NCCT Interactive Review: Claims Process

When completing the CMS 1500 form, were should the patient's secondary policy number be placed?

Block 9a Block 9 is used for the other insured's name information. Block 9a is for the other or secondary insurance identification/policy number. This information is needed to submit to the insurance company for coordination of benefits for payment of claims. This information should be put into block 1a, and is used for the primary insurance information. Block 11 is where the group number is listed for the primary insurance company.

Fee schedules are maintained and updated annually because fees should reflect which of the following? (Select the three (3) correct answers.) A. experience the providers have within their specialties. B. revenue necessary to maintain the financial stability of the practice. C. any new, deleted, or revised CPT® codes. D. changes to any insurance carrier policies regarding allowable amounts. E. type of services the provider delivers.

revenue necessary to maintain the financial stability of the practice., any new, deleted, or revised CPT® codes., changes to any insurance carrier policies regarding allowable amounts. Fee schedules are maintained and updated annually to reflect many different aspects that also change annually, such as coding updates, utilities and costs of operating the practice, and any cost updates that the insurance carriers may inflict.

A patient has made a payment towards his balance. Where should the insurance and coding specialist enter this payment?

the ledger card The patient ledger card is like a running record of all money owed and paid by the patient. All payments received or debts incurred are entered on the ledger card.

Which of the following ledgers should the insurance and coding specialist use to calculate cash, credit cards, and checks received from all patients during the business day?

total receipts The day's total receipts should be used to calculate all the payments for the day. Charges and adjustments are not payments. An EOB is a document sent from the insurance carrier and is not a payment.

To determine whether a claim is delinquent, which of the following reports should the insurance and coding specialist generate?

aging analysis An aging analysis is used to tell which claims are delinquent. The aging analysis will show how long the delinquency is and also the amount of the delinquency. This report shows all patient delinquencies.

Which of the following reports shows in detail the invoices that are overdue for payment?

aging report A financial summary report uses information from all aspects of the healthcare practice, such as expenses for equipment, payroll, and any other expenses and compares it to how much money was brought into the practice, by means of insurance companies, patients, etc. An aging report is a detailed invoice of overdue payments. It not only shows how much money is owed and by whom, but it also shows how long the money has been overdue. An accounts receivable report shows money that has been paid to the practice. A managed care analysis report summarizes managed care accounts.

The multipurpose billing forms should be reviewed and updated to include new or revised codes

annually. Codes can be added, deleted, or revised once a year, which means that billing forms should be updated annually to reflect the new changes, effective January 1st.

Which of the following is documented on a patient's ledger card once payment is received? A. CPT® codes B. ICD codes C. any credits D. balance due date

any credits Rationale A ledger card is a running account of a patient's total financial account. It is like a check book, because it should show any money that has been paid, any money that is owed, or any money that has been credited, along with the dates of the transactions. Due dates are not recorded on the ledger card, only financial situations that have already happened are recorded, not what is expected to happen in the future. Codes are not used on this form.

The insurance and coding specialist is required to post monthly payments from the insurance company that has a certain number of subscribers. A set dollar amount is received for each patient's services whether they were seen or not. Which of the following is this process is called?

capitation Capitation is used with HMO insurance companies. This is when the PCP is paid a flat fee per patient within their plan. It does not matter if the patient is seen several times per month or not at all. Claims will still be processed for additional payments and the patient pays the copay at the time of service.

Which of the following terms describes an insurance company paying the physician a set amount each month, regardless of the number of services the patient receives?

capitation Capitation is used with HMO insurance companies. This is when the PCP is paid a flat fee per patient within their plan. It does not matter if the patient is seen several times per month or not at all. Coinsurance is the percentage a patient would be responsible for with a PPO insurance plan. A monthly dividend or a payment scale would not be used in this manner.

Which of the following documents includes details of fees for services rendered in a clinical setting?

encounter form An encounter form is used and generated by the practice. An encounter form is used for each patient visit and included details of the services rendered and the fees associated with those services. A charge master is used by the practice to keep track of the prices of the services provided by the practice. A financial responsibility form is used to document the person who is responsible for paying for services.

A patient presents for a procedure that Medicare will not pay for. Which of the following should the billing and coding specialist do? A. Collect payment in full before the procedure. B. Ask the doctor if only the allowable should be billed. C. Have the patient sign an advanced beneficiary notice. D. Obtain a letter of medical necessity.

Have the patient sign an advanced beneficiary notice. An advanced Beneficiary Notice, or ABN, is a form that Medicare requires all healthcare providers to use when Medicare does not pay for a service or procedure. Patients must sign the form to acknowledge that they understand they have a choice about their healthcare procedure or service in the event that Medicare does not pay. Choosing to proceed with the service or procedure holds the patient financially responsible for payment in full.

The provider has a capitation plan that states he will provide examinations for 100 employees. The insurer will reimburse at the rate of $100 per employee, paid in monthly installments. During the month of March only 80 patients were provided exams. Which of the following is the expected reimbursement for March?

$10,000 When a provider has a capitation plan, the insurance always pays for the full amount of patients, regardless of how many patients were seen. Since this plan covers 100 employees, and the insurer has agreed to pay $100 per employee, the physician will always receive $10,000 (100 x 100) per month, throughout the length of the contract.

In order to determine if a claim is delinquent, which of the following reports must be generated?

A/R aging report The A/R aging report is a report of all delinquent patient accounts. It includes how long the accounts have been delinquent and how much money is owed. A daily balance report is generated to show the money generated in a day. A batch report shows all of the encounters that have been billed out, in the groups in which they have been entered. An analysis report is a very broad term that can mean many different things in the healthcare world. Almost any data that can be formatted into a report can be called an analysis.

Box 13 on the CMS-1500 form stating, "Signature on File", is allowing which of the following? A. Primary Policy Holder B. Accept Assignment C. Assignment of Benefits D. Information about Third-Party Liability

Assignment of Benefits The patient's signature or the statement "signature on file" in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization.

Which of the following the steps are appropriate to reconcile the day's financial transactions? (Select the three (3) correct answers.) A. Close out batches and add the balances. B. Post payments prior to bank deposit. C. Post copays after closing the batch. D. Issue receipts for all services rendered. E. Run an audit trail.

Close out batches and add the balances., Post payments prior to bank deposit., Issue receipts for all services rendered. Nothing should be posted after the closing of the daily batch. this This will result in an inaccurate balance. Receipts should be issued for all services rendered, all payments should be posted prior to the bank deposit preparation. Once the batches are closed, the balances are added to be sure of the calculations.

Which of the following are required, daily reconciliations in the physician office? (Select the three (3) correct answers.) A. EOB B. patient payments C. trial balances D. AR days E. AR balance

EOB, patient payments, AR balance Daily reconciliation is a compilation of money owed and money received, including past due balances. For the daily reconciliation, all of the EOBs are needed, the patient payments received on that day, as well as the AR balance.

Which of the following signed documents should the insurance and coding specialist obtain from all new patients? (Select the three (3) correct answers.) A. insurance eligibility B. HIPAA acknowledgement C. financial responsibility D. advance beneficiary notice E. assignment of benefits

HIPAA acknowledgement, financial responsibility, assignment of benefits Every new patient should receive a copy of HIPAA guidelines and sign an acknowledgement of it. A financial responsibility form should be signed by the patient/guardian acknowledging financial responsibility. Assignment of benefits needs to be signed giving the office authority to bill on his/her behalf.

8. Which of the following are common reasons for a claim to be rejected by a primary payer? (Select the three (3) correct answers.) A. On the CMS 1500 form, Block 29, Amount Paid, is blank. B. Insurance ID number is incorrect. C. Tertiary insurance information is missing. D. Dates of service do not match charges. E. Diagnosis codes are not linked to procedures.

Insurance ID number is incorrect., Dates of service do not match charges., Diagnosis codes are not linked to procedures. A claim can be rejected for many reasons. Some examples of claim rejection by the insurance carrier are: the insurance ID number is incorrect, the dates of service are incorrect, the diagnosis codes are not linked to the procedures, the physician information is missing, or the secondary insurance information is missing. It is allowable for the "Amount Paid" space to be left blank. There is no space on a CMS-1500 form for a tertiary (3rd) payer.

On a CMS-1500 form, which of the following fields does not have to be filed out for every patient?

LMP The LMP (last menstrual period) section of the CMS-1500 form will not be filled out for every patient. It will only be filled out for female patients who are pregnant, have recently been pregnant, or are experiencing medical issues with their reproductive system. The DOS (date of service), DOB (date of birth), and POS 9place of service) must be filled out on every claim form, for every patient.

To verify that multiple CPT® codes may be billed together without being considered unbundled, the insurance and coding specialist should query the

NCCI edits. NCCI edits are published by Medicare as guidelines to their coding practices. NCCI edits contain services that are bundled together and should not be billed separately. Please note that not every code is mentioned in the NCCI edits, but should always be reviewed for information. Even though these edits are published for Medicare patients, may other insurances also use these guidelines.

Which of the following requires a patient's signature for the medical facility/provider to be paid by the carrier?

SOF SOF stands for "Signature on File". This abbreviation is used on a claim form and means that the provider has a document that has been signed by the patient, stating that the provider is allowed to accept payment on behalf of the patient. An ABN, or Advanced Beneficiary Notice, is a notice that a patient signs agreeing that he will pay for a procedure because it is already known that the insurance company will not pay for that particular service. NPP stands for Notice of Privacy Practices and outlines a patient's privacy rights within a practice. RA stands for Remittance Advice, which is a document provided by the insurance payer and explains reasons for payments, denials, adjustments, etc.

Which of the following is the definition of capitation payments?

a fixed, monthly payment Capitation payments are made monthly. Physicians that participate in capitation programs receive a monthly, predetermined, fixed payment for each patient that they see who are enrolled with that particular insurance's capitation program, regardless of how many times the patient has been seen. The patient may not have been seen at all.

The physician requests the amount of monies unpaid on all accounts. The insurance and coding specialist should run the report for

accounts receivable aging. An accounts receivable aging report will breakdown claims by the number of days unpaid. This report can be used to reconcile the oldest cases first.

An Advance Beneficiary Notice must be signed

before a service which is not covered is provided An ABN is used to let the patient know that a service that is going to be provided to the patient might not be paid or processed by Medicare. This must be filled in completely and explained to the patient that he/she may be responsible for the charges in the event the services are not covered. This is always done prior to any of the services being performed.

Payment received from the payer based on the number of enrollees and entered as monthly payment to the ledger is called

capitation. Capitation is the payment system in which the carrier will pay the provider monthly for each patient who is enrolled, regardless if the patient was seen or not. An EFT, electronic fund transfer, is the way that payments are made by the carriers to the physician. A premium is the cost of the insurance, that is paid by the patient to the carrier. Fee for services determines how much should be paid for each service, depending on where the patient is seen.

A claim that is not missing information is called

clean. A claim that is not missing any pertinent information is called a clean claim. A claim that is missing information is a dirty claim. A scrubbed claim has been reviewed by a third party, such as a clearinghouse, and the errors or missing information have been corrected. A pending claim is being reviewed by the insurance carrier.

Patient A/R aging reports relieve staff of time-consuming activities such as

counting dollar amounts in outstanding accounts. The Patient A/R aging report is a report of all delinquent patient accounts. It includes how long the accounts have been delinquent and how much money is owed. This report can save the office staff time-consuming activities such as counting dollar amounts in outstanding accounts. This report is only used to track outstanding balances owed for services rendered.

Which of the following data elements are required on a CMS 1500 form? (Select the three (3) correct answers.) A. date of service B. physician's billing address C. chief complaint D. payer ID E. patient's date of birth

date of service, physician's billing address, patient's date of birth There are many elements that must be included on a CMS-1500 form. Some of these elements are patient demographics (such as the patient's name, date of birth, and address), physician demographics (such as the physician's name, NPI number, service location, and billing address), and the specifics of the service (such as the date of service, the CPT® codes, and ICD-10 codes). The chief complaint (written out in word form) and the payer ID are not needed on the CMS-1500 form.

Which of the following is required information from the encounter form necessary for insurance reimbursement? (Select the three (3) correct answers.) A. date of service B. procedure codes C. physician's signature D. HCPCS codes E. authorization number

date of service, procedure codes, HCPCS codes An encounter form is used for each patient visit. It is usually made specifically for that practice and includes common codes that the providers use. The providers then check off the codes as the patient's visit progresses. A date of service is used on this form, since it is expected that a patient will have many of these in his chart (from previous dates of service). A medical biller or coder will use the data from the encounter form to fill out portions of the claim form. A physician's signature is not required on an encounter form. An authorization number is also not included on an encounter form, as it should usually be prepared prior to a visit.

The Patient Information section of an encounter form contains A. diagnosis codes. B. date of service. C. physician's signature. D. treatment codes.

date of service. The patient information section of an encounter form includes the patient's name, date of birth, and date of service.

Which of the following should the insurance and coding specialist verify upon receiving an encounter form? (Select the three (3) correct answers.) A. doctor assessment B. date of service C. authorization number D. provided service E. patient balance

doctor assessment, date of service, provided service An insurance and coding specialist should verify the following information upon receiving an encounter form: The physician's assessment, the date of service, the services provided, the patient's name, and any additional diagnoses. Authorization numbers and patient balances are not found on encounter forms. This information can usually be found on claim forms and ledger cards.

Which of the following are factors in negotiating fee structures? (Select the three (3) correct answers.) A. how difficult it is for the provider to do the procedure B. involves the amount of overhead expenses for the procedure C. the relative risk that the procedure presents to the patient and provider D. the year's conversion factor E. fee based payment method

how difficult it is for the provider to do the procedure, involves the amount of overhead expenses for the procedure, the relative risk that the procedure presents to the patient and provider There are many factors that are used in negotiating fee structures, which can raise or lower the allowed amount of a service. The difficulty level, the office overhead expenses, the risk of the procedure, the demographics of the place of service, and how common the procedure is can all affect the fee structure.

Charge information can be taken from an encounter form and entered into the patient's

ledger. Charge information can be taken from an encounter form and entered into the patient's ledger. A patient encounter form contains the information on the services rendered to that patient for that day. The services rendered can be applied from the encounter form to the patient ledger card, which is a running monetary balance owed by the patient. A ledger is balanced similarly to a check book, adding new fees and subtracting credits paid.

How often does a capitation payment get applied to a patient's account?

monthly Capitation payments are made monthly. Physicians that participate in capitation programs receive a monthly, predetermined, fixed payment for each patient they see who are enrolled with that particular insurance's capitation program, regardless of how many times the patient has been seen. The patient may not have been seen at all.

The Assignment of Benefits form is used to allow the insurance company to

pay the provider directly. When a patient sees a new physician, one form that is filled out as part of the new patient paperwork is an Assignment of Benefits form. This form states that the patient is allowing the insurance company to pay the provider directly.

Office fees are set by the

physician. Office fees are set by the physician. The guarantor is the person responsible for paying for the patient's services. The third party payer is the insurance company, who may set forth an allowed amount.

Which of the following information will result in a rejected claim if left off a CMS 1500 form? A. dates of inpatient stay B. outside lab C. amount due D. place of service

place of service A rejection can happen if there is missing information or errors made on a claim. If the patient's name, date of birth, place of service, provider's NPI, CPT code, ICD-10 code, or date of service are missing, the claim will be rejected before it is even considered for payment. An amount due will not cause a claim to be rejected, as the insurance carrier will decide the amount due. Not every service requires an outside lab or an inpatient stay, so they will not cause a rejection if they are missing. Just because a claim does not get rejected, does not mean that it will be paid or denied.