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93 terms

Billing and Coding

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The health care plan that reimburses providers for individual health care services provided is a
fee for service plan
What Organization is responsible for the health of a group of enrollees and can be a health plan, hospital physician group, or health system
Managed Car Organization (MCO)
Managed care plan enrollees received care from
Their Primary Care Provider (PCP)
A method of controlling health care costs and quality of care by reviewing the appropriateness and neccessity of care provided to patients prior to the adminstration of care is
Utilization management
Prior to scheduling elective surgery managed care plans often require
Second Surgical Opinion
Which of the following would be considered an example of a managed care plan
Point of service plan
What organization is owned by hospital(s) and physician groups that obtain managed care plan contracts?
Physician hospital organization
A network of physicians and hospitals that have joined together to contract with insurance companies to provide health care to subscribers for a discounted fee is a
Prefered provider organization (PPO)
A plan offered either by a single insurance plan or as a joint venture by two or more insurance carriers and which provides subscribers or employees with a choice of MO, PPO, or triditional health plan is a
1. Triple option 2. cafeteria plan 3. flexible benefit plan
All 3 insurance plan offer this.
This is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees, health status, age sex, and occupation.
Risk Pool
Voluntary process that a health care facility or organization (e.g hospital or managed care plan undergoes to demonstrate that it has met standards beyond those required by law
Accreditation
When the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium, what type of consumer-directed health plan would this be
Customized subcapitation plan (CSCP)
Consumer - Directed health plans provide incentives for controlling health care expenses and give individuals a (an) ______ to traditional health insurance and managed care coverage
Alternative
Health insurance is available to
1. Individuals who participate in individual (personal) health plans.
2. of a prepaid health plan
3. individuals who participate in group ( employer - sponsored ) health plans
A contract that protects the insured form loss. It guarantees payment to the insured for an unforeseen event in return for the payment of premiums
Insurance
Indentification of disease and the provision of care and treatment such as that provided by members of the health care team to persons who are sick, injured, or concerned about their health
Medical Care
A contract between a policy holder and a third-arty payer or government program to reimburse the policy holder for all or a portion of the cost of medically necessary treatment.
Health Insurance
The most common form of Medicare fraud is
1. Billing for services not provided
2. Misrepresenting the diagosis to justify payment
3. Soliciting offering, or receiving a kick back.
All of the above
Not an Example of Abuse
Falsifying Certificates of Medical Necessity plans of treatment
The development of an _______ begins when the patient contacts a health care provider's office and schedules an appointment.
Patient File
The CMS 1500 Claim form is used to report
1. Professional Services
2. Technical Services
The CMS 1500 Claim form requires responses to standard questions pertaining to whether the patient's condition is related to
1. Auto Accident
2. Secondary Insurance
3. Employment
The check in procedure for a patient who is ____ to the provider's office is more extensive thatn for a ___ patient.
New and Returning
The ________ is the person responsible for paying the charges
Guarantor
Health Insurance information that is needed so the claim can be processed includes
1. Name and Phone of the third party payer
2. Name of policy holder
Copayments are to be paid
At the time of the visit
Before scheduling an appointment with a specialist, a managed care patient must obtain a
Referral from the PCP or Case manager
Generate a deparate __record and ____ for each patient to maintain each type of information
Financial and Medical
Contracts with participation providers and accepts whatever the plan pays for services performed
Participating Providers - PAR
Upon the patients arrival at the physician's office, the health information specialist should have the patient complete a
Patient Registration Form
______is the insurance plan responsible for paying health care insurance claims first.
Primary Insurance
The _____is/are the financial record source document (s) used by health care providers to record services and diagnoses rendered during the visit.
1. Encounter form
2. Superbill
Actions inconsistent with accepted practices
Abuse
Intentional deception or misrepresentation
Fraud
The practice of reporting multiple codes for a service when a single code should be assigned
Unbundling
Notes used in providers office to document patient visits
SOAP Notes
Computerized record of all financial transactions between patient and practice, also known as the Patient Ledge is know as the
Patient account record
Fathers plan is always primary when child is covered by both parents
Gender Rule
Chronological summary of all transactions posted on a specific day
Day Sheet
Physician does not contract with the insurance plan
Non - Par
Clearinghouse that involves vendors, like banks, in the processing of claims
Value add Network (VAN)
Supporting documentation associated wit a health care claim or patient encounter
Claim Attachment
Hospital Financial record source document
Charge Master
Reported on claims to provide clarification about procedures and services performed
Modifers
Maximum amount the payer will allow for a procedure or service
Allowed Charges
Clearinghouse claims processing format
Electronic Flat File
Employees and dependents who join a managed care plan
Enrollees
Pre-established payments for health care services
Capitation
Primary Care Provider (PCP)
Gatekeeper
Development of patient care plans
Case Management
Prevents providers from discussing all treatment options
Gag Clauses
Encouragement to reduce or limit services
Physician Incentivies
Physician or health care provider under contract to manage care plan
Network Provider
Nonprofit organization that contracts with and acquires the clinical and business assets of physician practices
Medical Foundation
Provides health care to enrolled members on prepaid basis
HMO
Patients may use HMO providers or self-refer to non-HMO providers
Point of service Plan
Physicians and Hospitals joined together to contract with insurance companies for a discounted fee
PPO
Subscriber or employee may coose beween HMO, PPO, or traditional health insurance plan
Triple option Plan
People grouped for insurance purposes, cost determined by employee's health status, age, sex, and occupation
Risk Pool
Health Care Accreditation
The Joint Commission
Provides practice management services to individual physician practices
MSO(Management Service Organization)
Identification of disease and provision of care
Medical Care
Contract that protects from loss
Insurance
The most common form of Medicare fraud is
1. Billing for services not provided
2. Misrepresenting the diagnosis to justify payment
3. Solicitng, offering, or receiving a kickback
All of these are common forms of fraud
Which of the following is not an example of abuse
Falsifying Certificates of medical necessity plans of treatment
The development of a __________begins when the patient contacts a heath care provider's office and schedules an appointment
Patient File
The CMS - 1500 claim form is used to report
1. Professional Services
2. Technical Services
The CMS - 1500 Claim form requires responses to standard questions petaining to whether the patient's condition
1. An auto accident
2. secondary insurance
3. employment
All of these are common forms of fraud
The _______is the person responsible for paying the charges
Guarantor
Health insurance information that is needed so the claim can be processed includes
1. Name, phone number of the third-party payer
2. Name of policyholder
Copayments are to be paid
At the time of the visit
A _____ contracts with a third-payer and accepts whatever the plan pays for procedures or services performed
Participation Provider
Before scheduling an appointment with a specialist, a managed care patient must obtain a
Referral from the PCP or case manager
Generate a separate _____ record and ____record for each patient to maintain each type of information
Financial and Medical
_________is the insurance plan responsible for paying health care insurance claims first
Primary Insurance
When children are covered by the insurance policies of both parents, the _____states that the parent whose birth month and day occure eariler in the calendar year holds the primary policy
Birthday Rule
Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions?
Truth in Lending Act
Which protects information collected y consumer reporting agencies
Fair Credit Reporting Act
Which is the best way to preven delinquent claims
Verify health plan indentification information onlall patients
Which is a characteristic of delinquent commercial claims awaiting ayer reimbursement
The delinquent claims are resolved directly with the payer
Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider
Common data file
Which is the fixed amount patients pay each time they receive healthcare services
Co - Payment
An elecronic claim is submitted using _____as its transmission media
Magnetic Tape
A claim that is rejected because of an error or omission is considered a
Open Claim
Contracted network of healthcare providers that provide care to subscribers for a discounted fee
PPO
Organization of affiliated providers sites that offer joint healthcare services to subscribers.
IDS
Provides benefits to subscribers who are required to receive services from network providers
HMO
Provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis
EPO
Patients are free to use the managed care panel of providers or self-refer to non-managed care providers
POS
Arranging appropriate healthcare services for discharged patients
Discharge planning
Review for medical necessity of inpatient care prior to admission
pre-admission review
Review for medical necessity of test/procedures ordered during ordered during inpatient hospitalization
concurrent review
Grants prior approval for reimbursement of a healthcare service.
preauthoration