difference between an integrated delivery system and a primary care network is
primary care network of physicians focusing on providing primary care services to pts., an integrated delivery system is an organization consisting of a network of providers organized within a health system to offer patients a full range of managed health systems.
formed for the purpose of providing some services that is designed to benefit the community.
Utilization management refers to procedures implemented to
manage the utilization of health care services.
changes in the health care system that occurred toward the close of the 20th century that contributed to the evolution of hospitals included
health care services advanced through new technologies and treatments, Providers had diversified into many aread of medicne and were referred to as specialists, services were delivered in a variety of different environments.
primary care network is
A network of physicians focusing on providing a primary care services to patients.
factors that influenced the rise in health care costs furing the 1900s include
advances of diagnosis and treatment of medical conditions, advancements of in technology and standards of medical care, increase in number of patients seen in hospitals.
Health Insurance Portability and Accountability Act (HIPAA)
what legislation was implemented to improve continuation of insurance coverage, prevent and detect fraud and abuse, simplify the administration of health insurance, and protect the privacy of health information.
Quality of Pt. Care, Improve public health, & control health care costs.
three areas of govermental responsibilities related to health care.
JCAHO and AOA (american Osteopathic Association.
Two organizations involved in the accreditation of hospitals.
Health Information Management is responsible for which of the following
Coding patients medical records, Charge Description Master (CDM) maintenance, & Auditing
Administrative, financial, operational, and clinical
four major hospital functions generally categorized according to a grouping of specific tasks highlights
Utilization review relates to medical necessity in the following:
Utilization reviews are conducted to ensure services provided are medically necessary.
Written Authorization for Release of Medical Information.
avoiding breach of confidentiality, a pt. must provide approval for release of information by signing the:
Purpose: ADMISSION PROCESS is to
Obtain required information for evaluation, treatment, and billing for pt. care services.
term used to describe the individual who is respinsible to pay for medical services provided is:
Assignment of Benefits
form signed by the pt. to instruct the insurance company or goverment plan to forward benefits to the hospital is:
Physician's orders outline instructions regarding diagnostic and therapeutic care that the pt. is to recieve, during the inpatient stay, according to the treatment plan physician orders are written by the:
APC, DRG, and RBRVS
Methods used by the goverment programs to provide reimbursement to hospitals for outpatient and inpatient services include:
CONTRACT RATE & CAPITATION
Reimbursment methods commonly utilized by managed care plans for outpatient and inpatient hospital services include:
FEE SCHEDULE, UCR case rate, PER DIEM, AND CONTRACT RATE
Reimbursment methods commonly used by commercial payers for inpatient services include:
a computerized system is designed to capture chardes for all services and ites provided for the purpose of posting charges to the patient's account and billing those charges on the claim form.
claim form to submit charges for outpatient professional services provided by a hospital-employed provider:
Billing a pt. for balance in excess of the payer's approved amount is inappropriate in accordance with payer contracts and is referred to as:...
Payers forward a remittance advice of ecplanation of benefits to the hospital that descrives how the claim was processed. Explanations of the claim process are indicated by using:...
Common reasons for CLAIM DENIALS
Service is only payable for a specific diagnosis, Serice does not meet standards of medical necessity with diagnosis submitted, The procedure is bundled in a more comprehensive procedures....
Fair Debt Collection Practice Act
law was designed to protect consumers from unfair collection activities:...
TRACKING, PROOF OF RECEIPT, PROCESSING TIME IS REDUCED
Advantages of electronic claim submission include:
Scanning has improved claim processing in the following ways:
Optical scanning replaces the process of having to input data manually from the claim form...
Relationship between CLAIM FORM & REIMBURSEMENT
claim form is submitted to payers, reimbursement is determined based on information reported on the claim form, Submission of a "clean claim" can ensure accurate and eddicient processing of a claim receipt for appropriate reimbursement...
DIRECT TRANSMISSION & through a CLEARINGHOUSE
Two ways that the Electronic claims process can be accomplished are:
TREATMENT AUTHORIZATION CODE
payer provides an authorization number that is reported on the claim when services are authorized. the number ir recorded on the CMS-1450(UB-92) and is called:
Certificate, Insured, or health insurance claim number.
what number is assigned by the insurance company or govermentprogram to identify the individual who is covered under the plan and reported in FL 60 on the CMS-1450(UB-92)
Are surgical in nature, Carry high procedural of anesthetic risk, Require specialized training.
procedure performed for definitive treatment of the principal diagnosis, or the procedure that is most closely related to the principal diagnosis, is the:
Used for statistical analysis by hospitals, Insurance companies, and health care facilities.
the original intent for coded health care data was for use in research and study. Currently, coded health care data:
major most significant reason for pt. care services is rendered in a physicians office is the:
in ICD-9-CM manual, the tabular list of diseases, two supplemental classifications, and appendices are in:
term that describes special terms, punctuation marks, abbreviations, or symbols used as shorthand in a coding system to communicate special instructions efficiently to the coder:
Numeric listing of patients signs, symptoms, injury, illness, disease, and other reasons for the visit: