Chapter 17: Insurance and Billing pt.1
Which of the following are roles of clearinghouses?
"Scrub" claims "clean" prior to submission Translate nonstandard formats into standard formats
A Medicare provider reports a usual charge of $200 for a service and the Medicare allowable charge is $84. The patient is responsible for 20% of the allowed charge. What is the total amount the patient will be responsible for paying?
$16.80
A Medicare provider reports a usual charge of $200 for a service and the Medicare allowable charge is $84. The patient is responsible for 20% of the allowed charge. What is the total amount Medicare will be responsible for paying?
$67.20
Medicare allows ______ for filing claims from the date of service.
1 year
Coordination of benefits clauses prevent payment duplication by restricting insurance company payments to no more than ______% of the covered benefit's cost.
100
Medicare Part C was introduced in ______.
1997
In an 80-20 coinsurance rate, the patient is responsible for what percentage of allowed charges?
20
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 which of the following?
20% coinsurance of the allowed charge Medicare Part B deductible
The Medicare Part D prescription drug plan coverage began in the year ______.
2006
The State Children's Health Insurance Plan was reenacted in ______.
2009
The employer must report the incident to the workers' compensation carrier and the state labor department within ______ hours of the incident.
24
Under the new healthcare act, parents will be allowed to keep their children covered under their family policy until age ______.
26
Most third-party payers used one of ______ methods for reimbursing providers.
3
There are ______ participants under insurance contracts.
3
TRICARE for Life is for TRICARE enrollees who are over the age of
65
What must a provider do to make up for the difference between the higher usual fee and an allowable charge?
Adjustment
Medicare requires which form, signed by the patient, explaining charges the patient is likely to pay for noncovered services?
Advanced Beneficiary Notice
For assigned claims, when should the patient be expected to pay account charges?
After an insurance claim has been filed and owed charges have been sent, the patient must pay within 30 days of invoice.
When do physicians write a charge slip?
After completing the visit, before the patient checks out
What is the most a payer will pay any provider for a procedure or service?
Allowed charge
For each service submitted to an insurer, an RA form gives which of the following information?
Amount billed by the practice Amount allowed Date of service and place of service
Which of the following are included on an explanation of benefits?
Amount paid Name of the insured and identification number Claim number
What should be checked with the payer before estimating a patient's bill?
Any deductible amount Payer's allowable charge Any coinsurance All covered benefits
Which of the following, signed by patients, allows a provider to submit healthcare claims for the patients?
Assignment of benefits
For unassigned claims, when is the patient expected to make payment?
At the time of the appointment
Which of the following describes the practice of billing a patient for the difference between a higher usual fee and a lower allowed charge?
Balance billing
Which president signed into law a bill that will extend insurance coverage to all Americans who lack healthcare coverage?
Barack Obama
The RAC program was initiated by
CMS
Which of the following is NOT a method used to transmit claims electronically?
CMS-1500 form
The paper claim alternative to the X12 837 is the
CMS-1500.
When calling an insurance company for prior authorization, which information should you have available?
CPT code of planned procedure and the ICD code for the diagnosis Patient's name and date of birth Patient's group number and ID number
Place the following steps for verifying workers' compensation coverage in order, with the first step on top.
Call the patient's employer and verify that the accident occurred due to employment. Obtain the employer's approval to provide treatment and the name of its workers' compensation insurance company. Contact the insurance company and verify that the employer has an active policy. Obtain the claim number assigned to the case from the insurance company. When then patient begins treatment, create a patient record.
Which of the following is a payment structure in which a health maintenance organization prepays a set fee per patient to a physician?
Capitation
What are 3 means of third-party reimbursements?
Capitation Allowed charges Contracted fee schedule
Which organization manages Medicare?
Centers for Medicare and Medicaid Services
Premium
Charge paid by the policyholder to keep an insurance policy in effect
What can be done to ensure prompt Medicaid payments?
Check deadlines on claim submission with the state's Medicaid office. Ensure that the physician has signed all claims.
What does the acronym CHAMPVA stand for?
Civilian Health and Medical Program of the Veterans Administration
In which method of electronic claims transmission are all required data sent to an outside company to translate into standard formats and to "scrub" the claims?
Clearinghouse
Which of these services are covered under Medicare Part B?
Clinical laboratory services Diagnostic testing Outpatient hospital services Speech and physical therapy
Which of the following is a fixed percentage of covered charges that must be paid after the deductible is met?
Coinsurance
Which of the following is NOT a task a medical billing program can perform when processing claims?
Collecting payments from patients
How is eligibility for CHAMPVA determined?
Contact the nearest Veterans Affairs medical center
In insurance policies, what is the legal clause that prevents duplication of payment?
Coordination of benefits
Coordinated care
Coordination of care across the spectrum of healthcare
Place the steps of tracking insurance claims submissions in order, with the first step on top.
Create a spreadsheet with columns for patient name, insurance company, date of submission. Use the list of claims already submitted to complete the blanks for each column. When an RA is received, complete the columns for date and response. Enter the date of resubmission if required. Enter the date of receipt and amount of payment if received. Record any patient balance and the date the patient is billed.
What is the first item an insurance carrier reviews when receiving a claim?
Date of service
Which of the following are columns to be included in tracking insurance claims submissions?
Date of submission Date of payment Payment amount Patient name
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?
Deductible
Which of the following payments may be covered by a patient's secondary insurance plan?
Deductibles Copayments Coinsurance
In addition to premiums, which of the following may patients be obligated to pay?
Deductibles Noncovered service charges Copayments
Which of the following are usually examples of exclusions in an insurance contract?
Dental care Eye examinations
What patient information can be found on a patient's charge slip?
Diagnosis Patient name Treatment
What does the acronym DDE mean?
Direct data entry
In which method of electronic claims transmission do medical offices and payers exchange transactions directly using EDI?
Direct transmission
Which type of insurance is activated when an insured individual is injured or disabled for nonwork-related reasons?
Disability insurance
Which of the following is another name for Medi/Medi?
Dual coverage
Which abbreviation represents a data interchange used to send billing information quickly and securely?
EDIE
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.
What does the acronym EDI stand for?
Electronic data interchange
Dual coverage
Eligibility for Medicare and Medicaid
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
Which types of patient information will you need to obtain to file an insurance claim?
Employer's address and telephone number Patient's current employer Name of the subscriber or insured
Quality and safety
Engaging in evidenced-based medicine
Beginning with the first step on top, list the steps for submitting the CMS-1500 form.
Enter the patients' name. Enter the insurer's name. Enter policy or group number. Enter current illness. Enter current illness.
Medicare Part A is financed through
FICA tax on earned income.
Where are fees generally listed?
Fee schedule
TRICARE Standard
Fee-for-service plan
Deductible
Fixed dollar amount that must be paid, or "met," once a year before a third-party payer will begin to cover benefits
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
Which of the following are the parts of the RBRVS system?
Geographic adjustment factor Nationally uniform relative value unit Nationally uniform conversion factor
GAF
Geographic adjustment to reflect the area's relative costs
Paper claims are not widely used because of current mandates set forth by
HIPAA
Which of the following is another name for medical insurance?
Health insurance
TRICARE Prime
Health maintenance organization
Third party
Health plan
Third-party payer
Health plan that agrees to carry the risk of paying for medical services
If you hear someone refer to a "5010 claim," that person is speaking of
If you hear someone refer to a "5010 claim," that person is speaking of
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
What is another term for fee-for-service plan?
Indemnity plan
Which of the following situations would be covered under liability insurance?
Injuries to another person caused by the insured Injuries that occur on the insured's property
Which of the following is insurance information you will need to obtain in order to file an insurance claim?
Insurance identification number Group plan number Insurance carrier
What fields are left blank for Medicare claims?
Insured's address
Medical offices use security measures to protect which aspects of individually identifiable health information?
Integrity Availability Confidentiality
Fee schedule
List of a physician's usual fees for procedures and services typically performed
Most employees covered by their employers' insurance have which type of health plan?
Managed care
TRICARE Extra
Managed care network of providers a family can use as needed without required enrollment
Which category of health plan controls both the financing and the delivery of healthcare to policyholders?
Managed care organizations
Preferred provider organization
Managed care plan that establishes a network of providers to perform services for plan members
Which of the following are synonyms for the term allowed charge?
Maximum allowable fee Maximum charge Allowed amount
Allowed charge
Maximum amount the payer will pay any provider for each service
Which insurance covers patients who cannot pay the difference between the bill and Medicare?
Medi/Medi
Which assistance program is known as the "payer of last resort"?
Medicaid
The health-cost assistance program run by CMS and designed for low-income, blind, or disabled patients and needy families is
Medicaid.
An ABN must be given to which type of beneficiaries if a specific case is not likely to be covered?
Medicare
Which federal insurance plan is the largest plan covering citizens age 65 and older?
Medicare
Which payer uses resource-based relative value scale to set fees?
Medicare
Which Medicare plan allows patients to select their healthcare providers as long as the providers have been approved by Medicare (the plan is operated by a private insurance company contracting with Medicare)?
Medicare Private fee-for-service plan
The original Medicare plan is also called
Medicare fee-for-service.
With which Medicare Choice Plus Plan can patients go outside their network for a slightly higher cost, such as higher copayment or coinsurance?
Medicare preferred provider organization
Which Medicare plan allows private insurance companies to contract with Medicare to provide services to beneficiaries?
Medicare private fee-for-service plan
TRICARE for Life is aimed at which of the following people?
Medicare-eligible military retirees Medicare-eligible family members of military retirees
Which of the following is additional insurance that can be enrolled in to pay for allowable Medicare charges and deductibles?
Medigap
What common errors can prevent clean claims?
Missing or invalid subscriber or patient information Missing payer name and/or payer identifier Missing or incomplete service provider name
Every physician or other provider who submits a claim to an insurance carrier must use a specific provider number, known as a(n)
NPI.
What services does a lifetime maximum benefit cover?
Nonessential services
Beginning with the first step on top, list the steps performed by the staff to complete an insurance claim.
Obtain patient information. Deliver services and determine the diagnosis and fee. Record charges, codes, and patient payments and prepare claims. Review the insurer's processing of the claim, remittance advice, and payment.
Which types of services are usually covered by capitation payments?
Office visits Preventive care
What are the most common ways that prior authorization can be performed?
Over the phone On the insurance carrier's website
More than half of all health plans are what type of managed care programs?
PPO
The part of Medicare is billed by hospitals is
Part A
Individuals entitled to Medicare Part A benefits automatically qualify for
Part B.
Which part of Medicare provides several plan choices for individuals called Medicare Advantage plans?
Part C
Which of the following is a physician who enrolls in a contract with a managed care organization?
Participating physician
Who is responsible for costs that are not covered by the third-party insurance company?
Patient
First party
Patient (policyholder)
Which of the following are NOT forms that need a release signature when the patient arrives at the office in order to bill correctly?
Patient medical history forms Records release forms requested from the office from prior physicians
Which of the following best describes Medicare managed care plans?
Patients pay a premium and small copayment but no deductible, and they must select a PCP from within the network; referrals are required.
Which of the following can occur if utilization review finds that services were not medically necessary?
Payment can be denied at a loss to the practice Patient cannot be billed for those services
Resource-based relative value scale
Payment system used by Medicare
Second party
Physician
Which areas of assistance does Medicaid cover?
Physician services Emergency services Lab services and X-rays Vaccines for children
Place the steps for submitting a request for prior authorization in order, with the first step on top.
Place a call to the insurance carrier or access the website if available. Explain that you would like to obtain prior authorization and answer the series of questions that follows. When prior authorization is obtained, carefully record the authorization number and the name and extension of the person issuing the authorization. Place the authorization number in the patient medical and financial record for further reference.
Which of the following pieces of information are required to obtain prior authorization?
Planned procedure and CPT code Insurance policy group and ID numbers Patient name and DOB
Patient centered
Practitioners partner with the patient and family with understanding and respect
Which of the following is the receipt of confirmation from the patient's insurance plan that the proposed procedure or service will be considered a covered service because of the individual patient's specific circumstance that requires the procedure or service to be performed?
Preauthorization
Which of the following is a charge for keeping an insurance policy in effect?
Premium
Identify payments a patient with a Medicare managed care plan will make.
Premium Copayment
When a patient brings you a superbill at the end of a visit, which of the following procedures might you perform, depending on practice policy?
Prepare and transmit a healthcare claim on behalf of the patient to the insurance company. Accept an insurance copayment or coinsurance from the patient and credit the account.
Which of the following is NOT a major section of the X12 837?
Prescriptions
When is predetermination done?
Prior to a procedure
How is "payer of last resort" defined?
Private insurance, if any, is billed first.
Place the major sections of data elements of the X12 837 in order, with the first section on top.
Provider Subscriber Patient Claim details Services
Which payment system is used by Medicare?
RBRVS
Which of the following steps performed by a provider's office staff begins the claims process?
Records charges, codes, and patient payments and submits claims Delivers services to the patient and determines the diagnosis and fee
Which of the following are true regarding Medicare Preferred Provider Organizations?
Referrals are not required Patients do not need a PCP
RVU
Relative value of a procedure based on the physician's work, practice cost, and cost of malpractice insurance
Which type of review compares doctor's fees with patients' health insurance benefits to determine subscriber liability?
Review for allowable charges
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.
Which of the following tasks can be performed with a medical billing program?
Reviewing and recording payments Recording the procedures and services performed Filing insurance claims and billing patients
Beginning with the first step on top, the steps you should take after obtaining personal and insurance information from the patient.
Scan or copy the patient's insurance card. Remind the patient that some services may not be covered. Have the patient sign a waiver of liability, if applicable in your office.
What are 3 security measures that should be used to protect identifiable health information transmitted electronically?
Security policies to handle violations that occur Access control, passwords, and log files to keep intruders out Backups to replace items after damage to a computer
Accessible service
Shorter wait time
Copayment
Small, fixed fee collected at the time of a visit
Which of the following pieces of personal information should be obtained and verified with patients when they first arrive at the office?
Social Security number Legal name Date of birth
Identify the sources of Medicaid funding.
State funds Government funding
Which insurance requires patients to be enrolled in the computer database Defense Enrollment Eligibility Reporting System to receive benefits as well as an identification card?
TRICARE
Which types of healthcare benefits are offered by TRICARE?
TRICARE Standard, fee-for-service TRICARE Prime, HMO TRICARE Extra, managed care
Comprehensive care
The medical team is responsible for the majority of the patients' physical and mental health
Patient Johnny Smith's parents each have an insurance plan through their employer; which plan is primary and which plan is secondary?
The parent whose birthday falls first in the calendar year is primary.
Which of the following does NOT happen during patient check out?
The provider fills out a superbill or charge slip.
The assignment of benefits statement states which of the following?
The provider receives payment directly from the payer. The provider accepts a payer's allowed charge.
Identify the characteristics of elective procedures.
They are done at convenience of the patient They are planned
What can happen to Medicaid claims that are submitted after the time limit?
They can be denied. They can be rejected.
Which of the following is true of practitioners who accept assignment for Medicaid patients?
They can bill patients for services that Medicaid does not cover. They cannot bill patients for the difference between their fee and the Medicaid payment.
In which of the following ways may referrals be completed?
Through the insurance plan's website In writing
Why must there be a signed authorization to release information in a patient's financial record?
To give legal permission to give the insurance carrier information regarding the patient's diagnosis and treatment
Health maintenance organization
Type of managed care organization in which physicians are often paid a capitated rate or a salary by the organization
Fee-for-service
Type of plan that repays policyholders for healthcare costs due to illnesses and accidents
CF
Uniform conversion factor used to multiply the relative values and produce a payment amount
Which of the following are covered by TRICARE?
Uniformed personnel Families of uniformed personnel Retirees from uniformed services
Which of the following are tips for entering data in medical billing programs?
Use only valid data in fields; avoid words such as "same."
Which of the following are covered by CHAMPVA?
Veterans with permanent, service-connected disabilities Surviving family members of veterans who died in the line of duty
When is the patient-physician contract created?
When a physician agrees to treat a patient who seeks services
Identify the individuals who are eligible for Medicare.
Workers with chronic kidney disease requiring dialysis People who are blind
Which type of insurance covers employment-related accidents or diseases?
Workers' compensation
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
If a patient is a member of ______, prior to scheduling an appointment with a specialist you will need to verify with the insurance plan that the company allows the specialist requested.
a managed care organization
When an injured person with disability insurance cannot work, the insurance company pays
a prearranged monthly amount.
A practitioner accepting a Medicare-allowed charge as payment in full is known as
accepting assignment.
If the difference between the higher usual fee and the lower allowed charge is not billed to patients, it is instead written off as a(n)
adjustment.
When entering data in medical billing programs, enter data in
all capital letters.
In addition to collecting payments at the time of service, the office can ask patients to ______ benefits to the practice to avoid collection issues in the future.
assign
To avoid the difficulty of collecting patient payments at a later date, practice may require that the patient either:
assigns benefits directly to the practice pays in full at the time of service
A health plan provides payment, otherwise known as ________, for medical services.
benefits
In exchange for paying a premium, a health plan provides ______ for medical services for a specified period of time.
benefits
The rule that determines the primary plan for dependents who are covered by 2 or more medical plans is called the
birthday rule.
Regardless of the number of patients seen by a provider, the same ______ rate is paid per patient.
capitation
A fixed prepayment to a physician by a health plan for each patient enrolled in the practice is called
capitation.
A healthcare claim without any errors is known as a _____ claim.
clean
Medical ______ is translating medical terminology to procedure and diagnosis codes onto healthcare claim forms.
coding
It is essential to verify that procedures checked off on superbill forms were actually completed by
comparing the superbill to the medical record.
With an HMO, the health plan pays the practitioner a set ______ rate agreed to by the plan and the practitioner for each service provided.
contracted
A small, fixed fee collected at the time of a visit is called a
copayment.
A PPO is a managed care plan that establishes a network of providers to perform services for plan members in exchange for
discounted fees.
If a patient with an HMO seeks services from a provider who is not in the health plan, the HMO
does not pay for the care.
A "planned" medical procedure that is medically necessary but is not needed to sustain life is considered a(n) ______ procedure.
elective
To transmit claims ______, providers and payers need information systems to conduct electronic data interchange.
electronically directly
An explanation of payment (EOP) is sometimes called a(n)
explanation of benefits (EOB).
The major types of health plans are
fee-for-service managed care
The oldest and most expensive type of health plan is
fee-for-service.
The goal of the national recovery audit contractor program is to
fight fraud and abuse in Medicare. prevent waste in Medicare.
There are ______ functions and attributes to the PCMH.
five
A list of approved drug brands by insurance company is called a(n)
formulary.
In an insurance plan with prescription drug benefits, a prescribed drug must be listed on the plan's
formulary.
Written contracts in the form of a policy between a policyholder and a health plan are also called
health insurance. medical insurance.
An NPI is a(n) ______ number assigned to each provider, and it must be submitted with each claim.
identification
The total sum that a health plan will pay out over a patient's lifetime is called a(n)
lifetime maximum benefit.
Under most insurance contracts, participating providers ______ balance bill patients.
may not
During preauthorization, the insurer agrees that the patient requires a procedure if it determines that the procedure is
medically necessary.
All payers require patients to pay for ______ services.
noncovered excluded
All Medicare beneficiaries can enroll in Medicare ______, which provides prescription drug benefits.
part D
Physicians who enroll in managed care plans with contracts that stipulate the fees are called ______ physicians.
participating
It is necessary to obtain ______ signatures on release of information and assignment of benefits form.
patient
Premiums are payed by
policyholders. subscribers.
A patient enrolled in an HMO pays
premiums and a copayment.
BCBS is a nationwide federation of organizations that provide ______ healthcare services to subscribers.
prepaid
A policy that pays benefits first when a patient is covered by more than 1 insurance plan is called
primary insurance.
When reviewing a claim that has been denied, examine all ______ and compare it with the patient's insurance information.
procedural codes diagnosis codes
After reviewing and accepting a claim, an insurer pays a benefit and sends a(n)
remittance advice (RA). explanation of payment (EOP).
Claims transmitted for payment will undergo a number of ______ by the insurer.
reviews
Each state's or local BCBS organization operates under
state laws.
TRICARE is run by
the Defense Department.
In predetermination, the insurer informs the provider of
the maximum amount it will pay for the procedure.
Finding out a patient's deductible, whether it has been paid, coinsurance, and the payer's allowed charges allows you to estimate
the patient's responsibility for charges.
Although the patient is legally responsible for paying for healthcare services, the ______ party agrees to carry the risk for those services.
third
There are ______ major methods used to transmit claims electronically.
three
For claims submitted electronically, the billing program creates a log of transmitted claims to allow
tracking of the progress of claims.
There are ______ major types of health plans?
two
As determined by an insurance plan, exclusions are ______ expenses.
unpaid uncovered
Fees that physicians charge most of their patients, most of the time, under typical conditions are called
usual fees.
A process by which medical peers review whether all services provided by the practitioner were medically necessary is known as
utilization review.
Which websites provide information about Medicare?
www.cms.gov www.medicare.gov
The deductible must be met every ______ before the third-party payer begins to cover medical expenses.
year
