Medical Office Procedures 7-9
The monthly bank statement shows a balance of $5,060.13. Three checks in the amounts of $89.50, $310.92, and $25.00 are still outstanding. What is the actual available balance of the checking account?
$4,634.71
HCPS
Alphanumeric coding system
Statutes of limitations for collecting debt
Are set state to state and may vary.
Which is the largest private-sector payer in the U.S.?
BCBS
managed care
Most popular insurance plan in the United States
coinsurance
Percentage of a covered claim
premium
Stated amount an insured must pay for an insurance policy
A Medicare participating provider decides whether to accept assignment on a claim-by-claim basis.
false
Using the same information from Question 6, calculate the monthly service charge of $10 into the actual available balance. What is the actual available balance after the service charge?
$4,624.71
Evan's hourly wage is $18 and he works 7.5 hours per day, 5 days per week. Based on a tax withholding of 7.5 percent, how much should be withheld from his wages for taxes?
$50.63
Using Evan's wage information from Question 8, if the state tax rate is 9 percent, what is his tax obligation?
$60.75
If the standard fee for a Medicare-covered services is $150 and the Medicare nonPAR fee schedule for the service is $80, what is the limiting charge for the service?
$92
____ is the organization that administers Medicare and Medicaid
CMS
The administrative medical assistant must call patients who accounts are 30 to 60 days past due. All of the following are recommended phone strategies except
Discuss results of lab tests and/or procedures.
capitation
Insurance payment that pays a prepaid, stated amount to the provider for covered services within a stated period of time
____ is a federal health plan that provides insurance to citizens and permanent residents aged 65 and older; people with disabilities, including kidney failure; and spouses of entitled individuals.
Medicare
CMS
Organization that administers Medicare and Medicaid
cycle billing
billing method used to provide consistent cash flow
third-party-payer
insurance carrier
Hope's insurance policy states she has a coinsurance of 90/10 of covered services. When she received her notice from the insurance carrier, it stated that the charges for her last office visit were not allowed. How much of the charges is Hope responsible for?
100%
Noelle's insurance policy states she has a coinsurance of 90/10 of covered services. When she received her notice from the insurance carrier, it stated that the charges for her last office visit were not allowed. How much of the charges is Noelle responsible?
100%
Dr. Alonzo has rendered a noncovered procedure to Mrs. Shepherd, who is covered by Medicare. She was not advised before the procedure that it is not covered. The medical office should
Adjust the procedure charge off Mrs. Shepherd's account
Before mailing patients statements, which of the following reports should be reviewed for delinquent accounts?
Aging report
To prepare for sending out patient statements for Dr. Conna's practice, Evan needs to know which accounts are more than 30 days past due. Which of the following reports should he reference for the information?
Aging report
Evan has been asked by Dr. Conna to establish policies and procedures to protect patients from identity theft. Which of the following is an identity theft alert? * A patient requests a change of address. * A patient is billed for a service she did not receive. * The name on a check is different from the patient's name. * All of the are identity theft alerts.
All of these are identity theft alerts.
Dr. Abrams receives payment from BCBS for services rendered to patients covered by the plan. This is known as
Assignment of benefits
Ensures that payment for medical expenses will not exceed 100 percent of the medical expenses.
COB
At the end of her visit, Katie was asked to pay $20, which is her coshare cost for today's office visit through her managed care health plan. The $20 represents Katie's
Copayment
Hardcopy insurance claim forms will produce which of the following?
EOB
Paper insurance claim forms will produce which of the following?
EOB
The oldest form of managed care is a
HMO
A claim was submitted with a diagnosis code for a Stage 4 ulcer and a procedure code for a hernia repair. Payment was denied. Which of the following is a reason for the denial?
Lack of medical necessity
Luke last visited his physician, who has a single-physician practice, in September 2006. He is at the office today for a sore throat and chest congestion. Since he was already a patient, the medical insurance coder submitted an established patient E/M code to Luke's insurance carrier for payment. The insurance carrier requested additional documentation on the visit. Which of the following may have been the reason?
Luke's visit should have been coded from the new patient E/M category.
Michelle and her husband, Drew, just had a baby. Michelle is laid off from her job, and Drew works part-time at a gas station. They are without insurance coverage. The administrative medical assistant should supply Michelle and Drew with the contact information for
Medicaid
Listed on an account are the father, the mother, and two minor children. One insurance policy, held by the mother, covers all four family members. Who is the guarantor of the account?
Mother
To complete the insurance form, the medical biller/coder needs the dates when Juan Gomez was unable to work. To find this information, the coder would refer to the
Patient's chart.
Which of the following is not necessary information on an insurance claim form?
Patient's sexual orientation
provider
Physician or other provider who agrees to treat the patient
Dr. Conna is considering purchasing her own EKG equipment to perform the procedure at the office instead of renting the equipment from a DME (durable medical equipment) distributor. She asked Evan (her administrative medical assistant) to give her the total number of EKGs performed and the revenue generated for the month of September. Which of the following reports should Evan reference for the information?
Practice analysis
Under his insurance plan, Tyler is required to have prior approval for his upcoming knee replacement. Before the surgery, the surgeon must have which approval document from the insurance plan for the surgery?
Preauthorization/precertification approval
An appointment was scheduled for a new patient, who asked how much the fee would be for the visit. The administrative medical assistant should
Provide an estimate of the exam but explain that the estimate is prior to other services, such as blood work.
PAR
Provider who agrees to offer covered services per a plan's contract rules and regulations
Since Dr. Conna is a cardiologist, she performs many high-cost procedures, which require her patients to establish a monthly payment schedule. Her office extends credit in accordance with the Truth in Lending Act. Based on extending credit, the practice may be considered a
Red flag creditor.
Which of the following would not typically be paid from petty cash funds?
Registration fee for a medical conference
An endorsement on the back of a deposited check states the following: PAY TO THE ORDER OF FIRST ANYWHERE BANK AND TRUST FOR DEPOSIT ONLY ALIANNA WELLINS, MD 123-99008876 This is an example of which type of endorsement?
Restrictive
During Luke's visit mentioned in Question 9, a CBC was performed. Which type of code(s) should be used for the service?
Unbundled codes
patient encounter form
Used to record patient encounter diagnoses and procedures
The insurance carrier has requested codes to indicate where its insured's injury took place. Which of the following code categories will be used?
V-Y codes
patient statement
an accounting of patient services, charges, payments/adjustments, and balance
Dr. Rodriguez receives payment from BCBS for services rendered to patients covered by the plan. This is known as
assignment of benefits
Patient A had a CBC and PFT performed. Which type of insurance will cover the services? Major medical
basic
Generally cover hospitalization, lab tests, surgery, and x-rays.
basic insurance
In a family with two family insurance contracts, determines which policy will be the primary carrier for the children
birthday rule
Insurance company that provides insurance benefits.
carrier
The letters "CM" in ICD-10-CM stand for
clinical modification
Provides reimbursement for income lost because of insured's illness.
disability insurance
Coinsurance is the amount of medical expense that the insured must pay before the insurance carrier begins paying benefits.
false
Everyone eligible for Medicare Part A (hospitalization insurance) automatically receives Medicare Part B (medical insurance).
false
In an indemnity plan, patients receive medical services from a primary care physician who coordinates the patients' overall care.
false
RBRVS is the payment system used by Medicare for determining how much it will pay for inpatient care.
false
When the amount the physician charges is more than the insurance company's allowed charge, the difference must be absorbed by the insurance company or the provider.
false
red flag requirements
federal regulations requiring creditors to implement procedures to protect personal data pertaining to a covered account
write-off
financial adjustment for PAR providers of the difference between submitted and allowable charges
Insurance through employment, with all employees having one master policy.
group insurance
Covers medically necessary services while insured is an inpatient.
hospital insurance
electronic claim
insurance claim prepared on and transmitted by computer
Person who is covered by an insurance policy.
insured
FUTA
law requiring employers to pay into an unemployment fund to be used by individuals unemployed for a specific amount of time by seeking new employment
FICA
law requiring withholding from wages for Social Security
fee schedule
listing of medical procedures/services and usual charges
Covers medical expenses in a catastrophic situation.
major medical insurance
Covers physician's services for office visits.
medical insurance
procedure day sheet
numeric listing of all procedures and related information performed on a given day
Which of these documents shows the professional services rendered to the patient, the charge for each service, payments made, and the balance owed?
patient statement
ERA
payment determination report sent by insurance carrier
collection ratio
percentage that shows the effectiveness of collection methods
balance sheet
period statement showing assets, liability, and capital
Person in whose name the policy is written.
policyholder
Rate charged for policy.
premium
Healthcare professional who supplies the healthcare.
provider
daily journal
record of provided services and their charges, payments received, and adjustments
direct earnings
salaries/wages from an employer
clearinghouse
service that collects, corrects, and transmits insurance claims
collection agency
service used to pursue payment for services
blank endorsement
signature of the payee on the back of the check
restrictive endorsement
stated the payee and purpose of a check
Covers physician's fee for surgery.
surgical insurance
ICD-10-CM codes are the ____ revision of ICD.
tenth
A term used to describe an insurance company in the context of the doctor's and patient's relationship.
third-party-payer
posting
transferring accounts from one record to another
A PAR provider who agrees to accept the allowed charge set forth by the insurance company as payment in full is accepting assignment.
true
A government agency called the Centers for Medicare and Medicaid Services (CMS) administers the Medicare and Medicaid programs.
true
Balance billing refers to billing the patient for any amount due on a provider's bill after the insurance company has taken care of its responsibility.
true
Coinsurance is the percentage of each claim that the insured must pay, according to the terms of the insurance policy.
true
Every time HMO and PPO members visit their physician, they pay a set charge called a copayment.
true
In a capitated plan, a physician may receive $35 per month for each patient assigned to him or her, even if the patient receives no care during that month.
true
The customary fee, insurance terms, is the most the insurance company will pay any provider for a given procedure.
true
CMS-1500 form
universal claim form
According to contract law, when a physician agrees to treat a patient who is seeking medical services, there is a(n) ____ contract between the two.
unwritten
Which type of fee is a charge for a certain procedure?
usual