BLUE MOD KAPLAN QUIZ REVIEW WEEK 1

MEDICAL BILLING
STUDY
PLAY

Terms in this set (...)

Name the non privacy HIPAA standards that CMS is authorized by HHS to investigate complaints of noncompliance and enforce them.
THE ELECTRONIC HEALTH CARE TRANSACTIONS AND CODE SETS (TCS) RULE
THE NATIONAL EMPLOYER IDENTIFIER NUMBER (EIN) RULE
THE SECURITY RULE
THE NATIONAL PROVIDER IDENTIFIER RULE
THE NATIONAL PLAN IDENTIFIER RULE (CURRENTLY UNDER DEVELOPMENT)
How many types of plans are there? And which one is the most popular one?
THERE ARE TWO TYPES OF PLANS, INDEMNITY, AND MANAGED CARE PLANS, AND MANAGED CARE PLANS ARE THE MOST POPULAR
Acute care facility
PROVIDES CONTINUOUS PROFESSIONAL MEDICAL CARE TO PATIENTS WHO ARE IN THE ACUTE STAGES OF CONDITIONS OR ILLNESSES.
Skilled nursing facilities (SNF)
PROVIDE DAILY CARE FOR INPATIENTS WHO REQUIRE MEDICAL OR NURSING CARE OR REHABILITATION SERVICES FOR INJURIES, DISABILITIES OR SICKNESS.
Intermediate Care Facilities
A HEALTH CARE FACILITY PROVIDING CARE TO PATIENTS WHO DO NOT REQUIRE PROFESSIONAL MEDICAL OR SKILLED NURSING SERVICES.
Hospice care
IS AN ORGANIZATION THAT PROVIDES HEALTH CARE FOR PEOPLE WITH TERMINAL ILLNESSES, THAT EMPHASIZES EMOTIONAL NEEDS AND COPING WIH PAIN AND DEATH RATHER THAN CURE.
Who does Medicare cover
100 PERCENT FEDERALLY FUNDED PROGRAM THAT COVERS PEOPLE WHO ARE AGE 65 OR OLDER ARE DISABLED, OR HAVE PERMANENT KIDNEY FAILURE (END STAGE RENAL DISEASE).
Title II Administrative Simplification
THE U.S. CONGRESS PASSED AN ACT WITH PROVISIONS FOR _______ ________ BECAUSE OF CONCERN OVER THE RISING COSTS OF HEALTH CARE. A SIGNIFICANT PORTION OF EVERY HEALTH CARE DOLLAR SPENT IN THE UNITED STATES GOES TO THE OVERHEAD ASSOCIATED WITH ADMINISTRATIVE AND FINANCIAL TRANSACTIONS, SUCH AS FILING CLAIMS FOR PAYMENT, CHECKING PATIENT ELIGIBILITY FOR BENEFITS, REQUESTING AUTHORIZATION FOR SERVICES, AND NOTIFYING PROVIDERS OF PAYMENTS.
What are the three main HIPAA laws under Title II?
• THE HIPAA PRIVACY RULE:
• THE HIPAA SECURITY RULE
• THE HIPAA ELECTRONIC HEALTH CARE TRANSACTION AND CODE SETS STANDARDS.
Who does Medicaid cover?
A FEDERAL PROGRAM THAT IS JOINTLY FUNDED BY FEDERAL AND STATE GOVERNMENTS, WHICH COVERS LOW INCOME PEOPLE WHO CANNOT AFFORD MEDICAL CARE.
Ambulatory surgery center
ASC- A HEALTH CARE FACILITY PROVIDING SURGICAL SERVICES ONLY ON AN OUTPATIENT BASIS
Under Indemnity Plans Name the four conditions that must be met before the insurance company makes a payment.
• THE MEDICAL CHARGE MUST BE FOR MEDICALLY NECESSARY SERICES AND MUST BE COVERED BY THE INSURED'S HEALTH PLAN.
• THE PREMIUM PAYMENT MUST BE UP TO DATE
• IF THE POLICY HAS A DEDUCTIBLE
• ANY COINSURANCE
THERE IS NO COPAYMENT INVOLVED.
What happens during pre-registration/registration process?
SCHEDULING APPOINTMENTS AND ESTABLISHING THE PATIENTS ACCOUNT ARE THE TWO MAIN TASKS INVOLVED. DURING SCHEDULING THE FIRST STEP FOR EITHER INPATIENTS OR OUTPATIENTS IS A PHYSICIANS REQUEST FOR SERVICES. THE ORDER ( THE PHYSICIANS DIAGNOSIS AND TREATMENT PLAN) IS SENT TO THE FACILITY BY FAX, LETTER, PHONE, OR EMAIL. DURING ESTABLISHING A PATIENTS ACCOUNT STAGE, PREREGISTRATION IS USED TO COLLECT AND ENTER THE BASIC DEMOOGRAPHIC AND INSURANCE INFORMATION REQUIRED TO ESTABLISH THE PATIENTS ACCOUNT. DURING PREREGISTRATION THE PATIENT FILLS OUT AN ADMISSION FORM, IT IS THEN ENTERED INTO THE SYSTEM CONTAINING THE FOLLOWING INFORMATION: PERSONAL DATA, BASIC BILLING DATA, MEDICAL INFORMATION, ACCOUNT NUMBER, AND THE MEDICAL RECORD NUMBER
Inpatient routine charge include:
• ADMISSION KITS AND PREP KITS
• LUBRICANTS
• OXYGEN
• IRRIGATION SOLUTIONS
• DRAPES
• GLOVES
• REUSABLE ITEMS SUCH AS MICROSCOPES AND HUMIDIFIERS
A ROUTINE CHARGE IS THE TOTAL OF THE COSTS OF ALL SUPPLIES THAT ARE CUSTORMARILY USED TO PROVIDE THE SERVICE
Ancillary charges include:
• OPERATING ROOM
• ANESTHESIA
• BLOOD PRODUCTS AND ADMINISTRATION
• PHARMACY
• RADIOLOGY SERVICES, SUCH AS XRAYS, CT SCANS, MRIS AND PET SCANS
• LABORATORY
• MEDICAL, SURGICAL, AND CENTRAL SUPPLIES (EACH ITEM TAKEN FROM INVENTORY MUST BE BILLED OUT)
• PHYSICAL, OCCUPATIONAL, SPEECH AND INHALATION THERAPY
Billing errors:
• BILLING FOR SERVICES AND SUPPLIES THAT ARE NOT DOCUMENTED IN THE PATIENTS MEDICAL RECORD
• BILLING FOR SERVICES THAT ARE INSUFFIENTLY DOCUMENTED IN THE PATIENT'S MEDICAL RECORD
• BILLING TWICE FOR THE SAME SERVICE (DOUBLE BILLING)
• BILLING FOR MEDICALLY UNNECESSARY SERVICES
• BILLING FOR SERVICES THAT ARE INCLUDED IN OTHER CHARGES
• BILLING INACCURATE INFORMATION ABOUT PROVIDERS OR THE WRONG PROVIDERS
What conditions a procedure must meet to be considered necessary?
• THE PROCEDURE MUST BE APPROPRIATE FOR THE PATIENTS DIAGNOSIS
• THE PROCEDURE IS NOT ELECTIVE (AN ELECTIVE PROCEDURE IS NOT REQUIRED BY THE PHYSICIAN TO TREAT A CONDITION BUT IS ELECTED TO BE DONE BY THE PATIENT)
• THE PROCEDURE IS NOT EXPERIMENTAL. THE PROCEDURE MUST BE APPROVED BY THE APPROPRIATE FEDERAL REGULATORY AGENCY, SUCH AS THE FOOD AND DRUG ADMINISTRATION
• THE PROCEDURE IS NOT PERFORMED FOR THE CONVEIENCE OF THE PATIENT OR THE PATIENTS FAMILY, RATHER THAN BEING ESSENTIAL FOR TREATMENT
• THE PROCEDURE IS FURNISHED AT AN APPROPRIATE LEVEL. STRAIGHTFORWARD DIAGNOSES USUALLY NEED UNCOMPLICATED PROCEDURES; COMPLEX OR TIME CONSUMING PROCEDURES ARE RESERVED FOR COMPLEX CONDITIONS.
Name the three major tasks the Health Information Management (HIM) is responsible for.
• MEDICAL TRANSCRIPTION:
• MEDICAL RECORDS:
• MEDICAL CODING:
Is it true to say that patient statements are generated after they are discharged?
FALSE THE INSURANCE IS BILLED FIRST AFTER THE RAS ARE RECEIVED AND POSTED PATIENT STATEMENTS (BILLS) ARE GENERATED.
Read page 48 Monitor Payer Adjudication-Claims follow up. Once claims are sent to payers. What will be the next step?
CLAIMS FOLLOW UP, AND THEN PAYMENT PROCESSING.