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Medical Code Sets

answer

Under HIPAA, data elements that are used to uniformly to document why patients are seen (diagnostic codes) and what is done to them (procedure codes)

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Third Party Payer

answer

A large percentage of reimbursement in the doctor's office generally comes from

question

Paper Claim

answer

one that is submitted on paper, including the optical character recognition form and converted to electronic by the insurance company

question

Physically Clean Claim

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is one that has no staples or highlighted areas and no deformed bar code.

question

Dirty Claim

answer

one that is submitted with errors, requires manual processing, or is rejected for payment

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Cash Flow

answer

the money available to a medical practice

question

15%-18%

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90 days or older; medical practice aged A/R balance should not exceed

question

Accounts Receivable

answer

the most important function of a practice management system

question

Once a Week

answer

verification of successful backups by comparing original records with copied records should be performed

question

Gibberish

answer

to protect information in electronic health records, data is encrypted and looks like__to unauthorized users

question

third party payers

answer

Large percentage of revenue for a medical office comes from

question

Ross-Loss medical group

answer

the oldest, privately owned, prepaid, medical group

question

Turfing

answer

to transfer the sickest, highest cost, patients to another doctor ro appear to be a low utilizer

question

Complaints

answer

insurance companies can be rated by the number of___about them

question

7-14 days

answer

insurance claims transmitted electronically are usually paid within

question

Verbal referral

answer

when a PCP inform a pt. and calls the referring provider that a patient is being referred for an appointment, this is called

question

State insurance commissioner

answer

help with payment problems, ignored claims, or exceeded time limits by insurance companies

question

Internal Revenue Service IRS

answer

and employers identification number assigned by the___

question

Preferred Provider Organization PPO*

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health benefit program in which enrollees may choose any doctor or hospital but obtain a higher level of benefits if preferred providers are used is a

question

Gatekeeper*

answer

in a manages care setting, a physician who controls patient access to specialist and diagnostic testing services is known as a

question

Carve-outs

answer

medical services that are not included in a managed care contract's capitation rate but that may be contracted for separately are referred to as

question

Network facilities

answer

plan-specified facilities listed in managed care plan contracts where patients are required to have laboratory and radiology tests performed are called

question

Quality Improvement Organization

answer

determines the quality and operation of health care; examines evidence for admission and discharge of a patient from the hospital

question

False

answer

an employer may offer the service of an HMO clinic if he or she has five or more employees

question

A/R accounts receivable*

answer

the unpaid balance due from patients for professional services rendered is known as

question

80%

answer

what is the collection rate if a total of $40,300 was collected for the month and the total of the accounts receivable is $50,670

question

Ask for photo i.d, accept card only if the person whose name is on the card, and get approval from the credit card company

answer

when accepting a credit cards as payment on an account, the proper guidelines to follow are

question

Restrictive endorsement

answer

insurance payment check should be stamped in the endorsement area on the back \"For Deposit Only\" which is called

question

True

answer

Insurance companies and the federal government do not recommend waiving copayments to patients.

question

8am-9pm

answer

Most state collection laws allows telephone calls to the debtor between___

question

False

answer

when a patient had declared bankruptcy, it is permissible to continue to send monthly statements for a balance due

question

Fair Debt Collection Practice Act

answer

a collection agency must follow all the laws stated in the __

question

Encryption

answer

the act of converting computerized data into a code so that unauthorized users are unable to read it is a security system known as

question

Direct links*

answer

medical practices that do not use the services of clearinghouses submit claims through a ____to the insurance company

question

NPI*

answer

all numeric 10-character number assigned to each provider and required for all transactions with health plans effective March 23, 2007

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Encoder

answer

add-on software to a practice management system that can reduce the time it takes to build or review a claim before batching is known as

question

Real time

answer

many insurance companies, such as Medicare, provide instant access information about pending claims through online

question

Explanation of Medicare Benefits (EOMB)

answer

the medicare electronic remittance advice was previously referred to as an

question

Nine

answer

under HIPAA transaction standard ASC X12 version 5010 a ___digit ZIP code is required to report service facility locations

question

Limitations

answer

access controls allow organizations to create___for each job category that will restrict access to certain data

question

Reasonable

answer

under HIPAA___ efforts must be made to limit the use and disclosure of PHI

question

Diagnosis codes, procedure codes, HCPCS codes

answer

encounter forms should be reviewed annually for changes that may have been to___

question

Macros

answer

a technique for entry of data, which can save time and key strokes by recording commands into memory is referred to as

question

ANSI 835

answer

electronic Medicare remittance advice that takes the place of a paper Medicare explanation of benefits is referred to

question

Incineration

answer

a method for ensuring that ePHI cannot be recovered from a hard drive that is being disposed of

question

False

answer

like paper claim, electronic claims require the performing physician's signature

question

True

answer

claims can be submitted to various insurance payers in a single-batch electronic transmission

question

True

answer

ICD and CPT codes are deleted and become obsolete, they should immediately be removes from the practice's computer system

question

False

answer

Implementation of the ICD-10 resulted in the upgrade to HIPAA transaction standard ASC X12 6010

question

False

answer

HIPAA requires that the NPI number be used to identify employers rather than inputting the actual name of the company when submitting claims

question

Syntax Errors

answer

when transmitting electronic claims, inaccuracies that violate the HIPAA standard transaction format are known as

question

Explanation of Benefits

answer

after insurance claim is processed by the insurance carrier a document known as ___ is sent to the patient and to the provider of professional medical services

question

Date claim paid column and blank*

answer

to locate delinquent claims on an insurance claim register quickly, which column should be looked at first and would it appear blank or completed

question

ticker file, suspense, follow-up

answer

in good office management, a manual method used to track submitted pending or resubmitted insurance claims called___

question

30-45 days*

answer

Medicare reconsideration by the insurance carrier is usually completed within

question

Appeal

answer

request for payment to a third party payer asking for a review of an insurance claim that has been denied is referred to as a

question

Soft denial

answer

insurance claim transmitted to the third party payer that is rejected because it contains a technical error, such as missing insured's birth date is also known as

question

True

answer

if the provider has no contract with the insurance carrier, the provider is not obligated to the carrier's deadline

question

False

answer

overpayment is receipt of less than the contract from a managed care plan for a patient who has received medical services

question

True

answer

a decision to appeal a claim should be based on whether there is sufficient data to back up the claim and if there is a large amount of money in question

question

Rebill

answer

if a claim has not yet been paid, don't automatically ___ the third party payer without researching the reason why it is still outstanding

question

Collection Ratio

answer

relationship of the amount of money collected on the physicians A/R

question

Age Analysis

answer

term used for procedure of systematically arranging the A/R by age from the date of service

question

Open book account

answer

Physicians' patient accounts are usually

question

Churning

answer

occurs when physician sees a patient more than medically necessary, thus increasing revenue through an increased number of services

question

Buffing

answer

the term for making this practice look justifiable to the plan turfing

question

Utilization review

answer

management system, necessary to control cost in a manage care setting

question

1.5-2x charges for one month service

answer

average amount of accounts receivable

MOA 140 Ch. 8, 9, 10, 11

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