review quiz 9 – Flashcards

False

CPT codes that appear in the hospital's chargemaster

The provider order entry system that is usually more reliable is electronic because the charge for the service or supply is entered at the point of service and automatically transferred to the patient account and posted to the patient claim. The paper system leaves more room for error

Accounts receivable

The ways that discrepancies between submitted charges and paid charges can be reconciled is by the provider contacting the patient to collect the outstanding deductible or copayment. In addition the facility needs to determine whether the claim can be corrected and resubmitted, if it cannot the facility has to write it off or make an adjustment on the patients account.

Medicare Administrative Contractor

compliance violations and lost reimbursements, Overpayment Underpayment Undercharging for services Claims rejections Fines Penalties

A current and accurate CDM is vital for proper reimbursement. Also, there are negative impacts that may result from an inaccurate CDM. Some of the negative impacts are: overpayment, underpayment, undercharging for services, claims rejections, fines and penalties.

30-day page 253

Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

1.to make sure the EOBs and the MSNs are provided to the facility. 2. is that the EDI reports claim rejections, denials, and payments to the facility

Contractual allowance

Some key performance indicators a provider's RCM team could use to learn the reasons for the surge in unpaid balances could be the days from discharge to coded, the percentage of denials from the third party payers, percentage of late charges, percentage of returned claims for corrections.

Once the claim is submitted to third-party payer p. 523

One source of new codes is the CMS release of updates to codes and billing guidance; the other is performance of new services at the healthcare provider that require line items to be added to the system.

Providers define optimal performance for units of the facility by establishing key performance indicators (KPI) which represent the areas that need to be improved. And by setting a standard for each indicator which can be measured to gauge performance improvement.

How has HIPAA changed claims processing?

sources of errors that can cause claim denials are invalid procedure, invalid revenue code, the code is not recognized or service unit out of range for procedure and data entry mistakes

The ways that discrepancies between submitted charges and paid charges can be reconciled is by the provider contacting the patient to collect the outstanding deductible or copayment. In addition the facility needs to determine whether the claim can be corrected and resubmitted, if it cannot the facility has to write it off or make an adjustment on the patients account. When batches of EOBs, MSNs, and RAs are received via the 835A or 835B electronic format, accounting personnel check the amount owed by the patient (listed as not covered on the EOB or MSN), and collections personnel contact the patient to collect deductibles, copayments, and charges remaining. Accounting personnel also check RAs for denied claims to determine whether corrected claims should be submitted to the insurer. When they cannot receive further payment from insurers or insureds, billing personnel write off the patients' accounts and the revenue cycle ends.

Fiscal Intermediary

Medicare Code Editor

After coding and before claim is submitted

Outpatient Code Editor

*facilities: -Paper UB04 or CMS -1450 -Electronic 837I *Physician: -Paper CMS 1500 -Electronic 837P

1) Patient present to hospital 2) Patient information collected, demographic and payer 3) Services rendered 4) Charge items are captured 5) Coding 6) Claims submitted to payer 7) Payer processes claim 8) Balance billed to other payers/patient

1) DNFB - days not final billed 2) DNFC - days not final coded 3) AR Days - days in account receivable 4) Percentage and/or amount of write offs 5) Percentage of clean claims 6) Percentage of denials or returned claims 7) Late charges

Some key performance indicators a provider's RCM team could use to learn the reasons for the surge in unpaid balances could be the days from discharge to coded, the percentage of denials from the third party payers, percentage of late charges, percentage of returned claims for corrections.

Providers define optimal performance for units of the facility by establishing key performance indicators (KPI) which represent the areas that need to be improved. And by setting a standard for each indicator which can be measured to gauge performance improvement.

Development and implementation of standardized health-related financial and administrative activities electronically, and the implementation of privacy and security procedures to prevent the misuse of health information by ensuring confidentiality.