Health Insurance Billing – Chapter 10
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CMS
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Centers for Medicare and Medicaid Services
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ECS
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electronic claims submission
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EDI
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electronic data interchange
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HIPAA
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Health Insurance Portability and Accountability Act
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PHI
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protected health information
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TPA
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third-party administrator
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electonic data interchange (EDI)
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A process that sends information back and forth between two or more individuals by computer linkages.
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electronic claim
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A claim that is submitted to the insurance carrier by computer modem or computer download or upload via the Internet.
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The identification of provider and insurance carrier responsibilities for accurate coding is part of ______.
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compliance monitoring
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The length of time from claims submission to claims payment is known as _____.
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turnaround time
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In order to establish electronic claims submission, the provider must _____.
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execute a contract with insurance carriers or a clearinghouse
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Confidentiality safeguards for electronic claims submission include _____.
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assigning and periodically changing passwords
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The process of sending information between two or more individuals via computer linkage is called _____.
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electronic data interchange
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Another name for clearinghouse is _____.
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third-party administrator
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For electronic claims submission, the phrase _____ is printed in place of the patient or provider signatures.
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signature of file
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As with paper claims submission, _____ is the most important factor in ECS.
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accuracy
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The _____ function of electronic claims processing software identifies invalid procedure codes.
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error-edit
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______ is defined as the ability to share information online.
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interactive communication
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Four advantages of electronic claims submission:
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saves time and money associated with mailing the claims, no paper storage, creates an audit trail, errors corrected almost immediately, improved cash flow
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False
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Confidentiality laws for paper records do not apply to electronic records.
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False
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Staff members should share a common password for efficient access to insurance files.
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True
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Confidential information should never be stored on a computer's hard drive.
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True
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A written policy should address electronic claims submission and confidentiality.
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True
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Electronic records management systems include the same components as a record management system for paper files.
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Electronic records are usually filed _____.
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numerically
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_____ must be backed up regularly.
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electronic claims
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All records---either electronic or paper---must be stored in a(n) _____ area.
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secure; climate-controlled
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Computer monitor _____ are one of the tools available to protect confidential information.
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privacy panels
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_____assigned to previous employees should be deleted from all electronic or computer program files.
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passwords
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False
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The CMS-1500 is made obsolete when using electronic claims submission.
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True
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Electronic claims submission software programs edit insurance claims data for accuracy.
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True
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A pattern of coding errors can trigger an investigation of fraud or abuse.
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True
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The provider is responsible for assigning accurate diagnostic and procedure codes. Note: Even if medical coders actually do the coding, the ultimate responsibility rests with the provider, agency, or physician.
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False
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Interactive communication is a time-consuming way to identify and correct insurance claims data.
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electronic claim
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A(n) _____ is submitted to the insurance carrier via the Internet.
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clearinghouse
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A(n) _____ distributes claims to the appropriate insurance carrier.
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carrier-direct
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The _____ electronic claims submission method allows the provider to communicate directly with the insurance company.
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error-edit
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_____ is a process that checks the claim for accuracy and completeness.
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unique identifier
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The clearinghouse assigns a(n) _____ to each insurance company (carrier).
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Components of an electronic claims processing agreement:
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cost of software; staff training; turnaround time; updates; service
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Components of an electronic claims processing agreement required by HIPAA:
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how the information is submitted; who has access to the information; security features; storage and retention policies
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Differences between carrier-direct and clearinghouse electronic claims submission options:
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Carrier-direct: provider retains control of claims submission; medical records are available; immediate feedback to error-edit messages; separate agreement for each insurance carrier. Clearinghouse: third-party involved in clams submissions; one agreement covers all submissions; equipment and software may be supplied by the clearinghouse
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Three types of information required by nearly all insurance carriers:
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patient demographic information, insurance program information, treatment or clinical information
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Two edits often included in insurance billing software:
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invalid diagnosis related to age, gender; invalid diagnosis and treatment codes; E/M code verification
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Sources and source documents for retrieving information for electronic claims submission:
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patient database, medical record, registration form, encounter form
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HIPAA's impact on electronic claims submission:
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HIPAA mandates security and privacy of electronic protected health information; controlled access; non-redisclosure policies/procedures; storage and retention policies; procedures. HIPAA also encourages electronic claims submission of Medicare claims.
