100 terms

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