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HIT 1121 Final

Study for final exam

Administrative medical office responsibilities include... claims submission.
What is "cash flow" in a medical practice? The actual amount of money available to a medical practice.
Which organization published diagnostic & procedure coding competencies for outpatient services and diagnostic coding and reporting requirements for physician billing? American Health Information Management Association (AHIMA).
A billing specialist is entrusted with... holding patients' medical information in confidence, collecting monies, and being a reliable resource for coworkers.
Medical etiquette refers to... consideration for others.
Medical ethics include... standards of conduct.
Physicians are legally responsible for the conduct & any actions of their employees performed within the context of their employment. This is referred to as vicarious liability, also known as... respondeat superior.
The earliest written code of ethical principles for medical profession is the... Code of Hammurabi.
What is the name of the modern code of ethics that the American Medical Association (AMA) adopted in 1980? The Principles of Medical Ethics.
Non-privileged information about a patient consists of the patients's... city of residence.
Exceptions to the right to privacy rule include... gunshot wound cases and all infectious disease cases.
What action could happen if an employee knowingly submits a fraudulent Medicare or Medicaid claim at the direction of the employer and subsequently the medical practice is audited? The employee and the employer could be brought into litigation by the state or federal government.
To bill Medicare beneficiaries at a higher rate than other patients is considered... abuse or fraud.
The office of Civil Rights enforces... privacy and security rules.
Most legal issues of private health insurance claims fall under... civil laws.
Medicare, Medicaid and Tricare programs fall under... federal laws.
Who is the individual who is designated to help a provider remain in compliance by setting policies & procedures in place, train staff regarding HIPAA, & act as the contact person for questions and complaints? Privacy officer/privacy official.
Who is a health care coverage carrier, clearing house, or physician who transmits health information in electronic form in connection with a transaction covered by HIPAA? Covered entity.
Who is an individual who renders medical services, furnishes bills, or is paid for health care in the normal course of business? Healthcare provider.
Who is the third-party administrator wh receives insurance claims from the physician's office, performs edits, and redistributes the claims electronically to various insurance carriers? Clearinghouse.
Who is an individual who is hired by a medical practice to process claims to a third-party payer? Business associate.
What is a concise statement usually in the patient's own words describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter? Chief complaint.
When does the physician/patient contract begin? When the physician accepts the patient and agrees to treat the patient.
Most physician/patient contacts are... implied.
In health insurance, the insure is also known as... The subscriber, the member, and the policyholder.
The insured is always... the individual enrollee or organization protected
If a child has health insurance coverage from two parents, according to the birthday law... the health plan of the person whose birthday (month & day) falls earlier in the calendar year will pay first.
Conditions that existed and were treated before the health insurance policy was issued are called... pre-existing.
An attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered is referred to as a/an... exclusion.
Mr. Ott was laid off from his job. He is protected by COBRA, which requires his employer to... extended group health insurance coverage for 18 months.
A patient intake sheet is also called a ... patient registration form.
The source document for insurance claim data is the... superbill.
A daily record sheet used to record daily business transactions is called a/an... day sheet.
This means stealing money that has been entrusted in one's care... embezzlement.
When state law takes precedence over federal law, this is called? state preemption.
Most policies, including Medicare part B have a cost sharing requirement which is known as? coinsurance.
These are conditions or qualifying factors that must be met before the patient receives benefits for medical services... eligibility.
This refers to discovering whether a treatment relates not only to whether a service is covered, but also to finding out whether it is medically necessary? pre-authorization.
In CPT coding, the three key components are? history, examination and medical decision making.
According to CPT guidelines, what type of patient is one who has received professional services from the physician or from another physician of the same specialty who belongs to the same group practice within the past three years? established.
According to CPT guidelines, what type of patient is one who has NOT received professional services from the physician or from another physician of the same specialty who belongs to the same group practice within the past three years? new.
What is a nurse practitioner, clinical nurse specialist, licensed social worker, nurse midwife, physical therapist, speech therapist, audiologist, or physician assistant who furnishes a consultation or treats a patient for specific medical problem? Non-physician practioner.
Who oversees the care of patients in a managed healthcare plan and refers patients to see specialists for services as needed? primary care physician.
Who is an individual in the hospital directing the selection, preparation, or administration of tests, medication, or treatment? ordering physician.
What is the condition of being secluded from the presence or view of others? privacy.
What term means using discretion in keeping secret information? confidentiality.
A person who has a condition that would make him or her ineligible for coverage is a case considered as... high risk.
What means a condition that runs a short (typically 3-5 days) but relatively severe course? acute.
The health insurance claim form (CMS 1500) is known as the universal claim form.
An insurance claim form that contains no staples or highlighted areas and on which the barcode area has not been deformed is called... a physically clean claim.
An insurance claim submitted with errors is referred to as... a dirty claim.
What is the protocol to follow on receiving an attending physician's statement from an insurance company on a patient who has applied for health insurance? Request a fee from the insurance company before sending the attending physician's statement.
Office visits may be grouped on the insurance claim form if each visit... is consecutive, uses the same procedure code, and results in the same fee.
OCR is the acronym for... optical character recognition.
To conform to CMS 1500 OCR guidelines,... do not fold insurance claim forms when mailing, do not use symbols with data on insurance claim forms, and do not strike over errors when making a correction on an insurance claim form.
A group of insurance claims sent at the same time from one facility is known as a... batch.
A clearinghouse is a/an... entity that receives transmission of insurance claims, separates the claims, and sends each one electronically to the correct insurance payer.
The most important function of a practice management system is... accounts receivable.
The employer's identification number is assigned by... the Internal Revenue Service.
Back up copies of office records should be stored... away from the office.
When a medical practice has its own computer and transmits claims electronically directly to the insurance carrier, this system is known as... carrier direct.
Back-and-forth communication between user and computer that occurs during online real time is called... interactive transaction.
If a payment problem develops with an insurance company and the company ignores claims and exceeds time limits to pay a claim, it is prudent to contact the.... state insurance commissioner.
The document together with the payment voucher that is sent to a physician who has accepted assignment of benefits is referred to as an... EOB.
An insurance claims register provided a... follow up procedure for insurance claims.
Pending or resubmitted insurance claims may be tracked through a... tickler file.
A follow up effort made to an insurance company to locate the status of an insurance claim is called a/an... inquiry and tracer.
If an insurance claim has been lost by the insurance carrier, the procedure(s) to follow is to... ask if there is a backlog of claims at the insurance office, submit a copy of the original claim, and verify the correct mailing address.
An example of a technical error on an insurance claim is... duplicate dates of service, transposed numbers, and missing place of service code.
An insurance claim with an invalid procedure code would be... rejected.
An insurance claim for a service that has been bundled with other services would be... denied.
An insurance claim for which prior approval was not obtained would be... denied.
What should be done if an insurance claim denial is received because a billed service was not a program benefit? Send the patient a statement with a notation of the response from the insurance company.
What should be done if an insurance company denies a service stating it was not medically necessary and the physician believes it was? Rebill with a letter of explanation from the physician.
When down-coding occurs, payment will... be less.
If an insurance company admits that a patient signed an assignment of benefits document and that it inadvertently paid the patient instead of the physician, the insurance company should... pay the physician within 2 to 3 weeks and honor the assignment even before the company recovers its money from the patient.
The total number of levels of re-determination that exist in the Medicare program is... five.
The correct method to send documents for a Medicare reconsideration (Level 2) is by... certified mail with return receipt requested.
A request for a Medicare administrative law judge hearing can be made if the amount in controversy is at least... $130.
How many levels of review exist for TRICARE appeal procedures? Three.
In a TRICARE case, a request for an independent hearing may be pursued if the amount in question is... $300 or more.
When insurance carriers do not pay claims in a timely manner, what effect does this have on the medical practice? Decreased cash flow & decreased co-payments.
What does the insurance billing specialist need to monitor to be able to evaluate the effectiveness of the collection process? Accounts receivable.
What should be done to inform a new patient of office fees and payment policies? Send a patient information brochure, send a confirmation letter, and discuss fees & policies at the time of the initial contact.
The patient is likely to be the most cooperative in furnishing details necessary for a complete registration process... before any services are provided.
Professional courtesy means... applying a discount % to the entire fee and making no charge to anyone, patient or insurance company, for medical car.
When collecting fees, your goal should always be to... collect the full amount.
When the physician's office receives notice that a check was not honored, the first thing to do is to... call the bank or patient.
Messages included on statements to promote payment are called... dun statements.
What is the type of billing system in which practice management software is used? Computer billing.
Employment of a billing service is called... outsourcing.
The first telephone call to the patient to try to collect on an account should be made... after there is no response from the third statement.
What is a card called that permits bank customers to make cashless purchases from funds on deposit without incurring revolving finance charges for credit? Debit card.
How many installments (excluding a down payment) must a payment plan have to require full written disclosure? Four or more.
Patient accounts that are 90 days or older should not exceed what percent of the total office accounts receivable? 15-18%.
What is the name of the federal act that prohibits discrimination in all areas of granting credit? Equal Credit Opportunity Act.
What is the name of the act designed to address the collection practices of third-party debt collectors and attorneys who regularly collect debts for others? Fair Debt Collection Practices Act.
All collection calls should be placed... after 8am and before 9pm.
In making collection telephone calls to a group of accounts, how should the accounts be organized to determine where to begin? Organize the accounts according to amounts owed and start with the largest amount.
A plan in which employees can choose their own working hours from within a broad range of hours approved by management is called? Flex time.
When writing a collection letter... use a friendly tone and ask why payment has not been made.
If an insurance company seems to be ignoring all efforts to trace a claim, send a copy of the... history of the account.
The part of the legal system that allows laypeople to settle a legal matter without use of an attorney is the... people's court, justice court, and small claims court.
In a bankruptcy case, most medical bills are considered... unsecured debt.
Which type of bankruptcy is considered "wage earner's bankruptcy" ? Chapter 13
True or false: In times past, physicians in private practice billed indemnity insurance plans and professional service were reimbursed on a fee-for-service basis. True.
True or false: Ross-Loos Medical Group, America's oldest privately owned prepaid medical group, started in Texas. False, in L.A.
True or false: The Health Maintenance Organization Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance. True.
True or false: Medicare-eligible patients are not involved with HMOs or prepaid health plans. False.
True or false: In a staff model HMO, physicians are hired directly by the health plan that pays their salary. True.
True or false: Exclusive provider organizations (EPOs) are regulated by the federal government. False.
True or false: The difference between an IPA and a PPG is that a PPG may not be owned by its member physicians, whereas an IPA is physician owned. False, a PPG is physician owned.
True or false: In a point of service (POS) program, members may choose to use a non-program provider at any time. True.
True or flase: The term "turfing" means to transfer the sickest high-cost patients to other physicians so that the provider appears as a low utilizer. True.
True or false: If a primary care physician sends a patient to a specialist for consultation and the specialist is not in the managed care plan, the specialist may bill the primary care physician for payment. True.
True or false: In certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists. True.
True or false: Managed care plans allow laboratory tests to be performed at any facility the patient chooses. False.
True or false: Managed care plans never require a CMS-1500 claim form to be completed and submitted. False.
True or false: Usually, there are no deductibles for managed care plans. True.
True or false: A copayment in a managed care plan is usually a fixed dollar amount (predetermined fee). True.
What is America's oldest privately owned, prepaid medical group? Ross-Loos Medical group.
What plan allows members of Kaiser Permanente Medical Care program to seek medical help from non-Kaiser physicians? Point of service (POS)
Kaiser Permanente's medical plan is a closed panel program, which means... it limits the patient's choice of personal physicians.
A significant contribution to HMO development was the... Health Maintenance Organization Act of 1973
When an HMO is paid a fixed amount for each patient served without considering the actual number or nature of services provided to each person, this is known as... capitation.
What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care? Foundation for medical care.
An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an... preferred provider organization (PPO).
A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a/an... Point of service (POS) plan.
When a physician sees a patient more than is medically necessary, it is called... Churning.
Referral of a patient recommended by one specialist to another specialist is known as... tertiary care.
The abbreviation MCO stands for? Managed Care Organization.
The law states that an employer employing how many people may offer the services of an HMO clinic as an alternative health treatment plan for employees. 25 people or more.
A primary care physician who controls patient access to specialists is called a/an... gatekeeper.
Benefits under the HMO Act fall under two categories... Basic health services and supplemental health services.
UR is the abbreviation for... Utilization Review, which is necessary to control costs in the health care setting.
When a capitated patient's services go over a certain amount and the physician can begin asking the patient to pay (fee for service), this arrangement is provided in a... stop loss limit section of the managed care contract or agreement.
When a certain percentage of the monthly capitation payment is held out of the premium fund to pay for operating an IPA, it is known as a/an... withhold.
A patient intake sheet is also called a... Patient registration form.
This means stealing money that has been entrusted in one's care: embezzlement.
Title of a nurse practitioner, clinical nurse specialist, licensed social worker, nurse midwife, physical therapist, speech therapist, audiologist or physician assistant who consults or treats patients for specific medical problem? non-physician practitioner.
Back and forth communication between user and computer that occurs during online real time is called... interactive transaction.
An insurance claim for a service that has been bundled with other services would be... denied.
When downcoding occurs, payment will... be less.
In a bankruptcy case, most medical bills are considered: unsecured debt.
Medicare part A is run by... The centers of medicare and medicaid services. (CMS)
Medicare is a... federal health insurance program.
The letter "D" following the identification number on the patient's Medicare card indicates a... widow.
The letters preceding the number on the patient's Medicare identification card indicate... railroad retiree.
Part A of Medicare covers... hospice care.
Part B of Medicare covers... diagnostic tests.
The Medicare part A benefit period ends when a patient... has not been a bed patient in any hospital or nursing facility for 60 consecutive days.
Medigap insurance may cover... the deductible not covered under Medicare.
When a Medicare beneficiary has employer supplemental coverage, Medicare refers to these plans as... MSP.
Some senior HMOs may provide services not covered by Medicare, such as... eyeglasses and prescription drugs.
A program that contracts with CMS to review medial necessity and appropriateness of inpatient medical care is known as a... QIO.
A participating physician with the Medicare plan agrees to accept... 80% of the Medicare approved charge.
In the Medicare program, there is mandatory assignment for... clinical laboratory tests.
When a Medicare patient signs an advanced beneficiary notice, the procedure code for the service provided must be modified using the HCPCS level II modifier... -GA.
Under the prospective payment system (PPS), hospital treating Medicare patients are reimbursed according to... pre-established rates for each type of illness treated based on diagnosis.
The 1987 Omnibus Budget Reconciliation Act (OBRA) established the... MAAC.
Organizations handling claims from hospitals, nursing facilities, intermediate care facilities, long-term care facilities, and home health agencies are called... fiscal intermediaries.
When a Medicare carrier transmits a Medigap claim electronically to the Medigap carrier, it is referred to as a/an... crossover claim.
An explanation of benefits document for a patient under Medicare program is referred to as the... Medicare remittance advice document.
When a remittance advice (RA) is received from Medicare, the insurance billing specialist should... Post each patient's name and the amount of payment on the day sheet and the patient's ledger card.
Aliens qualified for medicaid have.. green card/resident alien status.
Do you need to apply for Medicaid? Yes.
What did CHAMPVA become? TRICARE (in 1994).
What does OSHA (1970) do for employees? Protects them from workplace health and safety hazards. It applies to most businesses.
What is IMC? Industrial Medical Council.
What is a lien? Legal claim on the property of another for the payment of debt. Null and void at the end of a specified time limit. A subsequent/amended lien can be field. Should be signed by patient/employee & patient's attorney.
What is Third-party subrogation? transfers claims from workers comp. insurance carrier to third-party liability carrier.
How should you handle health information record keeping in worker's comp. cases? Maintain separate medical record, maintain separate financial ledger, keep appointments for occupational injury or illness separate from unrelated matters, and keep documentation/dictation for each appointment separate from regular health record.
Explain a double indemnity policy... policy will pay twice the face amount to beneficiaries in cases of accidental death.
Explain Social Security Disability Insurance: long term plan provides benefits to workers and self employed who meet eligibility criteria. Insured may be eligible for Medicare after 24 months. Converts to retirement benefits at age 65.
Name two kinds of statutes under workers' compensation federal compensation laws and state compensation laws.
An unexpected, unintended event that occurs at a particular time and place, causing injury to an individual not of his or her own making, is called a/an... accident.
An illness/condition associated with your employment is called an... occupational illness/disease.
Name the federal workers' compensation acts that cover workers: Workmen's comp law of D.C., Federal coal mine health & safety act, Federal employees' compensation act (FECA), and Longshoremen's ad harbor workers' compensation act.
State compensation laws that require each employer to accept its provisions and provide for specialized benefits for employees who are injured at work are called... compulsory laws.
State compensation laws that may be accepted or rejected by the employer are known as... elective laws.
State five methods used for funding workers' compensation: State fund, territorial fund, self-insurers, competitive state fund and private insurance company.
Who pays the workers' compensation insurance premiums? employer
What is the time limit in your state for submitting the employers' and/or physicians' report on an industrial accident? Two working days between the 15th and 25th of the month.
When an employee with a preexisting condition is injured at work and the injury produces a disability greater than what would have been caused by the second injury alone, the benefits are derived from a/an second injury fund.
Name jobs that may not be covered by workers' compensation insurance: laborers, babysitters, newspaper vendors, charity workers, gardeners, and domestic/casual employees.
What is the minimum number of employees per business needed in Illinois for workers' compensation statues to become effective? One.
What waiting period must elapse in Illinois before workers' compensation payments begin? Three days.
Name five types of workers' compensation benefits: medical treatment, temporary disability indemnity, permanent disability indemnity, death benefits for survivors, and rehabilitation benefits.
Who can treat an industrial injury? any physician.
What are three types of workers' compensation claims and the differences among them? Non-disability claims, temporary disability and permanent disability.
Explain Non-disability claims: involves minor injury where patient seen by a doctor, but able to continue working.
Explain temporary disability: injury/illness occurs, patient is unable to return to work for a specific period of time.
Explain permanent disability: patient is unable to ever return to work due to a very severe injury.
Weekly temporary disability payments are based on: Percent of employee's earnings at the time of the injury.
What is the name of the treatment program in which the patient is given real work tasks for building strength and endurance? Work hardening.
When an industrial case reaches the time for rating the disability, this is accomplished by what state agency? State industrial accident commission.
Can an injured person appeal his/her case if he/she is not satisfied with the rating? Whom do they appeal to? Yes, they can petition WCAB or the Industrial Accident Commission.
When fraud or abuse is suspected in a workers' compensation case, the physician should report the situation to... their insurance carrier.
Explain third-party subrogation: a process of initiating legal claim against individual/insurer or one's own insurance company. Transfers claims and rights to third -party liability carrier.
When an individual suffers a work-related injury or illness, the employer must complete and send a form called a/an... employer's report to the insurance company and workers' compensation state offices.
If an employee is sent to a physician's office for medical care, the employer must complete a form called a/an... medical service order, which authorizes the physician to treat the employee.
Employers are required to meet health and safety standards for their employees under federal and state statues known as... Occupational Safety and Health Administration (OSHA) Act of 1970.
The process of carrying on a lawsuit is called... litigation.
A proceeding during which an attorney questions a witness who answers under oath but not in open court is called a/an... deposition.
The legal promise of a patient to satisfy a debt to the physician from proceeds received from a litigated case is termed a/an... promissory note.
When a physician treats an industrial injury, he/she must complete a First Treatment Medical Report or Doctor's First Report of Occupational Injury or Illness and send it to the following: insurance carrier, employer, and state workers' compensation office.
True or false: The first thing an employee should do after he/she is injured on the job is to notify his/her employer/immediate supervisor. True.
Are family/friends covered under workers' compensation insurance if they are injured at the employee's job? No, only the employee would be covered.
True or false: A stamped physician's signature is acceptable on the Doctor's First Report of Occupational Injury or Illness form. False, the physician MUST sign the form.
True or false: In a workers' compensation case, bills should be submitted monthly or at the time of termination of treatment, and a claim becomes delinquent after a time frame of 45 days. True.
True or false: If an individual seeks medical care for a workers' compensation injury from another state, the state's regulations are followed in which the injured person's clam was originally filed. True.
True or false: When a patient arrives at a medical office and says he/she was hurt at work, you should verify insurance information with the benefits coordinator for the employer. True.
Created by: sophie4335