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Chapters 1-5

Medical Administrative Practices

What is the 1st step in the billing cycle? Pre-register Patients
What is the 2nd step in the billing cycle? Establish Financial Responsibility
What is the 3rd step in the billing cycle? Check In Patients
What is the 4th step in the billing cycle? Check Out Patients
What is the 5th step in the billing cycle? Review Coding Compliance
What is the 6th step in the billing cycle? Check Billing Compliance
What is the 7th step in the billing cycle? Prepare and Transmit Claims
What is the 8th step in the billing cycle? Monitor Payer Adjudication
What is the 9th step in the billing cycle? Generate Patient Statements
What is the 10th step in the billing cycle? Follow Up Patient Payments and Handle Collections
What are the responsibilities of Step 1 in the billing cycle? Collect name, contact information, insurance information, determine reason for visit and whether the patient is new or established.
What are the responsibilities of Step 2 in the billing cycle? Find out if the patient has insurance and what percentage they will pay and what will be paid by the patient.
What are the responsibilities of Step 3 in the billing cycle? Patient fills out a Patient Information Form which contains personal, employment, and insurance information. Their identity is identified and copay is collected.
What are the responsibilities of Step 4 in the billing cycle? Documentation of the encounter is recorded on a medical record (chart). The physician gives a diagnosis and performs procedures which are translated into a standardized code that goes on an encounter form or superbill.
What are the responsibilities of Step 5 in the billing cycle? Codes are assigned and should be logically connected so the medical necessity of the charges is clear to the insurance company.
What are the responsibilities of Step 6 in the billing cycle? Analyze what can be billed on health care claims.
What are the responsibilities of Step 7 in the billing cycle? Gather all information to send a claimto insurance company to receive payment.
What are the responsibilities of Step 8 in the billing cycle? Monitor the adjudication process that the insurance company uses to determine if a claim should be paid.
What are the responsibilities of Step 9 in the billing cycle? List all services and their charges plus the amount paid by the insurance company and the remaining amount that is owed by the patient.
What are the responsibilities of Step 10 in the billing cycle? Keep track of payments made to a patients account and proceed with steps if payment is not made.
What is a policy holder? The person who buys insurance, the insured.
What is a premium? The amount the policy holder pays for health insurance.
What is coinsurance? The percentage of charges that an insured person pays for health care services after paying the deductible.
What is a deductible? The amount due before benefits start.
What is a diagnosis? A physicians opinion of the nature of the patients illness or injury.
What is coding? The process of translating a description of a diagnosis or procedure into a standardized code.
What is medical necessity? The connection between an illness or injury and the treatment or means of diagnosing that is used by the physician.
What is an explanation of benefits (EOB)? A paper document sent from the insurance company to the patient that shows what they are covering and how it was determined.
What are the Administrative Safeguards of HIPAA? Policies and procedures that protect electronic health information. EX. Policy manual and training.
What are the Physical Safeguards of HIPAA? Mechanisms required to protect electronic systems, equipment, and data. EX. Back up of computerized information, restricting access to computers.
What are the Technical Safeguards of HIPAA? Automated processes used to protect data and control access to data. EX. Passwords, antivirus and firwall software, and secure transmission systems.
When is a patient considered a new patient? When they have not received services from that provider for a period of 3 years or more.
When is a patient considered an established patient? When they have received services from that provider within 3 years.
What is a guarantor? The person who is financially responsible for the patients account.
What is a primary insurance carrier? The first insurance carrier that a claim is submitted to
What are access rights? A security option that determines who can have access to certain patient information as well as who has the right to enter or edit that information.
What is protected health information? Information about a patient's health or payment for healthcare that can be used to identify the person.
What is a breach? The access, use, or disclosure of protected health information that violates HIPPA's Privacy Rule.
What is a clean claim? Claims that are done correctly and do not require additional documentation.
What is HIPAA? Increases accountability and decreases fraud and abuse in healthcare system. Mandates standards for health information and ensures the security and privacy of health information.
What is a clearinghouse? A company that receives claims from a medical provider, checks them for errors, and sends them to the insurance company.
Created by: JennGuest