CHAPTERS 12-16 HOUR TEST
Match each claim-adjustment reason code with its description
1- deductible amount 2- coinsurance amount 3- copayment amount 4- the procedure code is inconsistent with the modifier used. or a required modifier is missing 5 - the procedure code or bill type is inconsistent with the place of service 8- the procedure code is inconsistent with the provider type/specialty (taxonomy) 15- payment adjusted because the submitted authorization number is missing, is invalid, or does not apply to the billed services or provider 16- claim/service lacks information that is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate 18- duplicate claim/service 24- payment for charges adjusted. Charges are covered under a capitation agreement/ managed care plan 50- these are noncovered services because this is not deemed a medical necessity by the payer 51- these are noncovered services because this is a pre existing condition 65- procedure code was incorrect. This payment reflects the correct code 114- procedure/product was not approved by the Food and Drug Administration 125- payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.
Drag the appropriate term to its definition.
1. Day sheet - report summarizing the business days charges and payments 2. Patient statement - shows services provided to a patient, total payments made, total charges, adjustments, and balance due 3. Collections - all activities related to patient accounts and follow up 4. Embezzlement- stealing of funds by an employee or contractor 5. Fair debt collection practices act of 1977 -laws regulating collection practices 6. Equal credit opportunity act - prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because a person received public assistance 7.Telephone consumer protection act of 1991- law regulating consumer collections to ensure fair and ethical treatment of debtors 8. Truth in lending act - law requiring disclosure of finance charges and late fees for payment plans.
Put the steps of the workers' compensation claim process in the correct order.
1. an employee is injured on the job 2. the injury is reported to the employer(within a time period, usually in writing) 3. the employer notifies the state workers' compensation office and the insurance carrier 4. the employee is given a medical service order to take to the physician who provides treatment 5. the injured employee is treated (often by a provider selected by the employer or insurance carrier) 6. providers submit their charges to the workers' compensation insurance carrier and are paid directly by the carrier 7. the insurance carrier assigns a claim number to the case, determines whether the claim is eligible for workers' compensation, and notifies the employer 8. the worker is informed of the outcome within a given number of days 9. if the employee is eligible for compensation for lost wages checks are sent directly to him or her, and no income taxes are withheld from the payments. If the claim is denied, the employee must pay all medical bills associated with the accident.
Put the steps in the RA/EOB review process in the correct order.
1. check the patients name. account number, insurance number, and date of service against the claim 2.verify that all billed cpt codes are listed 3. check the payment for each CPT against the expected amount, which may be an allowed amount or a percentage of the usual fee. 4. analyze the payer's adjustment codes to locate all unpaid, downcoded, or denied claims for closer review 5. pay special attention to RA/EOBs for claims submitted with modifiers 6. decide whether any items on the RA/EOB need clarifying with the payer, and follow up as necessary
Which law required consumer reporting agencies to have reasonable and fair procedures?
FCRA
What provides workers' compensation benefits for civilian employees of the federal government?
FECA
Drag the terms to the blanks in the sentences below.
If problems result from the automated review, the claim is suspended and set aside for development, which means that more information is needed for claim processing Claims are sent to the payer's medical review dept, where a claims examiner reviews the claim and may ask for clinical documentation from the provider When there is insufficient guidance on the point in question, examiners may have it reviewed by staff medical professionals For each service line on a claim, the payer makes a payment determination If the examiner determines that the service was at too high a level for the diagnosis, a lower level code is assigned, in a process known as downcoding If a payment is due, the payer sends it to the provider along with a remittance advice (RA) or electronic remittance advice; the old paper version of this document is called the explanation of benefits
Successful Technique: 1. Identify yourself 2. talk to the person responsible for the account 3. call in the evening 4. use positive wording (the expectation of a payment) 5. use a pleasant manner 6. ask to discuss the bill 7. listen carefully 8. if promised a payment, ask for date, method of payment, and for what amount 9. record the outcome of the conversation 10. inform the patient that you need to know why the bill has not been paid yet
Inappropriate Technique: 1. Call during the workday 2. threaten the patient 3. talk to someone in the household who is not responsible for the account 4. call before 8 am 5. call the patients place of employment 6. don not allow the patient to discuss the bill 7. ignore the patients responses 8. show irritation to make the patient pay the bill 9. disclose personal health information to prove that you are calling from a medical office 10. dont waste time by taking notes during the conversation
What was created to protect workers from health and safety risks on the job?
OSHA
Various programs that are administered by the ___________ cover work-related illnesses or injuries suffered by civilian employees of federal agencies, including occupational diseases they acquire.
OWCP
Match the Claims Adjustment Group code to the appropriate definition
PR -Appears next to an amount that can be billed to the patient or insured CO - appears when the payment between the patient and provider resulted in an adjustment CR- appears to correct a previous claim QA - used only when neither PR or CO applies, as when another insurance is primary PI- appears when the payer thinks the patient is not responsible for the charge, but there is no contract between the payer and the provider
Drag the appropriate term to its definition.
Prepayment plan-Payment before medical services are provided Credit reporting -analysis of a person's credit standing during the collections process Credit bureaus - organizations that supply information about consumers' credit history Fair credit reporting act - law requiring consumer reporting agencies to have reasonable and fair procedures Fair and accurate credit transaction act- laws designed to protect the accuracy and privacy of credit reports Bad debt - account deemed uncollectible Means test - process of fairly determining a patient's ability to pay Bankruptcy - declaration that a person is unable to pay his or her debts
What program helps to pay living expenses for people who are blind or have disabilities and those of low-income older people?
SSI
The law that regulates calling hours and collections methods is:
Telephone Consumer Protection Act
A patient presents with a form of cancer developed from radiation exposure during their work in a federal weapons facility. By which OWCP programs are they are likely to be covered?
The Energy Employees Occupational Illness Compensation Program
A patient presents with an injury suffered while working on an offshore fishing ship. By which OWCP program are they likely to be covered?
The Longshore and Harbor Workers' Compensation Program
Which of the following statements is true?
The guarantor and the patient may be the same person
Drag the terms to the blanks in the sentences below.
When the payer initially receives claims, it issues an electronic response to the sender showing that the transmission has been successful. Each claim then undergoes a process known as adjudication, made up of steps designed to judge how it should be paid. Each claim's data elements are checked by the payers front-end claims processing system Paper claims and any paper attachments are date-stamped and entered into the payer's computer system Claims with errors or simple mistakes are rejected by the computer system Payors' computer systems then apply edits that reflect their payment policies
Subrogation refers to
actions a payer takes to recoup paid claim expense in certain circumstances
After an account is determined to be uncollectible, it is removed from the practice's expected accounts receivable and classified as:
bad debt
__________ is after an account is determined to be uncollectible and is removed from the practice's expected accounts receivable.
bad debt
When a person receives a legal declaration of the inability to pay debts, it is called:
bankruptcy
The Federal Black Lung Program provides benefits for individuals who work in
coal mines
To avoid having to bill patients for unassigned claims, most practices:
collect these fees from patients at the time of service
Assigning patient accounts to a specific time of the month to standardize the times when patients are mailed and payments are due is known as:
cycle billing
The ________________ totals the transactions that were posted to all patient ledgers on a particular business day.
day sheet
What is a summary of the financial transactions that occur each day?
day sheet
Where is payment made when a federal worker injured on the job is treated by a physician authorized by the OWCP?
directly to the provider
Who may file the first report of injury?
employer or physician
Collections from patients are classified as consumer collections and are regulated by _____ and state laws.
federal
What classification of disability describes an individual who may work in an upright or walking position as long as no greater than minimal effort is required?
limitation to light work
A _______________ may be used to fairly determine a patient's ability to pay for medical services.
means test
The _________ helps a practice decide whether patients are indigent.
means test
When a payment plan is agreed to by patient and practice that involves no finance charge or late fees, and has four or fewer payments, it is:
not regulated by federal law
The ___________ report is the start of the process of collecting payments due from patients.
patient aging
When money needs to be refunded to patients because the practice has overcharged a patient for a service, it is known as a:
patient refund
What is a printed bill that shows the amount a patient owes?
patient statement
What classification of disability describes an individual who has lost 50 percent of heavy lifting ability?
precluding heavy lifting
What classification of disability describes an individual who has lost 50 percent or more of the ability to lift, push, pull, bend, stoop, and climb?
precluding heavy work
What classification of disability describes an individual who has lost 25 percent of the ability for very heavy lifting?
precluding very heavy lifting
Patients may agree to a(n)____________ for expensive procedures before the date of service.
prepayment plan
A ________________ is a log of how long various types of documents must be stored for a particular practice.
retention schedule
The ______________ process is used to locate a patient who owes an account balance to the practice.
skip tracing
What is the claim status when the payer is developing the claim?
suspended
The OWCP is part of what branch of the federal government?
the U.S. Department of Labor
The claim turnaround time is the period between:
the date of claim transmission and receipt of payment
An incomplete or inadequate medical report often leads to
the denial of a disability claim
What type of workers are covered by the programs of the OWCP?
those who have sustained workplace injuries
Which types of services are offered by the programs administered by the OWCP?
vocational rehabilitation, medical treatment, and cash benefits for lost wages
