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45 terms

Health Insurance Specialist Career

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the patient is not responsible for paying what the insurance plan denies
If the insurance plan has a hold harmless clause; it means
make certain they are on mailing lists to recieve newsletters from third-party payers; remain current on news released by the CMS; stay current with the DHHS updates. All of the above
To remain up-to-date with the frequent changes of health insurance processing, health insurance specialists should:
Coding
The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim is called:
facilitate analysis of the practice's patient base for improvement and efficiency and communicate diagnostic and treatment data to insurance plans for maximum recovery of benefits.
Accurate coding of diagnoses, procedures, and services rendered to the patient allows a medical practice to:
American Medical Association
Which of the following is not a professional association for health insurance specialists?
Denied
If preauthorization for treatment by specialists and post-treatment reports were not filed, the claim would be:
reimbursement specialist
Another name for health insurance specialist is:
practice's patient data base; number of claims requirements and reimbursement regulations; time the office staff must devote to fulfilling contract requirements; all of the above
Each new provider-managed care contract increase the:
9-17%
According to the occupational outlook handbook published by the U.S. Department of Labor-Bureau of Labor statisitics, health care facilities and insurance companies will hire insurance specialists at an increased rate per year of:
Diagnosis coding and medical necessity
What involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity of performing that procedure of service?
electronic claims processing
Providers who send data in a standardized machine-readable format to an insurance company via disk, telephone modem, or cable are implementing:
International Classification of Diseases-Ninth Revision, Clinical Modification
ICD-9-CM stands for:
Current Procedural Terminology
What does CPT stand for?
American Medical Association
The CPT manual is published by the?
attention to details; strong sense of ethics; ability to work independently; all of the above
A successful health insurance specialist should have which of the following characteristics:
Preauthorization
Prior approval
Hold harmless clause
Patient not responsible for paying what the plan denies
health care provider
Physician
Electronic Data Interchange
Exchange of data between provider and insurance company
ICD-9-CM
Diagnostic codes
CPT
HCPCS level 1 codes
Ethics
Principles of right or good conduct
EOB
Results of processing a claim sent to patient
Remittance advice
Provider's notification regarding payment of claim
Respondeat superior
Physician's legal responsibility for actions of employees
AAPC
Certified Professional coder
Medical malpractice insurance
Liability insurance for providers
Professional liability insurance
Errors and omissions insurance
HCPCS level II codes
National codes
Coding
Reporting diagnoses, procedures, and services
review health-related claims for accuracy; determine medical necessity for procedures or services performed; refer claim to an investigator for a more thorough review; check patient's current eligibility and benenfit status at each office visit; assign codes to diagnoses and procedures; process claims for reimbursement
List some of the job duties performed by a health insurance specialist
a health care facility(or physician) that employs health insurance specialists is legally responsible for employees' actions performed with in the context of their employment
Explain what is meant by respondeat superior
medical malpractice insurance is a type of liability insurance which covers physicians and other health care professionals for liability as to claims arising from patient treatment
Explain what medical malpractice insurance is and why it is important to physicians and other health care professionals
The American Academy of Professional Coders(AAPC); The American Health Information Management Association(AHIMA); The American Medical Billing Association(AMBA)
Name the three professional associations that offer credentials for health insurance specialists
Medical necessity involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity for performing that procedure or service
Explain what is meant by medical necessity and give an example
Providers send data in a standardized machine-readable format to an insurance company via disk, telephone modem, or cable
What is electronic claims processing
A mutual exchange of data between the provider and insurance company, often used by clearinghouses.
What is electronic data interchange?
Current procedural terminology(CPT) and HCPCS level II (national codes)
List the levels of the Healthcare Common Procedure Coding System
amount of control the hiring organization exerted over the worker's activities; responsibility for costs of operation(e.g. equipment and supplies); method and form of payment and benefits; length of job commitment made to the worker; nature of the occupation and skills required.
List the 5 ways to determine independent contractor status according to the common law "right to control" test
health insurance specialists are guided by a scope of practice, which defines the profession, delineates qualifications and responsibilities, and clarifies supervision requirements
What is meant by scope of practice?
Bonding; liability; property; workers' compensation.
List the four types of insurance that health care providers and facilities typically purchase to cover their employees
Preauthorization, or prior approval for treatment by specialists, is important because if the requirements are not met, the payment for the claim will be denied.
Why is perauthorization important?
a hold harmless clause means that the patient is not responsible for what the insurance plan denies. The health care provider can not collect the fees from the patient
Explain what is meant by a hold harmless clause
Coding is the process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim
Describe what is meant by coding
The International Classification of Disease, Ninth Revision, Clinical Modification(ICD-9-CM) is the coding system used to report diagnoses and resons for encounters on physician office claims
Explain what the ICD-9-CM manual is