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

Electronic Claims Processor

The ability to input data and transmit insurance claims accurately either directly or through a clearinghouse, as well as update and maintain software applications to requirements of third-party payers, is a technical skill required in the job of a/an ________.

facilities where facility billing is used

hospitals, acute care hospitals, skilled nursing or long-term care facilities, rehabilitation centers, and ambulatory surgical centers

examples of non-physician practitioners (NPPs)

physician assistant, nurse practitioner, advanced registered nurse practitioner, certified nurse anesthetist, physical therapist, speech therapist, licensed clinical social worker, and certified registered nurse practitioner

Insurance Billing Specialist, Multiskilled Health Practitioner (MSHP), and Claims Assistance Professional (CAP)

Identify three career opportunities (job titles) available after training in diagnostic and procedural coding and insurance claims completion.

some of the responsibilities and duties an insurance billing specialist might perform generally, as well as when acting as a collection manager

Review Documentation, Review Diagnostic and Procedural Coding, Submit Insurance Claims, Collect data required for billing from all health care providers, hospitals, outpatient clinics and laboratories, Act as an insurance counselor, Provide credit counseling, Answer routine enquiries related to account balances and insurance submission dates, Assist patients in setting up a payment schedule, Follow up on delinquent accounts, Trace denied, "adjusted," or unpaid claims

duties of a Claims Assistance Professional

help patients organize, file, and negotiate health insurance claims; assist the consumer in obtaining maximum benefits; and tell the patient how much to pay the providers to make sure there is no overpayment OR review and analyze existing or potential policies; render advice; and offer counseling, recommendations, and information

1 to 5

Insurance claims must be promptly submitted within ________ business days to ensure continuous cash flow.

cash flow

the amount of actual cash generated and available for use by the medical practice within a given period of time

reasons for a medical practice's large accounts receivable

failure to verify insurance plan benefits, failure to obtain authorization or precertification, failure to collect copayments and deductibles, and inadequate claims filing

skills required for an insurance billing specialist

Solid foundation and working knowledge of medical terminology, including anatomy, physiology, disease, and treatment terms, as well as the meanings of abbreviations; Expert use of procedural and diagnostic code books and other related resources; Precise reading skills; Basic mathematics; Knowledge of medicolegal rules and regulations of various insurance programs; Knowledge of compliance issues; Basic keyboarding and computer skills; Proficiency in accessing information through the Internet; Knowledge of billing and collection techniques; Expertise in the legalities of collection on accounts; Generate insurance claims with speed and accuracy

medical ethics

standards of conduct by which an insurance billing specialist determines the propriety of his or her behavior in a relationship

unethical (depending on state law, it may also be illegal)

Complete the statement with either the word illegal or unethical:
To report incorrect information to the Aetna Casualty Company is ________.


Complete the statement with either the word illegal or unethical:
To report incorrect information to a Medicare fiscal intermediary is ________.


Complete the statement with either the word illegal or unethical:
In certain circumstances, it may be ________ for two physicians to treat the same patient for the same condition.

vicarious liability or respondeat superior

When a physician is legally responsible for an employee's conduct performed during employment, this is known as ________ or ________.

Errors and Omissions Insurance

A claims assistance professional neglects to submit an insurance claim to a Medicare supplemental insurance carrier within the proper time limit. What type of insurance is needed for protection against loss for the client?


Two billing components are facility billing and professional billing. Professional billing is done for ________.

non-physician practitioners (NPPs)

Physician extenders are health care personnel trained to provide medical care under the direct or indirect supervision of a physician, such as ________.


The individual responsible for documenting the patient's clinical notes and assigning a diagnosis code and a procedure code for medical services rendered is a/an________.

multi-skilled health practitioner

An individual cross-trained to function in more than one job is known as a/an ________.

federal and state programs

Third-party payers that require the provider to submit insurance claims for the patient are ________.


Physicians are paid according to relative value units that are based on cost of delivering care, malpractice insurance, and the physician's work. (T/F)

false (Code manuals and other reference books are used to assign accurate codes for each case billed.)

It is not necessary to refer to coding books because medical practices use a fee schedule. (T/F)


It is the coder's responsibility to inform administration or his or her immediate supervisor if unethical or illegal coding practices are occurring. (T/F)

false (Unbundling services provided into separate codes when one code is available and includes all the services is an example of illegal or unethical coding.)

When one code is available that includes all of the services, it is permissible to bill using separate codes for the services. (T/F)


Depending on the circumstances of the case, an insurance billing specialist can be held personally responsible under the law for billing errors. (T/F)

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