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After setting up a provider, it nessesary, the first step in entering information into the medical practice management software is to

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enter new patients to the list

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payment posting includes all of the following except

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payments to suppliers

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the department or function in a medical office that is typically responsible for payment posting is

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accounts recievable

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to review a list of outstanding patient accounts, the medical specialist will refer to

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aging reports

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the medical office speciaist should enter ICD-9 codes obtained from

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encounter form

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when posting charges to a patient account, the medical specialist should obtain the CPT code from the

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encounter form (superbill)

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if the med specialist cannot find a CPT code in the med practice management software, she/she should

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enter the new code in the database

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the report medical specialist should run at the end of the day to balance all transactions is the

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patient day sheet report

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the med office specialist will post any insurance payments and adjustments from

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explanation of benifits from (EOB)

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the EOB from an insurance company will include

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payments and adjustments from the carrier

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the guarantor on a patient account is the person who

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is responsible for paying the bills

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medical practice management software allows the user to

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submit claims electronically, print paper claims, check claim data onscreen

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the subscriber on an account

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can be the guarantor and patient

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Patient demographic and insurance info can be found on

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registration form

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a list of modifiers commonly used with procedural codes can be found on the

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encounter form

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providing additional clinical information to an insurance company as part of an attempt to overturn a claim denyal is know as submitting an

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appeal

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some insurance carriers percieve automatic rebilling after 30 days to be aggressive and a

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fraudulent practice

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Reasons to rebill an insurance claim include all of the following EXCEPT

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the patient was not eligible when initial claim was filed

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an examination and verification of claims and supporting documentation submitted by a doctor is known as an

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audit

question

If the claim is denyed as a noncovered service, the med office specialist should

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bill the patient

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If a claim was denied because services provided before insurance coverage was in effect, the med office specialist should

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bill the patient

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if a claim was denied because additional info is needed to prove medical nessessity, the office specialist should

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submit the required information and follow up with the carrier

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the patient is not responsible for payment when a claim is denied when

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services that were provided were not preauthorized

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if patient objects to bill being denied never do this

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ask patient to call and follow up with the insurance company to try to get them to reconsider

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an objective, unbiased group of doctors that determines what payment is adequate for services

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peer review

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if peer review determines services were not medically nessesary

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physician must pay for everything

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the medical specialist should learn about the appeals process with insurance carrier through:

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newsletter from carrier,, and administrative manual and phone calls to the carrier

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what claim appeal cannot be made by telephone

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claim was considered not medically nessessary

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simple appeals may be accepted by

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telephone or fax

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an appeal must be made in writing if

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billing error was made by medical assistant

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benifits not covered by Employee Retirement Income Security Act (ERISA) include:

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church plans

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the law that protects the interests of benificiaries enrolled in private employee benifits plan is known as

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ERISA

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ERISA is known as

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employee retirement income security act

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according to ERISA, a plan must pay a claim or respond reguarding its status within

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90 days

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medicaid is health coverage for

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low income individuals

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medicaid is paid for by

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federal and state government

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The largest funding for healthcare for america's low income individuals comes from?

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medicaid

question

groups who qualify for medicaid

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categorically needy, the medically needy, special groups

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States will NOT agree for federal matching funds for the categorically needy groups such as..

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individuals 65 or above

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the qualify for federal matching funds for the medically needy, states must include coverage for

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pregnant women

question

Under welfare reform bill, manditory covered services for immigrants include

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emergency services

question

eligibility for the temperary assistance for needy familys (TANF) is determined by..

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county

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the goal of the childrens health insurance program reauthorization act (CHIPRA) is to expand Medicaid eligibility to more

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children without health insurance

question

the early and periodic screening, diagnosis and treatment (EPSDT) program includes coverage for children younger than

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21

question

Optional medicaid services that are eligible for federal matching funds include all of the following except

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acupuncture

question

Care provided under the PACE program can be rendered in??

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nursing homes, hospitals and the patients home

question

The early and periodic screening, diagnosis, and treatment (EPSDT) program provides coverage for?

answer

early and periodic screening, diagnosis and treatment

question

early and periodic screening, diagnosis, and treeatment program includes covwerage for children younger than..

answer

21

question

early and periodic screening, diagnosis, and treatment include coverage for

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well child checkups, vision screening and dental screening

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HCPCS

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Healthcare Common Procedure Coding System

question

Five digit CPT codes used to report services and procedures performed by healthcare providers are known as

answer

level 1 HCPCS codes

question

level 1 HCPCS codes are also known as

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CPT codes

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level 2 are updated anually by HCPCS codes

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Centers for Medicare and Medicaid Services (CMS)

question

HCPCS Level II codes would NOT include..

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surgical services

question

Example of HCPCS Level II code

answer

J0290

question

Which type of coding error involves reporting items or services that are NOT documented in the medical record?

answer

"Assumption coding"

question

HCPCS modifiers consist of

answer

two letters or one letter and one number

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Inaccurate coding and incorrect billing can result in

answer

delayed in recieving payments, prison sentences, loss of the providers licence to practice medicine

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Code linkage refers to the connection between the

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diagnosis and procedure

question

procedure and diagnostic codes would be appropiate to the patients

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age, gender, health condition

question

The legislation that prohibits submitting a fraudulent claim or making a false statement in connection with a claim is called the

answer

Federal Civil False Claims Act (FCFCA)

question

Under civil law, the max penalty for medical fraud is

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$10,000

question

An action tht misuses money the government has allocated is considered..

answer

abuse

question

To bill for procedure that was not performed is considered

answer

fraud

question

insurance coverage for American workers and their families as they change jobs, protection of personal health information, reduces waste, fraud and abuse, sets national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers

answer

three reasons HIPAA was established

question

the health insurance portability and accountability act (HIPAA) was signed into law in 1996, and covered entities were required for fully implement its guidlines by

answer

2003

question

health care claims, claim status requests and reports, eligibility requests and verifications

answer

HIPAA guidelines apply to which of the following types of healtcare administrative transactions

question

privacy rule

answer

The provision of HIPAA that applies to the use and disclosure of protected information is the

question

the patient agrees verbally, in writing or consent is implied

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a physician is allowed to discuss health information with someone else under HIPAA rules if

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designation for release of medical information form

answer

The document used to authorize permission for release of proteted information (PHI) is the

question

person has been exposed to certain communicable diseases

answer

Providers are legally obligated to disclose protected health information (PHI) to public authorities when a

question

paper and electronic records

answer

HIPAA privacy protections apply to which type of healtcare data

question

DHHS Office for Civil rights (OCR)

answer

A person who has a privacy complaint can file it with the

question

400

answer

Approximentaly how many different for are currently being used for electronic health records?

question

Indemnity plan

answer

what does NOT have a network of providers?

question

dermatologist

answer

In a managed care organization (MCO), a primary care physican (PCP) is NOT this

question

referring patients to specialists, acting as gatekeeper to services and coordination patient care

answer

the duties of a primary care physician (PCP) in health maintenance organization (HMO) include

question

policyholder or member

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The subscriber in a health maintenence organization (HMO) can also be..

question

copayment

answer

The fixed dollar amount a member pays at each specific office visit or hospital encounter is the

question

coinsurance

answer

the percentage of the providers fees that the patient pays is known as the

question

family, general practive, internal medicine, OB/GYN

answer

PCPs in a health maintenence organization (HMO) can include

question

health maintenance organization (HMO)

answer

the most uptight and restrictive type of managed care is

question

provide members with more choice

answer

HMO plans add point of service (POS) option to

question

physicians run the risk of adverse selection by enrollees

answer

Advantages of managed care do not include this

question

low income

answer

Individuals elegible for Medicare may be classified into one or more of the following except

question

Medicare Part A

answer

Medicare coverage that consists of hospital insurance is

question

Medicare Part B

answer

Medicare coverage that pays for physicians services is?

question

Medicare Advantage (MA)

answer

The medicare program that provideds expanded benifits through private managed care health plans is

question

pay claims for medicare benificiaries

answer

The role of the Centers for Medicare and Medicaid Services (CMS) does NOT do this

question

social security administration

answer

The organization that enrolls new Medicare benificiaries into the program is the

question

contractors

answer

organizations that are hired by CMS to carry out day to day Medicare program operations are known as

question

also eligble for medicare coverage

answer

a spouse of a deceased, retired, or disabled individual who was or is eligible for medicare benifits is

question

more than 2 years

answer

To qualify for Medicare, disabled adults must have been receiving Social Security disability for

question

100 days

answer

For each benifit, a medicare Part A beneficiary will recieve quality coverage for how many days of skilled nursing care?

question

medicare part A

answer

Coverage for end of life hospice care is provided by..

question

purchasing Part A coverage

answer

To obtain medicare part B coverage, individuals must qualify by meeting eligibility requirements for Part A or..

question

a joint medicare-medicaid program

answer

The program of All-Inclusive Care for Elderly (PACE) is a program for low income elderly individuals that is actually considered..

question

annual physical examinations

answer

medicare Part B covers

question

HMO plans, PPO plans, fee for service plans

answer

Medicare part C plans are offered through..

question

Physical Therapy

answer

What is covered by Medicare Part A or Part B

question

Fee-for-service

answer

The origional medicare plan is based on which type of payment method..

question

PPO and HMO plans

answer

The types of medicare advantage managed care plans include..

question

Physical therapist

answer

Medicare does not consider this individual provider a doctor..

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