Billing and Insurance

Which services are covered under Medicare Part B

!. Diagnostic testing 2. clinical laboratory services 3. speech and physical therapy 4. Outpatient hospital services.

Medicaid

-also run by CMS -health benefit program designed for low-income, blind, or disabled patients; needy families; foster children; and children born with birth defects.

Medicare Part C

-introduced in 1997 -provides several plan choices for individuals called medicare advantage plans. -theses include PPOs, HMOs, private fee-for-service plans, special need plans, and medicare medical savings account (MSA) plans.

What areas of assistance does Medicaid cover?

-lab services and x-rays -emergency services -vaccines for children -physician services

Medicare part D

-passed in 2003 -prescription drug plan

Which types of patient information will you need to obtain to file an insurance claim?

-patients current employer. -name of the subscriber or insured. -employer's address and telephone number.

Medicare allows ___ for filing claims from the date of service.

1 year.

Medicare allows ____ for filling claims from the date of service.

1 year.

Place the following steps for verifying workers' compensation coverage in order, with the first step on top.

1. Call the patient's employer and verify that the accident occurred due to employment. 2. Obtain the employer's approval to provide treatment and the name of its workers' compensation insurance company. 3. Contact the insurance company and verify that the employer has an active policy. 4. Obtain the claim number assigned to the case from the insurance company. 5. When the patient begins treatment, create a patient record.

Which of the following are insurance information you will need to obtain in order to file an insurance claim?

1. Group plan number. 2. Insurance identification number. 3. Insurance carrier.

Place the steps for submitting a request for prior authorization in order, with the first step on top.

1. Place a call to the insurance carrier or access the website if available. 2. Explain that you would like to obtain prior authorization and answer the series of questions that follows. 3. When prior authorization number is obtained, carefully record the authorization number and the name and extension of the person issuing the authorization. 4. Place the authorization number in the patient medical and financial record for further reference.

Which of the following tasks can be performed with a medical billing program?

1. Recording the procedures and services performed. 2. Filing insurance claims and billing patients. 3. Reviewing and recording payments.

Which of the following pieces of personal information should be obtained and verified with patients when they first arrive at the office?

1. Social Security number. 2. Date of birth. 3. Legal name.

Place the steps of tracking insurance claims submissions in order, with the first step..

1. create a spreadsheet with columns for patient name, insurance company, date of submission. 2. Use the list of claims already submitted to complete the blank for each column. 3. When an RA is received, complete the columns for date and response. 4. Enter the date of resubmission if required. 5. Enter the date of receipt and amount of payment if received. 6. Record any patient balance and the date the patient is billed.

What are 3 security measures that should be used to protect identifiable health information transmitted electronically?

1. security policies to handle violations that occur. 2. access control, passwords, and log files to keep intruders out. 3. backups to replace items after damage to a computer.

Which of the following are roles of clearinghouses?

1. translate nonstandard formats into standard formats. 2. "Scrub" claims "clean" prior to submission.

Which of the following tasks can be performed with a medical billing program?

1.Reviewing and recording payments. 2.recording the procedures and services performed. 3.filing insurance claims and billing patients.

Which of the following are covered by TRICARE?

1.Uniformed personnel 2.retirees from uniformed services 3. families of uniformed personnel.

Under the Medicare fee-for-service plan, the patient is responsible for _____% of charges after meeting the annual deductible.

20%

Medigap insurance can be used to pay for?

20% coinsurance of the allowed charge. Medicare Part B deductible.

The state children's health insurance plan was reenacted in

2009

Most third-party payers used one of _____ methods for reimbursing providers.

3

Which of the following is NOT a task a medical billing program can perform when processing claims?

A. Collecting payments from patients. B. Recording the procedures and services performed. C. Verifying patient coverage. D. Gathering and recording patient information. Answer: A

What is the most a payer will pay any provider for a procedure or service?

Allowed charge

Explanation of Benefits

Another name for explanation of payment.

Explanation of payment

Another name for remittance advice.

In exchange for paying a premium, a health plan provides ______ for medical services for a specified period of time. Multiple choice question.

Benefits

Which of the following is NOT a method used to transmit claims electronically?

CMS-1500 form

premium

Charge paid by the policyholder to keep an insurance policy in effect.

A healthcare claim without any errors is known as a ______ claim.

Clean claim

Medical _________ is translating medical terminology to procedure and diagnosis codes onto healthcare claim forms.

Coding

Which of the following is a fixed percentage of covered charges that must be paid after the deductible is met?

Coinsurance

coordinated care

Coordination of care across the spectrum of healthcare.

in addition to premiums, which of the following may patients be obligated to pay?

Copayments. deductibles. noncovered service charges.

Medicare Part B

Covers a portion (usually 80%) of the allowed charges for a wide range of outpatient procedures and supplies.

Which of the following is a fixed dollar amount that must be met, in addition to the premium, before the third party will pay for medical services?

Deductibles

In which method of electronic claims transmission do medical offices and payers exchange transactions directly using EDI?

Direct transmission

Which of the following is a disadvantage to direct data entry?

Each claim must be hand-keyed into the system each time the patient is seen.

To transmit claims _____, providers and payers need information systems to conduct electronic data interchange.

Electronically and directly

Which of the following pieces of personal information must you verify with a patient when you are completing an insurance claim?

Emergency contact information. current home telephone number. current home address.

quality and safety

Engaging in evidenced-based medicine.

An explanation of payment (EOP) is sometimes called a(n)

Explanation of benefits (EOB)

Remittance advice

Explanation of payment sent to a provider from an insurer, also called an explanation of payment.

Medicare Part A is financed through

Federal Insurance Contributions Act (FICA) tax on earned income.

Coinsurance

Fixed percentage of covered charges after the deductible is met.

Capitation

Fixed prepayment from a payer for each patient who enrolls with a physician.

Medicare Part A

Hospital benefit, which is billed by hospitals (or other healthcare facilities) and financed through contributions collected from the Federal Insurance Contributions Act (FICA) tax on income earned by workers and the self-employed.

To have children be eligible for health coverage under SCHIP, a family must meet which requirements?

Income too low to afford private insurance. Income too high to qualify for Medicaid.

Which of the following pieces of information are required to obtain your authorization?

Insurance policy group and ID numbers. Planned procedure and CPT code. Patient name and DOB.

Medical offices use security measures to protect which aspects of individually identifiable health information.

Integrity. confidentiality. availability.

The health-cost assistance program run by CMS and designed for low-income, blind, or disabled patients and needy families is

MEDICAID

Allowed charge

Maximum amount the payer will pay any provider for each service.

Medigap insurance can be used to pay for which of the following?

Medicare Part B deductible and 20% coinsurance of the allowed charge.

Which part of Medicare provides several plan choices for individuals called Medicare Advantage plans?

Medicare Part C

Which of the following is additional insurance that can be enrolled in to pay or allowable Medicare charges and deductibles?

Medigap

Clearinghouse

Outside company used to send and receive data in correct EDI format.

Which types of patient information will you need to obtain to file an insurance claim?

Patient's current employer. Name of the subscriber or insured. Employer's address and telephone number.

Which of the following are columns to be included in tracking insurance claims submissions?

Payment amount. Date of payment. patient name. Date of submission.

Patient centered care

Practitioners partner with the patient and family with understanding and respect.

Which of the following is a charge for keeping an insurance policy in effect? Multiple choice question.

Premium

Elective procedure

Procedure done at the convenience of the physician or patient.

preauthorization

Process in which a provider contacts an insurer to see if a proposed procedure is a covered service under the patient's plan.

the assignment of benefits statement state which of the following?

Provider received payment directly from the payer. patient receives payment directly from the payer.

Place the steps taken for a rejected or denied claim in order, with the first step on top.

Review the claim, examining all procedure and diagnosis codes for accuracy. contact the insurance company by telephone to find out how to resolve the problem. Submit a corrected claim to obtain payment/

accessible service

Shorter wait time.

identify the sources of Medicaid funding

State funds and Government funding

Birthday Rule

States that the insurance policy of the policyholder whose birthday comes first in the calendar year is the primary payer for all dependents.

If you hear someone refer to a "5010 claim," that person is speaking of

The current format for electronic claims submission.

What does NOT happen during patient check out?

The provider fills out a superbill or charge slip.

Which of the following is an electronic claim transaction, the HIPAA Health Care Claim or Equivalent Encounter information?

X12 837

Which benefits are NOT covered under workers' compensation?

Yearly sums paid to patients for permanent or temporary disability. Costs such as utilities and rental payments up to 1 year of missed compensation.

which of the following, signed by patients, allows a provider to submit healthcare claims for the patients?

assignment of benefits.

What are 3 means of third-party reimbursement?

capitation. allowed charges. contracted fee schedule.

It is essential to verify that procedures checked off on superbill forms were actually completed by

comparing the superbill to the medical record.

Which of the following is a disadvantage to direct data entry?

each claim must be hand-keyed into the system each time the patient is seen.

After reviewing and accepting a claim, an insurer pays a benefit and sends an

explanation of payment (EOP). and remittance advice (RA)

deductible

fixed dollar amount that must be paid, or "met," once a year before a third-party payer will begin to cover benefits.

fee schedule

list of a physician's usual fees for procedures and services typically performed.

Which of the following are synonyms for the term allowed charge?

maximum allowable fee. maximum charge. allowed amount allowed fee. and allowable charge.

The original medicare plan is also called

medicare fee-for-service

The amount a patient owes the practice is known as

patient liability

The amount a patient owes the practice is known as

patient liability.

When reviewing a claim that has been denied, examine all _______ and compare it with the patient's insurance information.

procedural codes and diagnosis codes

After reviewing and accepting a claim, an insurer pays a benefit and sends a

remittance advice and explanation of payment.

Which type of review compares doctor's fees with patients' health insurance benefits to determine subscriber liability?

review for allowable charges.

Claims transmitted for payment will undergo a number of _____ by the insurer.

reviews

copayment

small, fixed fee collected at the time of a visit.

TRICARE is run by

the Defense Department

If you hear someone refer to a "5010 claim," that person is speaking of

the current format for electronic claims submissions.

Comprehensive care

the medical team is responsible for the majority of the patient's physical and mental health.

Although the patient is legally responsible for paying for healthcare services, the ______ party agrees to carry the risk for those services.

third party

For claims submitted electronically, the billing program creates a log of transmitted claims to allow

tracking of the progress of claims.

For claims submitted electronically, the billing program creates a log of transmitted claims to allow.

tracking of the progress of claims.

what websites provide information about medicare

www.medicare.gov and www.cms.gov

The deductible must be met every ______ before the third-party payer begins to cover medical expenses.

year