Ch. 17 Medical Billing and Reimbursement (WB)

Transmitter ID

Found on the patient's health insurance ID card and is needed to identify the specific health plan to which the claim should be submitted

Preauthorization

Obtained from health insurance companies and gives the provider approval to render the medical service

Remark Codes

On the EOB where the payer indicates the conditions under which the claim was paid or denied

Claims Clearinghouse

An intermediary that accepts the electron claim from the provider, reformats the claim to the specifications outlined by the insurance plan, and submits claim

How can the medical assistant help prevent delays in reimbursement and denial of payment?

Understand and comply with specific guidelines on form completion

Downcoding

When a lower specificity level, or more generalized code, is assigned

Upcoding

When provider may be inclined to code to a higher specificity level than the service provided actually involved

At the time of the appointment, what two things are copied or scanned into the computer?

1. both sides of patients insurance card 2. government issued picture ID

Capitation agreements

A contract between a provider and an insurance company in which the health plan pays a monthly fee per patient while the provider accepts the patient's copay as payment in full for office visits

Explanation of Benefits (EOB)

A form that is sent by the insurance company to the provider who submitted the insurance claim with an accompanying check or a document indication that funds were electronically transferred

Participating Provider

A healthcare provider who has signed a contract with a health insurance plan to accept lower reimbursement for services in return for patient referrals

Copayment

A patient financial responsibility that is due at the time of the office visit

Deductible

A patient financial responsibility that the subscriber for the policy is contracted per year to pay toward his or her healthcare before the insurance policy reimburses the provider

Coinsurance

A policy provision in which the policyholder and insurance company share the cost of covered medical services in a specific ratio

Audit

A process done prior to claims submission to examine claims for accuracy and completeness

Explain the role of a claims clearinghouse.

Acts as an intermediary between the healthcare facility and the health insurance company

National Provider Identifiers (NPI)

An identifier assigned by the Centers for Medicare and Medicaid Services (CMS) that classifies the healthcare provider by license and medical specialties

Describe how the patient's insurance eligibility is confirmed

By calling the provider services desk phone number on the back of the insurance card or using the provider Web portal sponsored by the patient's health insurance company

Dirty claims

Claims with incorrect, missing, or insufficient data

What information might be found in the Remarks codes on the EOB?

Conditions or remarks under which the claim was paid or denied

Describe the information provided in the explanation of benefits (EOB).

Copayment- fixed amount at the time of service Coinsurance- Cost-share percentage Deductible- must be met by the patient before benefits begin

CMS-1500

For used by most health insurance payers for claims submitted by providers and suppliers

Intentional

Determining whether fraudulent medical billing practices were done with purpose or by accident

Medical Necessity

Insurance carrier's decision if the test and treatments indicated by the CPT and HCPCS codes meet the accepted standard of practice to treat the patient's diagnosis indicated by the ICD code

Direct Billing

Process by which an insurance carrier allows a provider to submit insurance claims directly to the carrier electronically

Electronic data interchange

The electronic transfer of data (e.g., electronic claims) between two or more entities

Precertification

The process of obtaining the dollar amount approved for a medical procedure or service before it is scheduled

Precertification

The process of obtaining the dollar amount approved for a medical procedure or service before the procedure or service is scheduled

What is the purpose of "claim scrubbers"?

They ensure claims are clean before they are submitted to payers. They help avoid denials and delays

List four types of information collected when a patient calls to schedule an appointment

a. information about the insured b. his/her employer c. demographic information d. health insurance data