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Medical Insurance Billing: Chapter 16 & 17 Multiple choice

Terms in this set (50)

Specific areas of administrative simplification addressed by HIPPA include all of the above except:
Accreditation
The organization created to reform health insurance and simplify the healthcare administrative processes is knows as:
HIPPA
The electronic transfer of information in a standard format between two entities is known as:
EDI
The numbers used in the administration of healthcare to distinguish individual providers, health plans, employers, and patients are called:
Identifiers
To send claims electronically, the medical practice needs:
HIPPA-Compliant software
If a medical practice chooses to submit claims electronically to an insurance carrier, it must go through a:
Enrollment process
A business entity that receives claims from several medical facilities, consolidates these claims and transmits them to various insurance carriers is called:
Claims clearinghouse
The system wherein data representing money are moved electronically between accounts or organizations is called:
Electronic Funds Transfer (EFT)
An Electronic file wherein patients health information is stored in a computer system is called:
Electronic Medical record ( EMR)
One of the most significant activities of the healthcare industry us:
Information Management
One of the major disadvantages of EMR's is:
Keeping hardware and software up to date
Submitting claims directly to an insurance carrier is referred to as:
Direct Data Entry (DDE)
if the practice submits claims primarily to one carrier it may be advisable to use:
DDE
The ultimate goal in healthcare is to establish an EMR system that is:
Intercommunicative
The acronym for the organization enacted by Congress to improve the administration of Medicare by taking advantage of the efficiencies gained through electronic claim submission is:
ASCA
The code set currently used for physician diagnosis is:
ICD-10-CM
The record keeping method in which some documents are stored electronically and some are kept in paper form is referred to as:
Combination records
if the goal of a healthcare office is to change to a completely electronic medical record system, a ____________ may be a good choice.
Digital imaging Hybrid
Disadvantages to EMR include all of the following except:
Cost
To qualify for Medicare/ Medicaid monetary incentives to put EMR's into operation providers must demonstrate ______________________EMR's
Meaningful us of
Payment to the insured (or his or her provider) for a covered expense or loss experienced by or on behalf of the insured is referred to as:
Reimbursement
A system of payment whereby the provider charges a specific fee for each service rendered and is paid that fee by the patient or by the patient's insurance carrier is called:
fee-for-service
Medicare's system for reimbursing Part A inpatient medical costs is called:
PPS
The amount of payment in the PPS is determined by the assigned:
Diagnosis-related group (DRG)
A common method of paying physicians in health maintenance organizations is:
capitation
PPS for acute hospital care for Medicare patients was mandated by:
social security amendments of 1983
The method of determining Medicare's reimbursement for services based on establishing a standard unit value for medical and surgical procedures is:
RVS
Patients whose hospital stays are either considerably long or considerably shorter than average are referred to as:
Cost Outliers
In the _____________ payments for service are determined by the resource cost needed to provide them rather than actual charges
RBRVS system
The key piece of information in determining the DRG classification is the patient's:
principal diagnosis
Also taken into consideration in determining the DRG is the patient's _______ and any additional operations and procedures done while in the hospital
Principle Procedure
A computer software program that identifies a patient's DRG category by interpreting certain coded information is called
DRG grouper
The service classification system that was designed to explain the amount and type of resources used in an outpatient encounter is called
APCs
Ambulatory payment classifications are made up of coding and classification of services provided to the patient based on the:
CPT coding system
The basic idea of the resource utilization group (RUGs) is to calculate payments according to severity and level of care in:
Skilled nursing facilities
A factor used by Medicare to adjust for variance in opening cost of medical practices located in different parts of the united states is the:
GPCI
Calculating DRG payments involves a formula in which the DRG weight is multiples by a ____________ a figure representing the average cost per case for all Medicare cases during the year.
Standardized amount
Under Medicare's PPS, long-term care hospitals (LCHs) Generally treat patieents who require hospital level care for an average of:
25 days
An adjustment to the federal payment rate for LTCH stays that are considerably shorter than the average length of stay for an LTC-DRG is called a(n):
Short-stay outlier
Under the Home Health PPS, an adjustment for the health condition and service needs of the beneficiary is referred to as the:
case-mix adjustment
An Organization typically composed of physicians and other healthcare professionals who are paid by the federal government to valuate the service provided by other practitioners and to monitor the quality of patient care is called:
PRO
if an agreement does not exist between the provider and the insurance carries to accept the payer's allowed amount as payment in full, the provider can bill the patient for the outstanding amount, which is referred to as:
Contractual write-offs
Under PPS, reimbursements for each hospital are adjusted for differences in all of the following except:
Provider's specialty
Similar to the RVS, the componets of the RBRVS include all of the following except:
Patient diagnosis
When the healthcare provider has signed an agreement with the third party not to bull for any charges remaining after all required payments have been, it is called:
A contractual write-off
A buisness entity that specializes in consolidating claims recieved form providers and transmitting them in batches to each repective thrid-party payer is a
Cleaninghouse
Documents needed to generate an insurance claim include all of the following expect a
Patient driver's license
The electronic computer file that stores patients' health information is called
Electronic medical record (EMR)
The paper claim form approved by the AMA Council on Medical Service that was subsequently adopted by all government healthcare programs is the
CMS-1500
A standard format used to transfer information electronically between two parties is known as
EDI
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