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chapter 17practice

Terms in this set (75)

Some insurance carriers perceive automatic rebilling after 30 days to be aggressive and a:
fraudulent practice.
Reasons to rebill an insurance claim include all of the following:
the medical office specialist made a mistake on the claim, charges on the original claim were not detailed, some of the services provided to a patient were not billed on prior claims.
An examination and verification of claims and supporting documentation submitted by a physician is known as a(n):
audit.
If a claim is denied as a noncovered service, the medical office specialist should:
bill the patient.
If a claim is denied because services were provided before insurance coverage was in effect, the medical office specialist should:
bill the patient.
If a claim is denied because additional information is needed to prove medical necessity, the medical office specialist should:
submit the required information and follow up with the carrier.
The patient is responsible for payment when a claim is denied in all of the following cases when:
services were for treatment of an excluded preexisting condition, services were provided after coverage was canceled, services were provided before coverage was in effect.
If a patient is upset about a claim denial, the medical office specialist should do all of the following:
explain in simple language why the insurance carrier denied payment, use respect and care when explaining policy benefits, if the denial was due to a need for additional information, submit the additional documentation immediately and let the patient know it has been done.
An objective, unbiased group of physicians that determines what payment is adequate for services provided is a(n):
peer review.
If a physician requests a peer review that results in confirmation that services were medically necessary:
the patient should be billed for the review, the insurance carrier will pay for the review, there is no charge for the review.
Of the following, who may ask the state insurance commissioner for help in resolving a payment dispute?
Patients, physicians, and insurance carriers
The chronological recording of pertinent facts and observations regarding a patient's health status is known as:
documentation.
From the insurance carrier's perspective, if a service is documented in the medical record, the:
patient should be contacted to confirm the service was rendered, medical office specialist should be contacted to modify the record, physician should verbally verify that the service was provided.
In medical record documentation, a commonly used format is SOAP, which stands for:
subjective, objective, assessment, plan.
Using the SOAP format, the patient's chief complaint and reason for the encounter as the patient told it to the doctor are:
subjective information.
Using the SOAP format, the evaluation and management (E/M) history that the physician takes is:
subjective information.
Using the SOAP format, documentation of the physical examination performed by the physician is:
objective information.
Using the SOAP format, the diagnosis made by the doctor is:
part of the assessment.
Using the SOAP format, the physician's recommended treatment, testing, or therapy is:
part of the plan.
Using the SOAP format, the documentation of vital signs, height, weight, and blood pressure is:
objective information.
Using the SOAP format, documentation of the physician's medical decision making is:
part of the assessment.
Using the SOAP format, medication ordered for the patient is:
part of the plan.
The medical office specialist can learn about an insurance carrier's appeals process through:
an administrative manual, newsletters from the carrier, phone calls to the carrier.
When appealing disallowances resulting from low maximum allowable fees, the medical office assistant should include information:
about payment from other carriers for the reported service.
When appealing a denial made because the carrier doesn't believe the services were medically necessary, the medical office assistant should include information:
from the patient's medical record.
All of the following claims can be appealed by telephone those in which:
a modifier was used to indicate multiple procedures that the carrier bundled, the carrier requested information from the patient that was not received, the patient had a routine service covered by the policy.
An appeal must be made in writing if:
a billing error was made by the medical office assistant.
According to ERISA, a plan must pay a claim or respond regarding its status within:
90 days.
According to ERISA, decision to appeal by insured made within:
120 days.
According to ERISA, a provider has _____ to appeal denied claims
60 days.
The second level of Medicare appeals is a request for:
review by a qualified independent contractor.
The third level of a Medicare appeal is a request for:
review by an administrative law judge.
Qualified independent contractors must process a reconsideration within:
30 days.
Medicare carriers must process a redetermination within:
30 days.
Physicians must file a Medicare appeal with an administrative law judge within:
60 days.
To take a Medicare appeal to the level of a decision by an administrative law judge, the claim must be for a minimum of:
$130.
The number one reason that appeals of Medicare Part B claims are returned is for not:
including a valid signature.
When a provider receives a partial payment on a claim because the amount billed was in excess of the maximum allowed charge, this is a:
disallowance.
Statistics show that the percentage of claims typically overturned on the first appeal is:
25%.
If a denial is upheld when regulatory information was included in the original appeal, the medical office assistant should appeal to the:
carrier legal department.
If a denial by a self-funded plan is upheld, the medical office assistant should appeal to the:
Department of Labor.
In general, Medicaid can request refunds for overpayments to providers for up to:
5 years.
The statute of limitations for refunds in cases in which no contract language covers refunds is:
4 years.
Wrongfully keeping an overpayment is illegal and is called:
conversion.
T or F: A medical office specialist can appeal a claim in writing or over the telephone.
True
T or F: If a claim is denied due to services NOT being covered under the insurance policy, the patient cannot be billed for the services.
False
T or F: When payment is denied, the insurance carrier only notifies the patient.
False
T or F: If a procedure is NOT documented in the medical record, it cannot be reported or billed.
True
T or F: The plan section of the medical record includes the diagnosis made at the time of the encounter or shortly thereafter.
False
T or F: If the services provided are NOT appropriate in light of the diagnosis and the claim is denied, a telephone appeal can resolve the situation.
False
T or F: If a claim is denied because the carrier does NOT have details about an accident, the appeal can be handled through a telephone call.
False
T or F: Church and government health benefit plans are NOT regulated by the Employee Retirement Income Security Act (ERISA).
True
T or F: A stamped provider signature or that of an authorized employee is acceptable on Medicare appeals.
True
T or F: To be reconsidered for payment by qualified independent contractors (QICs), a claim must be for an amount greater than $100.
True
T or F: An appeal letter is more effective when the medical office specialist includes information about the federal and state laws that affect the claim submission.
True
T or F: A copy of an appeal letter sent to a carrier should also be sent to the patient.
True
To ensure timely payment, claim status must be __________ and follow-up done with the insurance carrier.
monitored
When rebilling using paper claims, the second submission should be clearly identified as a(n) __________ billing.
second
The government official whose office regulates the insurance industry and who serves as a liaison between patients and carriers, and physicians and carriers, is the state __________ .
insurance commissioner
Credit balances and refunds result from __________ by patients and third-party payers.
overpayments
When a carrier denies a claim because it determines that another carrier should be the primary payer, __________ of benefits is needed to determine the responsibility of each payer.
coordination
Credit balances and refunds are a result of an overpayment by the __________ or the insurance carrier.
patient
Negative adjustments will __________ the balance, while positive adjustments will __________ the balance on a patient account.
increase/decrease
The submission of additional clinical and other pertinent information to an insurance carrier to overturn a denied or downcoded claim
appeal
The law that protects the interests of beneficiaries enrolled in private employee benefit plans
Employee Retirement Income Security Act (ERISA)
The first level of a Medicare appeal in which the carrier is asked to review its initial decision
redetermination
The section of the law that governs refunds of overpayments where no contract language exists
Civil Practice and Remedies Code
List three situations in which the carrier may ask for rebilling.
Three situations in which the carrier may ask for rebilling include when the wrong diagnosis codes or procedure codes are submitted; when information is incomplete or missing; and when the charges, units, and costs do NOT total properly.
What is a claim appeal?
A claim appeal is a formal way of asking an insurance carrier to reconsider its decision about a claim. It usually involves submitting additional clinical and other pertinent information for consideration.
Why is documentation important?
An unwritten rule states that if a service or procedure is not documented, it was not performed. Therefore, no payment can be made on the claim. Complete and accurate documentation is critical to support the medical necessity of services provided.
What is the difference between subjective information and objective findings?
Subjective information includes the chief complaint or the reason for the medical encounter as the patient has told it to the doctor. It generally includes the history of the present illness and a review of systems. Objective findings include the patient's vital signs and the results of the physical examination.
List at least three reasons for contacting an insurance carrier to follow up on a claim.
Reasons for contacting an insurance carrier to follow up on a claim can be any three of the following: carrier sends a letter saying the claim is being investigated; the claim is denied; an incorrect payment is received; payment is received with no indication of the allowed charge or the amount the patient is responsible for; payment is received for an unknown patient; the carrier asks for a narrative description of a procedure for which there is no current CPT code.
What are the three levels of Medicare appeals?
The three levels are redetermination, reconsiderations by qualified independent contractors, and a hearing by an administrative law judge (ALJ).
What information should be included in an appeal letter?
An appeal letter should include a specific description of the charges being appealed, the names of people contacted at the insurance company with dates of any conversations, a concise explanation of what is being requested, and the anticipated result of the appeal letter.
Where can a medical office specialist find sample appeal letters?
Sample appeal letters and case studies can be found online at www.appealsolutions.com.
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