Chapter 3

A patient wants her results called to her home and states the physician is to talk to her husband. What form should be completed before this is done? a. Authorization to Disclose Health Information b. Consent for Payment c. Consent for Treatment d. Patient Information Form

a. Authorization to Disclose Health Information Section 164.508 of the HIPAA privacy rule states that covered entities may not use or disclose protected health information without a valid authorization. The Authorization to Disclose Health Information lists the names of the individuals to whom the PHI can be disclosed.

The type of coverage that a patient has and what services are covered is defined as the patient's insurance ___________. a. Benefits b. Deductible c. Co-insurance d. Out-of-network

a. Benefits The definition of benefits is the type of coverage that a patient has - whether medical, dental, or vision.

Which of the following lists the life cycle of a claim? a. Claims submission, claims processing, claims adjudication, payment/denial b. Claims submission, claim denial, statement sent c. Claims submission, claims processing, patient payment d. Claims submission, claims processing, claims adjudication

a. Claims submission, claims processing, claims adjudication, payment/denial There are 4 steps to life cycle of a claim which include claims submission, claims processing, claims adjudication, and payment/denial.

A child is brought in by the mother to be seen. The mother (DOB 02/08/83) is the custodial parent and is remarried. She has an individual policy. The father (DOB 10/10/82) is covered by a policy from work. The step-father is also covered at work. Which of the following is correct? a. The mother's insurance is primary b. The step-parent is primary c. The father is always primary d. Either the mother or the father can be primary

a. The mother's insurance is primary In divorce cases where the custodial parent has remarried—The custodial parent coverage is primary, with the step-parent being secondary. The non-custodial parent is the payer of last resort.

In what circumstance would the checkout process be unnecessary? a. The patient made a copay during the check-in process and no follow up appointment is necessary b. The patient needs to make a follow-up appointment c. The patient had a procedure performed in addition to the E/M and need to return in a week d. The patient has services performed that are not covered by the insurance

a. The patient made a copay during the check-in process and no follow up appointment is necessary The discharge process is also called check-out. This is done after the patient has been seen by the provider. The receptionist should review the encounter form to make sure it has been completed. If the copayment was not collected at check-in, it should be collected at check-out. Any deductibles and payment for services that are not covered by insurance should also be collected. If the patient needs a follow-up appointment, it can be done so during the check-out process. Additional procedures or services not covered by the insurance carrier may require additional copay or deductibles to be collected. If a patient requires a follow-up appointment check-out would be necessary.

What is a deductible? a. A fixed amount the patient is responsible to pay at time of visit b. Amount of expenses that must be paid before any payment is made by the insurance company c. A percentage the patient is responsible to pay at the time of visit d. The amount paid by the insurance company

b. Amount of expenses that must be paid before any payment is made by the insurance company A deductible is an amount that is paid by the patient before any payment is made by the insurance company. This amount varies by each patient policy.

Which statement is TRUE regarding appointment reminders? a. Appointment reminders do not help mitigate the risk of missed appointments. b. Appointment reminders can be sent via text. c. You must have a HIPAA authorization for release of information to send appointment reminders. d. The staff time required for appointment reminders makes it unnecessary to remind patients of upcoming appointments.

b. Appointment reminders can be sent via text. Some of the ways to remind the patient of the appointment is with the following:Reminder cards - If the patient schedules the appointment in the office, an appointment card can be givenSend reminders - Reminders can be sent by mail, email, or text confirmations to the patientPhone calls - Phone calls can be made the day before the appointment to confirm the appointment

Patient insurance card will contain vital information that will allow a claim to be processed. Which of the following is NOT provided on the insurance card? a. Policy holder, group number b. Claim number, CPT code, diagnosis c. Policy holder, copay, deductible d. Claims address, Group number

b. Claim number, CPT code, diagnosis The insurance card will not contain specific information regarding the encounter. It will contain information regarding the policy holder, group number, copay, deductible and address to mail the claim.

What authorizes information to be sent to the insurance payer so payment of medical benefits can be processed? a. MSP b. Consent for payment c. Encounter form d. Chargemaster List

b. Consent for payment The consent for payment authorizes information to be sent to the insurance payer so payment of medical benefits can be processed. It also demonstrates responsibility of the patient or responsible party for copayments, coinsurance, deductibles, and fees that exceed the payment made by insurance if the physician does not participate with the patient's insurance. This agreement must be in writing in order to collect any amount from the patient.

When entering patient data information into a PMS: a. Assume the information is correct b. Enter the patient information accurately from the insurance card and patient registration form c. Review the information annually for correctness d. The format of the information is not important but must be entered

b. Enter the patient information accurately from the insurance card and patient registration form Information gathered during the registration process is imperative to the success of a clean claim. If information is entered into the PMS incorrectly, it can result in denied claims or delayed payment. This information should be reviewed, at every visit, for any changes.

If your clinic has patients that do not show for their scheduled appointments it would be good clinical practice to: a. Not schedule them again b. Make reminder calls 1-2 days in advance c. Double book all appointments d. Charge for the visit

b. Make reminder calls 1-2 days in advance No-show appointments cannot be eliminated altogether; however, it is beneficial to make reminder calls 1-2 days in advance. Double booking is not recommended and charging for the visit is not appropriate as a face-to-face encounter with the patient is required for this service.

The group number on the insurance card is used to identify: a. The insured b. The covered employer group c. The insurance company d. The policy number

b. The covered employer group The group number identifies the employer group that covers the patient with health coverage. The verification information should be retained for future use.

Child presents for care with the father. Both parents have coverage, date of birth for mother is 3/21 and date of birth for father is 6/20. The mother is covered by a COBRA. What is the primary coverage for the child? a. The mother's coverage is primary based on the birthday rule. b. The father's insurance is primary because the mother has COBRA c. The father is primary because he is older d. The father's is primary because he consented for care.

b. The father's insurance is primary because the mother has COBRA When following the birthday rule the parent with the birthday closest to the first of the calendar year is primary. An exception to that rule states if one of the plans is COBRA, COBRA is secondary.

A female patient is covered by her employer and her husband's insurance plan. His birthday is 3/21 and hers is 6/18. Which insurance is considered primary? a. The husband's insurance because of the birthday rule b. The patient's insurance because she is the primary subscriber c. The husband's insurance is primary, because he is the head of the household d. Either can be filed as primary

b. The patient's insurance because she is the primary subscriber When a patient has insurance where they are the subscriber, this coverage is primary. The birthday rule applies only to children when both parents provide insurance coverage.

How do most practices submit claims to the insurance company? a. Directly from the PMS to the insurance carrier b. Through a clearinghouse c. Through a claims analyzer d. By hiring a claims adjudicator

b. Through a clearinghouse Each practice can submit claims either directly to the insurance carrier or through a clearinghouse. Most practices utilize the services of a clearinghouse to submit claims instead of submitting the claims directly to the payer.

Information about deductibles, copays, eligibility dates, and benefit plans is completed during what step? a. Patient registration b. Verification of Benefits c. Patient check-in d. Consent for payment

b. Verification of Benefits Verification of Benefits provides information concerning the patient's coverage. This should be performed during the appointment scheduling process and before the patient arrives at the office. This step verifies eligibility effective dates, patient coinsurance, copay and deductible amounts and plan benefits as they pertain to specialty and place of service. Benefit information allows staff to be informed and ready to collect the appropriate copay, deductible, coinsurance or full balance due at the patient's visit.

Which of the following is NOT considered a part of the authorized process when the patient signs the consent for payment? a. Authorize payment to the provider b. Authorize submission of a claim to insurance company c. Authorization for treatment d. Accept responsibility for any balance that is not covered by the patient's insurance

c. Authorization for treatment The patient registration form contains patient demographic information and the authorization for payment. Consents for treatment would be handled by clinical staff.

A claim that is sent for reimbursement that contains all the required data elements to process the claim is referred to as a: a. Submitted b. Adjudicated c. Clean Claim d. Medically necessary

c. Clean Claim A clean claim contains all required data elements needed to process and pay the claim.

The parent with which the child resides is considered to be a: . Step-parent b. Non-custodial parent c. Custodial parent d. Natural parent

c. Custodial parent A custodial parent is one with which the child resides. A natural parent is also called a biological parent, a step parent is one that is married to a natural parent.

When insurance coverage is being verified, which of the following is NOT a method on which to rely? a. Phone b. Internet c. Patient d. Clearinghouse

c. Patient Verification of coverage should be done through the insurance company. Insurance coverage can be verified by phone or by an electonic eligibility verification tool with the insurance company. A clearinghouse report shows when a claim has been received by the payer and may contain notes from the payer such as a patient not eligible for the date of service. Best practice would NOT be to rely on patient knowledge of their coverage.

Which of the following statements is TRUE regarding patient demographics? a. Demographic information can only be provided by the patient. b. Patient demographic information can be released to a third party. c. Patient demographic information entered incorrectly can result in claim denials. d. Claim processing is not affected by patient demographic information.

c. Patient demographic information entered incorrectly can result in claim denials. It is important that data entry information is entered correctly. Lack of completion or transposed information can result in claims denials.

The back of the health insurance card includes what information? a. Primary Care Provider b. Copays c. Phone or contact information for eligibility d. Group number

c. Phone or contact information for eligibility Phone and contact information for eligibility are located on the back of the card.

Which software system is used to store appointments, scheduling, registration, and billing and receivables? a. Electronic Health Record (EHR) b. Health Information Management System c. Practice Management System (PMS) d. Electronic Medical Record (EMR)

c. Practice Management System (PMS) Practice management system (PMS) is software used by physicians for scheduling, registration, billing and receivables management.

The insurance claim process begins with: a. Patient information b. Charge entry c. Scheduling an appointment d. Submitting a claim

c. Scheduling an appointment All the above processes are necessary for an encounter - the scheduling of the appointment is the initial step of processing a claim.

Listed below are examples of patient reminders for appointments. Which one is HIPAA compliant? a. "This is the obstetrical office calling to remind you of your appointment Tuesday, April 12 at 9 am for your annual exam." b. "This is Dr. Smith's office calling to remind you of your appointment Tuesday, April 12 at 9 am for your annual exam." c. "This is to confirm your appointment for your first prenatal visit with Dr. Jones. Please notify us if you are not able to keep this appointment." d. "This is the doctor's office calling to remind you of your appointment Tuesday, April 12 at 9 am."

d. "This is the doctor's office calling to remind you of your appointment Tuesday, April 12 at 9 am." HIPAA allows calls to verify appointments but the information should be the minimum necessary to accomplish the task. Giving the reason for the appointment is not necessary.

What information can be released based on this Disclosure form?AAPC Physician Practice are authorized to make the disclosure. The type of information to be used or disclosed is as follows:____ Problem list ____ Medication list____ List of allergies ____ Immunization records____ Most recent history __X_ Most recent discharge summary__X__ Lab results (dates or types) ________________________X__ X-Ray and imagining reports (dates or types) _____________________ Consultation reports from ______________________________________ Entire record a. The most recent visit b. Entire record c. Lab and X-ray d. Discharge summary, lab, and X-ray

d. Discharge summary, lab, and X-ray The discharge summary, lab, and X-ray can be disclosed to the individual(s) listed on the disclosure form. This would not pertain to release of information for treatment, payment, or operations.

Verification of insurance will allow the practice to know the amount to collect from the patient at the time of visit. Which of the following is TRUE? a. If the coverage is not in effect the patient should NOT be seen until the coverage can be verified. b. Money should NOT be collected from the patient at the time of the visit. c. The insurance should be verified with the patient only; it is the patient's responsibility to know what to pay. d. If the insurance is unable to be verified, the patient is offered an option to reschedule the appointment or proceed with the current appointment as a self-pay patient.

d. If the insurance is unable to be verified, the patient is offered an option to reschedule the appointment or proceed with the current appointment as a self-pay patient. Rationale: The patient's demographics and insurance information need to be available when verifying the insurance. If the patient is not eligible with the insurance company given, the patient needs to be contacted for updated insurance information. If the patient believes the information is correct and should be covered, the patient should contact the insurance company to have the eligibility files updated. Allow the patient to decide if they want to reschedule their appointment or be considered a self-pay patient and pay for the service out-of-pocket.

Which of the following does NOT qualify a patient for coverage under Medicare? a. End Stage Renal Disease (ESRD) b. Age 65 or older c. Under age 65 with disabilities d. Low income individual

d. Low income individual Medicare beneficiaries are eligible at age 65 and older, under 65 with certain disabilities, and those of all ages with ESRD. Low income individuals are covered by Medicaid.

What process would NOT be performed at the check-out process? a. Follow-up appointments b. Collection of copays or deductibles c. Review of charge ticket or encounter form d. Patient registration process

d. Patient registration process Patient registration should be completed at the start of the visit, or at check-in. Copays and deductibles can be collected at check-in or check-out.

Which of the following processes could result in lost charges? a. The total of daily charge tickets and the amount posted in the PMS balance b. Batch dates of service and post as a batch date c. Balance the charge tickets, copays, and the amounts posted in the PMS with the daily appointment schedule d. Posting charges and payment in different batches with no balancing

d. Posting charges and payment in different batches with no balancing All batches should balance and provide a process accounting for all charges and payments. Utilize the EMR to assist in tracking missed charges. If paper charge tickets are used, balance to the appointment schedule.

HIPAA Section 164.508 states that covered entities may not use or disclose protected information without a valid authorization. In what circumstances can a practice NOT release protected information? a. Records sent to a physician asked to consult with the patient b. Payment of claims c. Records requested by the health department for communicable diseases d. Records requested for life insurance

d. Records requested for life insurance HIPAA allows for release of records for treatment of the patient, payment of claims, and clinical operations. It does not allow for release of records for life insurance. This would need to be authorized by the patient.