My Medical Coding, Billing, Insurance TEST 1 STUDY Ch. 1-2-3

_____ explains how an insurance policy will pay if more than one policy applies.

** Coordination of benefits Patient data form Insurance rider form Assignment form

When prior authorization is approved, where does the medical assistant enter the prior authorization number for use later on a health care claim?

** PMP HSS CPT form ICD form

An encounter form is also called a(n) ____.

** superbill patient report insurance record data form

Health Care Providers

-A person or organization who furnishes, bills, or is paid for health care in the normal course of business. -Physicians -Hospitals -Pharmacies -Nursing Homes -Dentists

Not Covered by HIPAA

-A practice that does not send any claims electronically and does not employ someone else to send electronic claims to payers or health plans on its behalf.

Abuse

-An ambulance billing insurance for a patient who did not require an ambulance -Ordering tests on a patient who shows no symptoms related to that test.

Health Care Clearinghouses

-Companies that "translate" or "facilitate" translation of electronic transactions -Billing service company

Which of the following help to enforce the HIPAA security rule? ________

-Controlling access to protected health information -Securing Internet connections -Using a system to back up data -All of these ALL OF THESE

Health Plans

-Employee welfare benefit plans -An individual or a group plan that provides or pays for the cost of medical care

Fraud

-Forging another person's name on a check -Pretending to be a physician -Billing for services that were not performed -A patient exaggerating an injury to get a settlement from the insurance company.

Under the HIPAA Privacy Rule, physician practices must ________.

-Train employees about the practice's privacy policy -Appoint a staff member as privacy officer -Have privacy practices appropriate for its health care services -All of these ALL OF THESE

HMO's

-capitation -restricts patients' choice of providers -controls the use of service -controls drug costs -cost-sharing

Government- Sponsored Health Care

-includes Medicare -includes Medicaid -includes TRICARE -includes CHAMPVA

PPO's

-requires preauthorization for services -controls the use of services -most popular type of insurance plan -creates a network of physicians, hospitals, and other providers with whom they have negotiated discounts from the usual fees -directs patients' choices of providers through copayments

CDHP's

-similar to an individual retirement account (IRA) -uses "savings account" to pay bills before deductible is met

Drag the ten steps needed to complete the billing and reimbursement cycle into the appropriate order.

1- Preregister patients 2-establish financial responsibility 3-check in patients 4- review coding compliance 5-review billing compliance 6-check out patients 7-prepare and transmit claims 8-monitor payer adjudication 9-generate patient statements 10-follow up payments and collections

For up to how long can a medical office's financial records be audited after a patient's last visit (assuming that embezzlement or government funding has not occurred)? 3 years

7 years

The authorization to release information must contain ________.

A description of the information to be disclosed

Neither

A patient exaggerating an injury to get sympathy from friends and family. -Billing a patient for a treatment that was unsuccessful -Forging another person's name on a birthday card.

Coinsurance is calculated based on ________.

A percentage of a charge

A notice of privacy practices is given to ________.

A practice's patients

Monies used by the physician practice to pay for operating expenses such as salaries, supplies, and utilities are called ________.

Accounts Payable

The tertiary insurance pays ________.

After the first and second payers

When a patient has insurance coverage for which the practice will create a claim, the patient bill is usually done ________.

After the health claim has been transmitted and the payer's payment is posted

An electronic workflow requires a ________ and an electronic health record program that are capable of exchanging _________.

An electronic workflow requires a ____ practice management program and an electronic health record program that are capable of exchanging ____ data. -practice management program -data

Patients have the right to ________.

Authorize the release of information to anyone not directly involved in their care

The encounter form is a source of ________ information for the medical insurance specialist.

Billing

A completed encounter form contains ________.

Both information about the patient's diagnosis and information on the procedures performed during the encounter

Recognition of a superior level of skill by an official organization is called __.

Certification

If a patient's payment is later than permitted under the financial policy of the practice, the ________ may be started.

Collection process

A compliance plan contains ________.

Consistent written policies and procedures

Health plans pay for ________ services.

Covered

Health information that does not identify an individual is referred to as ________.

De-identified information

PM/EHR is a software program that combines ____.

Electronic Health Record and Practice Management Program

A system used to gather a patient's clinical information is a(n) ________.

Electronic health record

_________ are less prone to _________issues than are paper-based records.

Electronic health records are less prone to ____ privacy and security issues than are paper-based records. -electronic health records -privacy and security

Electronic health records are used to record data such as physicians' reports of examinations, test results, and ______________.

Electronic health records are used to record data such as physicians' reports of examinations, test results, and ____ surgical procedures and insurance claims -surgical procedures and insurance claims

A patient's PHI may be released without authorization to ________.

Employers' workers' compensation cases

Insurance that protects against financial loss as a result of unintentional failed work performance is ________.

Errors and omissions

HIPAA X12N 270/271 is ____.

HIPAA Eligibility for Service Form ** HIPAA Eligibility for a Health Plan electronic transaction form HIPAA Eligibility for Health Care at Hospital form HIPAA Eligibility For Health Care Out-of State Form

Which act requires covered entities to notify affected individuals following the discovery of a breach of unsecured health information?

HITECH

If a health plan member receives medical services from a provider who does not participate in the plan, the cost to the member is ________.

Higher

The major government-sponsored health programs are ________.

Medicare, Medicaid, TRICARE, and CHAMPVA

Which government agency has the authority to enforce the HIPAA Privacy Rule? ________

OCR

Participants in the medical insurance relationship include ________.

Provider Patient Health plan All of these

A certificate number for a procedure is the result of which transaction and process?

Referral certification and authorization

Sort the following characteristics into the type of health care provider they describe. Some characteristics may describe more than one provider.

SEE BELOW

If a husband has an insurance policy but is also eligible for benefits as a dependent under his wife's insurance policy, the wife's policy is considered ________ for him.

Secondary

Classify the following scenarios into Fraud, Abuse, or Neither.

See Below

HIPAA covers the following types of entities. Sort the descriptions or specific types of practices into their corresponding entities, or if the practice described is not covered by HIPAA, add it to the "Not covered by HIPAA" category.

See Below

When registering new patients, the practice must make a good-faith effort to have them sign

The Acknowledgement of Receipt of Notice of Privacy Practices

If a patient is a dependent child covered by both parents' health insurance plans, the child's primary insurance is usually determined by ________.

The birthday rule

Complete and comprehensive documentation shows that physicians have followed ________.

The medical standards of care

When communicating with a payer representative which of the following should be documented? ________

The outcome of the billing dispute The date of the communication The name of the representative All of these ALL of THESE

What information does a patient information form gather? ________.

The patient's personal information, employment data, and insurance information

Which of the following data is stored in a practice management program? ________

Transaction data Provider data Health plan data All of these

What establishes standards for the exchange of financial and administrative data among covered entities?

Transactions and Code Sets

Only ______ is required to give patients an acknowledgment of receipt of a privacy notice to read and sign.

an indirect provider ** a direct provider the insurance company the medical assistant

Which is (are) elements included in a compliance plan according to the Office of the Inspector General?

both training and ongoing communication

What is a medical practice's written plan for complying with regulations?

compliance plan

The policyholder or subscriber to a health plan or policy is called ____.

dependent ** insured underwriter endorser

A provider's analysis of a patient's illness or injury is called ____.

diagnosis

Correct behavior in the medical office is called ____.

etiquette

A retention schedule

explains what records to keep explains how long records must be saved covers the method(s) of record storage all of these ALL OF THESE

What is the best description of an encounter?

face-to-face meeting

_____ are benefits paid based on the fees physician charge for the services.

fee-for-service

Policyholders receive insurance benefits when which of the following is filed?

health care claims

When can information about a patient's drug abuse be disclosed without authorization?

if a prospective employer requests it if a physician from another practice requests it if the patient's spouse requests it None of these NONE OF THESE

___ are organizations that offer health plans that combine the financing and delivery of health care services.

managed care organizations

___ is a financial plan that covers the cost of hospitalization and medical care due to illness or injury.

medical insurance

Which of the following is not a type of information that is important to gather when a patient is new to the practice?

preregistration and scheduling information medical history assignment of benefits ** license plate number

A copayment is due when the patient ___.

receives the service

A compliance plan does not cover which of the following?

referrals and authorizations

Fees are set by ________ under a managed care plan.

the managed care organization

The provider owns the actual medical records, but the information in a record belongs to

the patient

If the plan is an HMO that requires a primary care provider (PCP), the general or family practice must verify which of the following?

the patient has paid their premium ** the patient is assigned to the PCP as of the date of service the insurance company has contacted the patient the pharmacy has been selected

Payers want the name of the patient on a claim _____.

to skip middle initials to include nicknames to be the same as on the patients social security card ** to be exactly as it is shown on the insurance card

To be paid for services, medical practices need to establish financial responsibility and the first step is ___.

verify what provider the patient will be seeing verify that the patient has paid his or her premium ** verify patients eligibility for benefits verify the patients chart number