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Comprehensive Medical Insurance: Billing, coding and reimbursement - Vines

what does payment per diem mean?

payment to the provider per day

payment per episode of care is also known as payment per


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


do PPOs utilize a network of providers


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


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


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


what services are typically covered under a capitation arrangement

primary care physician services

what is another term for primary care physician (PCP)



placement of a name on list as qualified for a profession; may require special testing


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


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.


The addenda to the ICD-9-CM are issued in June and take effect October 1 of each year.


An adverse effect is a harmful reaction caused by an overdose of a drug


The alphabetic index of the ICD-9-CM is used first when locating a diagnostic code.


A coexisting condition is reported when it affects the patient's primary condition or is also treated during an encounter.


The etiology is the origin or cause of a disease.


The manifestation is the cause or origin of an illness.


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.


The primary diagnosis represents the patient's most serious condition, regardless of the reason for the current encounter.


Subterms appear below the main term in the ICD-9-CM's alphabetic index.


Supplemental terms in the ICD-9-CM's alphabetic index are usually enclosed in parentheses or brackets.


V codes in the ICD-9-CM contain five numbers.


The ICD-9-CM diagnostic codes are made up of either three, four, or five digits and a description.


Codes in the tabular list of the ICD-9-CM are organized according to anatomic system or cause.


In the ICD-9-CM, parentheses are used around descriptions that are not essential parts of a term.


a formal examination of services billed, along with the codes submitted is known as an


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


what do cpt codes report

procedures and services provided by the doctor

how many digits do cpt codes have


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


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


why would an office use an audit tool

to ensure the appropriate E/M code that has been selected

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