
clinical laboratory tests
What is the correct procedure to collect a copayment on a managed care plan?
Collect the copayment when the patient arrives for the office visit
There are several ways to file pending insurance claims. What is the best way to file so that timely follow-up can be made?
File by date of service
Accounts that are 90 days or older should not exceed
15% to 18% of the total accounts receivable
An insurance claim submitted with errors is referred to as
a dirty claim
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?
The employee and the employer could be brought into litigation by the state or federal government
Confidential information includes
everything that is heard about a patient.
B) everything that is read about a patient.
C) everything that is seen regarding a patient
Insurance claims transmitted electronically are usually paid in
2 weeks or less
Confidential information includes
everything that is heard about a patient.
B) everything that is read about a patient.
C) everything that is seen regarding a patient
A clearinghouse is a/an
entity that receives transmission of insurance claims, separates the claims, and sends each one electronically to the correct insurance payer
If a payment problem develops with an insurance company and the company ignores claims and exceeds time limits to pay a claim, it is prudent to contact the
state insurance commissioner
Part B of Medicare covers
diagnostic tests
OCR guidelines for the CMS-1500 claim form state
it should not be photocopied because it cannot be scanned
Back-up copies of office records should be stored
away from the office
Which type of bankruptcy is considered "wage earner's bankruptcy
Chapter 13
A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as
CC
Part A of Medicare covers
hospice care.
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?
The employee and the employer could be brought into litigation by the state or federal government
How should blocks be treated on an OCR CMS-1500 claim form that do not need any information?
Leave the block blank
How many levels of review exist for TRICARE appeal procedures
Three
The time limit for submitting a Medicare claim is
the end of the calendar year following the fiscal year in which services were performed
What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care
Foundation for medical care
The medically needy aged
require help in meeting costs of medical care
What should be done if an insurance company denies a service stating it was not medically necessary and the physician believes it was?
Rebill with a letter of explanation from the physician
The Medicaid program was a direct result of
a law passed by Congress in 1950
A medical practice has a policy of billing only for charges in excess of $50. When the medical assistant requests a $45 payment for the office visit, the patient states, "Just bill me." How should the medical assistant respond
State the office policy and ask for the full fee.
How should an entry in a patient's medical record be corrected?
Cross out the incorrect entry, substitute the correct information, date and initial the entry
What is the correct procedure to collect a copayment on a managed care plan?
Collect the copayment when the patient arrives for the office visit
When a service is rendered that is not listed in the CPT codebook
use a code with a description stating "unlisted."
Back-and-forth communication between user and computer that occurs during online real time is called
interactive transaction
A code system used for managing patient electronic health records, information, indexing, and billing laboratory problems is called
SNOMED.
Which of the following cases should NOT use fax transmission?
Transmission of documents relating to information on sexually transmitted diseases
B) Any routine transmission of patient information
C) Transmission of documents relating to alcohol treatment
In a bankruptcy case, most medical bills are considered
unsecured debt
Under the prospective payment system (PPS), hospitals treating Medicare patients are reimbursed according to
preestablished rates for each type of illness treated based on diagnosis.
In the Medicare program, there is mandatory assignment for
clinical laboratory tests
70. The HCPCS national alphanumeric codes are referred to as
Level II codes
When a Medicare beneficiary has employer supplemental coverage, Medicare refers to these plans as
MSP
What is the name of the federal act that prohibits discrimination in all areas of granting credit?
Equal Credit Opportunity Act
When insurance carriers do not pay claims in a timely manner, what effect does this have on the medical practice
Decreased cash flow
Exceptions to the right of privacy rule include
gunshot wound cases
The total number of levels of redetermination that exist in the Medicare program is
five
Who may accept a subpoena
The prospective witness
B) An authorized person
An explanation of benefits document for a patient under the Medicare program is referred to as the
Medicare remittance advice document
In what case should a V code be used
Sterilization
Medicare is a
federal health insurance program
The patient is likely to be the most cooperative in furnishing details necessary for a complete registration process
before any services are provided
The Medicaid service for prevention, early detection, and treatment for welfare children is known as
EPSDT
What should you do if an insurance carrier requests information about another insurance carrier?
Provide the information
Basic Maternal and Child Health Program (MCHP) provisions offered in all states include
children with handicap needs who require orthopedic treatment or plastic surgery
A group of insurance claims sent at the same time from one facility is known as a
A group of insurance claims sent at the same time from one facility is known as a
If a physician accepts Medicaid patients, the physician must accept
the Medicaid-allowed amount
Medicaid eligibility must always be checked for the
month of service.
B) type of service
The frequency of Pap tests that may be billed for a Medicare patient who is low risk is
once every 24 months
What is the correct response when a relative calls asking about a patient?
Have the physician return the telephone call
Medical etiquette refers to
consideration for others
The reason for a fee reduction must be documented in the patient's
medical record.
Reasons for documentation are
defense of a professional liability claim.
B) insurance carriers require accurate documentation that supports procedure and diagnostic codes
Payments to hospitals for Medicare services are classified according to
DRGs
Referral of a patient recommended by one specialist to another specialist is known as
tertiary care.
Organizations handling claims from hospitals, nursing facilities, intermediate care facilities, long-term care facilities, and home health agencies are called
fiscal intermediaries
When a Medicare carrier transmits a Medigap claim electronically to the Medigap carrier, it is referred to as a/an
crossover claim
Medicare Part A is run by
the Centers for Medicare and Medicaid Services
When is the principal diagnosis applicable
Inpatient hospital coding
The key to substantiating procedure and diagnostic code selections for proper reimbursement is
supporting documentation in the health record
A new patient is one who
) has not received any professional services from the physician within the past 3 years
The TRICARE fiscal year extends from
October 1 to September 30
The CPT publication is updated and revised
annually
When a medical practice has its own computer and transmits claims electronically directly to the insurance carrier, this system is known as
carrier-direct.
State Children's Health Insurance Programs (SCHIPs)
operate with federal grant support under Title V of the Social Security Act
What is the consequence when a medical practice does not use diagnostic codes?
It affects the physician's level of reimbursement for inpatient claims.
B) Claims can be denied.
C) Fines or penalties can be levied
The time limit within which a TRICARE outpatient claim must be filed is
within 1 year from the date a service is provided
A participating physician with the Medicare plan agrees to accept
80% of the Medicare-approved charge
What should be done to inform a new patient of office fees and payment policies?
Send a patient information brochure.
B) Send a confirmation letter.
C) Discuss fees and policies at the time of the initial contact
What level of education is generally required for one who seeks employment as an insurance coder
Completion of an accredited program for coding certification
A medical report is a
permanent legal document, part of the health record
A state-based group of doctors working under government guidelines reviewing cases for hospital admission and discharge is known as a:
QIO
Medicare Part A benefit period ends when a patient
has not been a bed patient in any hospital or nursing facility for 60 consecutive days
When a remittance advice (RA) is received from Medicare, the insurance billing specialist should
post each patient's name and the amount of payment on the day sheet and the patient's ledger card
The CMS-1500 claim form is divided into which of the following major sections?
Patient and physician information
Medicare provides a one-time baseline mammographic examination for women ages 35 to 39 and preventive mammogram screenings for women 40 years or older
once a year
A Medicare prepayment screen
identifies claims to review for medical necessity.
B) monitors the number of times given procedures can be billed during a specific time frame
An example of a technical error on an insurance claim is
duplicate dates of service.
B) transposed numbers.
C) missing place of service code
If a check is received from Medicare and it is obvious that it is an overpayment, the insurance billing specialist should
deposit the check and then write to Medicare to notify them of the overpayment
An established patient is one who
has previously received professional services from a physician or another physician of the same specialty who belongs to the group practice within the past 3 years
An insurance claim submitted with errors is referred to as
a dirty claim
The diagnosis listed first in submitting insurance claims for patients seen in a physician's office is the
primary diagnosis
The employer's identification number is assigned by
the Internal Revenue Service
OSHA stands for
Occupational Safety and Health Administration