question

What is the billing cycle

answer

the step that leads to timely payment for medical service

question

Medical Insurance

answer

An agreement between policyholder and health plan

question

Tricare

answer

provides coverage for dependents of active duty service

question

Medicaid

answer

for people with low income

question

Preferred Provider Organization

answer

Common type of managed care, members pay higher fee if a provider outside the network is chosen

question

Capitation

answer

payment to a provider , covers each members plan for certain amount of time

question

Co-payment

answer

fixed fee paid for service at time of service

question

What must all new patients complete

answer

Information form

question

What is some important info needed on information form

answer

*personal,employment, and medical insurance info

question

What does the information form require

answer

signature

question

When patient info changes what does the information form do

answer

Update

question

What are 8 requirements for checking in patients

answer

*Verify identity *copy or scan patient insurance card *copy or scan photo *collect time of service payments *take payment by check credit or debit card *always give patient receipt *collect co-pay during check in *give new patients financial policy info

question

Diagnosis

answer

physicians opinion of the nature of the patients illness or injury

question

Procedure

answer

service performed

question

3 facts about procedure(service performed)

answer

*Each procedure is assigned a code that stands for a particular service or treatment *codes come from CPT book *book is updated by the AMA

question

What is a diagnosis communicated to a health plan as

answer

ICD-9 code

question

what is an encounter form referred to as

answer

Superbill

question

An encounter form can be what

answer

Can be paper or electronic

question

EHR

answer

A lifelong computerized health care record for an individual that incorporates data from providers who have treated the individual

question

(PMP) Practice management System

answer

Software program that automates the administrative and financial tasks required to run a medical practice

question

The diagnosis and the medical services documented should be what

answer

Logically connected so that the medical necessity of the charges is clear to the insurance company

question

Adjudication

answer

A series of steps designed to judge whether claim should be paid

question

How are results of adjudication sent

answer

Via EOB or remittance advice (RA)

question

3 facts about sending adjudication results

answer

*Usually sent electronically *Sent with payment and compared with claim *If there are descrepancies, a request for view is file with insurance company

question

Statements

answer

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

question

Accounting cycle

answer

The flow of financial transactions in a business

question

Accounts receivable

answer

monies flowing into a business

question

Day sheet

answer

lists all charges , payments and adjustments that occurred during the day

question

Health Insurance Portability Act of 1996 (HIPAA)

answer

*Ensures portability of insurance coverage when employees move from job to job *Increases accountability and decreases fraud and abuse in healthcare *Improves the efficiency of health care transactions and mandates health info *Ensures security and priva cy of health info

question

Title I (HIPAA) is what, describe

answer

Health insurance reform, The continuous coverage for workers and their insured dependents when they change or lose their jobs

question

Title II (HIPAA) is what describe

answer

Administrative Simplification, the uniform sets of standards that protect and place limits on how confidentially health info used

question

what is IIHI

answer

Patient-Identifiable Health Related Information or Individually Identifiable Health Information (IIHI) Patient name DOB Demographics Past/present/future medical or mental condition Coding and claim information

question

describe HIPAA Administrative safeguard

answer

Verify identification for individual trying to obtain info or records

question

describe HIPAA Technical safeguard

answer

Computer passwords, log in access

question

describe physical safeguard

answer

lock cabinets, limit access in the office

question

PMP (Practice management systems) functions

answer

patient scheduling recording patient info creating and transmitting electronic claims billing patients creating financial reports receiving payments electronically collecting overdue accounts

question

what is audit trail

answer

keeps track of data on computer and can be reviewed if any issues arise,,, can report when and who has accessed info

question

where can a claim be sent (2)

answer

health plan clearing house

question

what is a clearing house

answer

a company that collects electronic insurance claims from medical practices and forwards claims to the appropriate health plan

question

3 steps a clearing house will take

answer

Clearing house also translates claim data to fit the standard format required for physician claims Clearinghouse performs an edit to see that all necessary information is included to file claim Then, an audit/edit report is sent to practice. This lists problems that need to be corrected before claim can be sent to the health plan.

question

(the automated entry of information from a RA)

answer

Payments from insurance companies are auto posted

question

EMRs—

answer

computerized records of one physician's encounters with a patient over time

question

PHRs

answer

private, secure electronic files that are created, maintained and owned by the patient

question

advantages of EHR

answer

safety: Helps reduce medical errors by Medication and physician errors due to illegible handwriting Instant alerts for patient allergies and drug interactions Alerts when medications deemed unsafe have been pulled off the market Records are not lost due to natural disasters or intentional attacks Information is communicated timely

question

advantages of EHR

answer

Quality Providers get a complete picture of the patient's past and present condition Other ways EHRs enhance quality Patients are contacted with reminders about physicals Patients suffering from chronic diseases are able to monitor their conditions and report via the internet Patients can review data on quality for particular providers and facilities

question

advantages of EHR

answer

Efficiency Information retrieval is immediate Saves time Other ways EHRs improve efficiency Speed of delivery of test results Two or more people can work with a patient record at the same time Eliminates the need to search for a misplaced chart Permits physicians to review a summary of the patient's health information at a glance Eliminates the need to manually enter diagnosis and procedure codes from a paper encounter form Reduces the time it takes to refill a prescription Organizes all information in one place Enables physician to receive payment for services more quickly

question

e commerce

answer

med practices participate in this to purchase supplies over the Internet

question

the entity that criminal issues or complaints or non compliance of HIPAA regulations are referred

answer

Office of Inspector General

question

people in this field work with administrative and clinical computer systems

answer

HIM Health Information Management

question

insurance carrier that can be private or public

answer

third party payer

question

three types of PHI that patient does NOT have the right to access

answer

psychotherapy notes, records of legal proceedings, CLIA protected info

question

clearinghouses format electronic claims into this format

answer

HIPAA compliant

question

HIPAA meaning

answer

Health Insurance Portability and Accountability Act

question

you can find diagnoses in this book

answer

ICD-9

question

standardized code specifies services the physicians provided

answer

CPT (Current procedural Terminology

question

similar to EOB (explanation of benefits)

answer

RA (remittance advice)

question

THE 10 steps in The Billing Cycle

answer

#1 PRE-REGISTER PATIENTS #2 ESTABLISHED 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 PATIENT CLAIMS/COLLECTIONS

question

FORM GIVEN TO PATIENT AT FIRST APPOINTMENT OUTLINES RIGHTS COVERED BY LEGAL DUTIES IN REGARDS TO PHI

answer

Notice of Privacy practice

question

CPT was developed by

answer

AMA American Medical Assosiation

question

three examples of PHI

answer

EHR,EMR,lab results x rAy

question

THREE EXAMPLES OF IIHI

answer

patient name, demographics, med or mental conditions. coding and claim info

question

Auto posting

answer

automated entry of info from remittance advice into PMP practice management system

question

-billing in medical offices depends on these two types of services posting

answer

patient data transaction data

question

a practice must have this if using an outside billing service

answer

contract

question

a portion of charges that are a patients responsibility

answer

co -insurance

question

medical insurance represents a contract between this and health plan

answer

policyholder

question

this type of health plan has a high deductible but a small premium

answer

CDHP consumer driven health plan

question

electronic claim format used to bill physician service

answer

837P form in paper

question

these can be accessed in several locations at the same time

answer

EMR

question

used to record clinical data

answer

EMR

question

unlike paper form these do not use up space in the office

answer

EMR

question

eliminates medication errors that result from illegible handwriting prescription forms

answer

Electronic prescribing

question

refers to computer hardware and software that medical practices use to accomplish daily tasks

answer

IT information technology

question

these billing programs eliminate data entry errors

answer

computerized

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