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73 terms

Medical Insurance II

Comprehensive Medical Insurance: Billing, coding and reimbursement - Vines
STUDY
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what does payment per diem mean?
payment to the provider per day
payment per episode of care is also known as payment per
case
discounted fee for service is based on what type of fee
provider's usual fee and customary fees
T/F: HMO's are the most restrictive type of health plan
TRUE
do PPOs utilize a network of providers
yes
what is a staff model
type of HMO model that employs salaried physicians in a managed care organization owned and operated by a HMO
do medical specialists negotiate managed care contracts
no. The contracts are negotiated by physicians and insurers
can a participating provider of a managed care plan balance bill a patient
no. The difference between the amount billed and amount allowed must be written off or adjusted
T/F: in emergency situations, a patient may be treated in an out-of-network facility without a referal
true, however once the patient is stablized he or she is transferred to a facility within the network
what organization awards accreditation to managed care organizations and providers
national committee for quality assurance (NCQA)
what elements of a provider's background does the NCQA review during the credentialing process
criminal activity, malpractice hx, and disciplinary actions
why would a provider accept a discounted fee for service agreement
to receive an increased number of patient referrals from managed heatlh care organizations and other network providers
managed care systems ensure the delivery of high quality care while managing costs thru
networks and discounted fees
What are the four goals of managed care?
Delivery of high quality care in a facitility that manages and controls costs;

Medical care provided is medically necessary and appropriate for patient's condition or diagnosis;

medical care is rendered by appropriate provider;

Medical care provided is rendered in most appropriate setting
T/F: most managed care contracts state a specific timeframe for submitting claims
TRUE
what type of managed care plan can be used as either a HMO or PPO
Point of Service (POS)
what type of HMO model contracts with more than one multispecialty group to provide wider geographical coverage
Network HMO
what happens if an HMO enrollee sees an out of network provider without a referral
the HMO will not pay for the service and the patient may be responsible fot the full physician's charge
a managed care contract is considered a legal document between the physician and the insurer
physician and the insurer
T/F: Twenty years ago physicians rec'd the majority of their payments from individuals
TRUE
Where do the majority of payments rec'd by a medical facility come from today?
insurance carriers
what is the earliest example of managed care
western clinic in Tacoma, WA provided medical services to lumber mill owners and employees in 1910
are procedures that are experimental, investigative or unproven considered medically necessary
no
what services are typically covered under a capitation arrangement
primary care physician services
what is another term for primary care physician (PCP)
Gatekeeper
registration
placement of a name on list as qualified for a profession; may require special testing
layperson
one who does not have training is a specific profession
scope of practice
the boundries of acceptable diagnosis and treatment by nurses, doctors, and a variety of midlevel medical personnel
medical malpractice
medical professional misconduct which differs from negligence because it is performed by a licensed medical professional
vicarious liability
legally obligated in place of someone else
procedures manual
a reference handbook explaining procedures to be followed when performing a task by which a legal right might be enforced
due care
the duty to have adequate regard for another person
certification
a record of being qualified to perform certain acts after passing an examination given by an accredited professional organization
A sudden flare-up of a patient's chronic condition may be characterized as acute.
TRUE
The addenda to the ICD-9-CM are issued in June and take effect October 1 of each year.
FALSE
An adverse effect is a harmful reaction caused by an overdose of a drug
FALSE
The alphabetic index of the ICD-9-CM is used first when locating a diagnostic code.
TRUE
A coexisting condition is reported when it affects the patient's primary condition or is also treated during an encounter.
TRUE
The etiology is the origin or cause of a disease.
TRUE
The manifestation is the cause or origin of an illness.
FALSE
In the ICD-9-CM, NOS, or not otherwise specified, indicates a code to be used when too little information is available to assign another, more specific code.
TRUE
The primary diagnosis represents the patient's most serious condition, regardless of the reason for the current encounter.
FALSE
Subterms appear below the main term in the ICD-9-CM's alphabetic index.
TRUE
Supplemental terms in the ICD-9-CM's alphabetic index are usually enclosed in parentheses or brackets.
TRUE
V codes in the ICD-9-CM contain five numbers.
FALSE
The ICD-9-CM diagnostic codes are made up of either three, four, or five digits and a description.
TRUE
Codes in the tabular list of the ICD-9-CM are organized according to anatomic system or cause.
TRUE
In the ICD-9-CM, parentheses are used around descriptions that are not essential parts of a term.
TRUE
a formal examination of services billed, along with the codes submitted is known as an
audit
what are two ways that internal audits are performed
retrospectively and prospectively
what is a retrospective audit
audit performed after a claim is submitted
what are three types of claims submitted
internal, external and accreditation
the concept of linking icd-9 code to a cpt code is known as
code linkage
what are the three key components of an E/M code
level of history, level of examination, level of MDM
what codes are used to bill for durable medical equipment and other supplies provided by medical practices to patients
hcpcs level ii
what does hcpcs stand for
healthcare common procedural coding system
what do icd-9 codes report
patient's condition or illness at time of service
what coding manual will replace icd9-cm in 2012
icd-10-cm
what do cpt codes report
procedures and services provided by the doctor
how many digits do cpt codes have
5
what law regulates doctor self-referrals
stark law
what is unbundling
use of multiple cpt codes when only one code is required
what is assumption coding
when items or services are reported that are not actually documented but the coder assumes they were performed
using a procedure code that provides higher reimbursement rate than the code actually reflects the services provided for is referred to as
upcoding
what initiative is designed to edit coding errors such as unbundling codes, use of appropriate modifiers and mutually exclusive codes
national correct coding initiative (NCCI)
what federal publication includes the compliance program guidance for individual and small group physician practices
the federal register
what act prohibits a fradulent claimor making false statements or representation in connection with a claim
the federal civil false claim act
what act created the healthcare fraud and abuse control program
health insurance portability and accountability act
the duration of the patient's symptoms from the first sign of the illness to the present is known as
the history of present illness (HPI)
when are icd-9-cm codes updated
annually on october 1st
what volume of ICD-9-CM is used by hospitals to bill for procedures
Vol 3
what is the first section of the CPT manual
E/M
why would an office use an audit tool
to ensure the appropriate E/M code that has been selected