question

Billing Cycle:

answer

1. preregister patients 2. establish financial responsibility 3. check in patients 4. check out patients 5. review coding compliance 6. check billing compliance 7. prepare and transmit claims 8. monitor payer adjudication 9. generate patient statements 10. follow up payments and collections

question

New patient:

answer

hasn't received services from the physician within the last 3 years

question

Established patient:

answer

has had an appointment within a 3 year time frame

question

policyholder:

answer

a person or entity who buys an insurance plan ;the insured

question

health plan:

answer

a plan, program, or organization that provides health benefits

question

premium

answer

the periodic payment the insured pays to a health plan for insurance coverage

question

payer

answer

private or government organization that pays for health care

question

fee-for-service:

answer

health plan that repays the policyholder for covered medical expenses

question

**deductible:

answer

amount due before benefits start

question

**coinsurance:

answer

PERCENTAGE of charges that an insured person must pay for health care services after payment of the deductible amount

question

managed care:

answer

a type of insurance where the carrier is responsible for both the financing and the delivery of health care

question

PPO

answer

"preferred provider organization" managed care network of health care providers who agree to perform services for plan members at discounted fees.

question

HMO

answer

"health maintenance organization" managed health care system where providers agree to offer health care to the organization's members for fixed payments

question

capitation

answer

payment to a provider that covers each plan member's health care services for a certain period of time

question

**copayment:

answer

FIXED FEE paid by the patient at the time of an office visit

question

CDHP

answer

"consumer-driven health plan" managed care where a high-deductible, low premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses

question

patient information form

answer

form including a patient's personal, employment, and insurance data needed to complete an insurance claim

question

documentation

answer

a record of health care encounters between the physician and the patient, created by the provider

question

medical record:

answer

a chronological record of a patient's medical history and care that indicates information that the patient provides, as well as the physician's assessment, diagnosis, and treatment plan

question

diagnosis

answer

physician's opinion of the nature of the patient's illness or injury

question

procedure

answer

medical treatment provided by a physician or other health care provider

question

coding

answer

the process of translating a description of a diagnosis or procedure into a standardized code

question

diagnosis code

answer

a standardized value that represents a patient's illness, signs, and symptoms

question

procedure code

answer

a code that identifies a medical service

question

modifier

answer

a 2-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service

question

**encounter form

answer

"routing slip" or "superbill" list of the procedures and charges for a patient's visit

question

**EHR

answer

"electronic health record" computerized lifelong health care record for an individual that incorporates data from providers who treat the individual

question

**PMP

answer

"practice management program" a software program that automates many of the administrative and financial tasks in a medical practice

question

medical coder

answer

a person who analyzes and codes patient diagnoses, procedures, and symptoms

question

code linkage provides __.

answer

medical necessity

question

**medical necessity

answer

treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and is provided in accordance with generally accepted standards of medical practice

question

***adjudication

answer

series of steps that determine whether a claim should be paid

question

RA

answer

"remittance advice" an explanation of benefits transmitted electronically by a payer to a provider

question

EOB

answer

"explanation of benefits" paper document from a payer that shows how the amount of a benefit was determined

question

statement

answer

a list of all services performed for a patient, along with the charges for each service

question

accounting cycle

answer

the flow of financial transactions in a business

question

AR

answer

"accounts receivable" monies that are flowing into a business

question

HIT

answer

"health information technology" technology that is used to record, store, and manage patient health care information

question

PMP

answer

"practice management programs"

question

Functions of PMP include:

answer

1. scheduling 2. claims and billing 3. reimbursement

question

information about many aspects of the business is recorded, including: (4)

answer

1. information about each patient 2. information about each provider 3. data about the health plans used by the practice's patients 4. codes used by the practice to note a diagnosis and the treatment provided

question

clearinghouse

answer

a company that receives claims from a provider, prepares them for processing, and transmits them to the payers in HIPAA-compliant format

question

audit/edit report

answer

a report that lists errors in a claim

question

**walkout statement

answer

a document listing charges and payments that is given to a patient after an office visit

question

**autoposting

answer

an automated process for entering information from a remittance advice (RA) into a practice management program

question

**EMRs

answer

"electronic medical records" the computerized records of one physician's encounters with a patient over time

question

**PHRs

answer

"personal health records" private, secure electronic files that are created, maintained, and owned by the patient

question

electronic prescribing

answer

the use of computers and handheld devices to transmit prescriptions in digital format

question

evidence-based medicine

answer

medical care based on the latest and most accurate clinical research

question

**advantages of electronic health records: (3)

answer

1. safety 2. quality 3. efficiency

question

HITECH

answer

"health information technology for economic and clinical health act" part of the American Recovery and reinvestment act of 2009 that provides financial incentives to physicians and hospitals to adopt EHRs and strengthens HIPAA privacy and security regulations

question

workflow

answer

a set of activities designed to produce a specific outcome

question

computer-assisted coding

answer

assigning preliminary diagnosis and procedure codes using computer software

question

**HIPAA

answer

"health insurance portability and accountability act" of 1996 federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information

question

HIPAA electronic transaction and code sets standards

answer

regulations requiring electronic transactions such as claim transmission to use standardized formats

question

EDI

answer

"electronic data interchange" the transfer of business transactions from one computer to another using communications protocols

question

**EFT

answer

"electronic funds transfer" the electronic routing of funds between banks

question

X12-837 Health care claim (837 P)

answer

HIPAA standard format used by physician offices to bill for services

question

CMS-1500 (08/05)

answer

the mandated paper insurance claim form

question

NPI

answer

"national provider identifier" a standard identifier for health care providers consisting of 10 numbers

question

HIPAA privacy rule

answer

regulations for protecting individually identifiable information about a patient's health and payment for health care that is created or received by a health care provider

question

**PHI

answer

"protected health information" information about a patient's health or payment for health care that can be used to identify the person

question

HIPAA security rule

answer

regulations outlining the minimum administrative, technical, and physical safeguards required to prevent unauthorized access to protected health care information

question

**administrative safeguards

answer

policies and procedures designed to protect electronic health information outlined by the HIPAA security rule

question

physical safeguards

answer

mechanisms required to protect electronic systems, equipment, and data from threats, environmental hazards, and unauthorized intrusion

question

technical safeguards

answer

automated processes used to protect data and control access to data

question

**audit trail

answer

a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed

question

**breach

answer

the acquisition, access, use, or disclosure of unsecured PHI in a manner not permitted under the HIPAA privacy rule

question

**the HITECH act's impact on privacy and security:

answer

-breach notification -monetary penalties -enforcement

question

**database

answer

a collection of related bits of information

question

medisoft program date

answer

date the program uses to record when a transaction occurred

question

MMDDCCYY format

answer

the way dates must be keyed

question

knowledge base

answer

a collection of up-to-date technical information

question

backup data

answer

a copy of data files made at a specific point in time that can be used to restore data

question

restoring data

answer

the process of retrieving data from backup storage devices

question

rebuilding indexes

answer

a process that checks and verifies data and corrects any internal problems with the data

question

packing data

answer

the deletion of vacant slots from the database

question

purging data

answer

the process of deleting files of patients who are no longer seen by a provider in a practice

question

recalculating balances

answer

the process of updating balances to reflect the most recent changes made to the data

question

access rights

answer

security option that determines the areas of the program a user can access, and whether the user has rights to enter or edit data

question

auto log off

answer

feature of medisoft that automatically logs a user out of the program after a period of inactivity

question

govt funded ins. plans

answer

-medicare -medicaid -tricare -Champva -workers comp

question

on a RA/EOB

answer

date of service service provided pt name pt control # provider ID #

question

funct of EHR

answer

results mgmt order mgmt decision support pt support health info

question

found in data base

answer

pt data provider data ins. carriers diagnosis codes procedure codes

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