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Customer Service impressions are formed by the staff's ________ (state of mind) and ______________ (action/reaction) towards them. Attitude and Behavior
_____________ may be any patient, family member, visitor, physician, other hospital personnel, third party payer, vendors, suppliers, etc. Customers
INTERNAL CUSTOMERS are people in other ___________, fellow _________ management, information services, etc. WITHIN THE _____________ who all work together in caring for the patient. Departments, employees
EXTERNAL CUSTOMERS are those ____________ the organization who work with us in caring for the patient. Outside
Demonstrating _______________ is equally as important as assuring a clean and accurate claim is generated. Compassion
THREE KEY QUESTIONS TO HANDLE CUSTOMER ISSUES: a. What is the _________ ? b. What has the customer attempted to do to __________ the problem? c. What would the customer like to see as an ___________ ? Problem, correct, outcome
Every effort should be made to resolve the problem at the _______ level. If unable to do so, submit the issue in _________ to the manager who will follow up with the patient. Unit, Writing
Patient safety is enhanced when patients are _________ in the healthcare process a much as possible. Partners
__________ patients on their rights and responsibilities enhances this partnership. Educating
The PAS should recognize that each patient is an individual with unique healthcare needs, and be committed to assist them in exercising their own healthcare __________. Decisions
State and federal laws require us to provide the rights and responsibilities to patients upon admission in a ___________ they can understand, in no smaller than ____ point font. Language, 12
Patient's Rights will be _______ in key locations throughout the facility as well. Posted
COMPASSION=_______________ Competence
______________ is the process in which messages are transmitted. Effective communication isn't only talking; is also includes ENSURING YOUR MESSAGE HAS BEEN ___________. Communication, Received
Communication is ___% Body Language, ____% Tone of Voice, and ___% the words you use. 55, 38, 7
Messages are ________ through words, gestures, tone of voice, etc. Encoded
Messages are _____________ face to face, over the phone, letter, email, text, etc. Transmitted
Messages are ________ by the person who receives it when they try to figure out what it means. Decoded
When communicating, you must OBTAIN ________ to clarify the message was received accurately. Feedback
Fancy medical words that the patient may not know are referred to as ________ ________. Avoid using this at all costs. Medical Jargon
Tone, pitch, quality and range of speech that is affected by cultural and regional dialects and accents is known as ____________. Paralanguage
Reading ____________ communication cues from patients will often tell you if they are nervous, defensive, angry, etc. Nonverbal
Apply HEAT to situations involving angry patients. H-_________;E-_______;A-________;T-___________ Hear them out, Empathize with the customer, Apologize, Take responsibility.
Ask _______ ended questions that begin with who, what, when, where, why. Open
Your role in dealing with angry patients is to _______ the situation by acting with patience, tact, and diplomacy. Diffuse
Never ________ or make light of their problem. Belittle
Three things registration staff should be able to do is: a. Ask the right questions to complete ________ and verify _________. b. Answer patient's questionsrelating to registration and __________. c. Complete registration with a high level of _________ registration, Insurance, Billing, Accuracy
Scheduling is necessary to maximize patient _____ and _________ wait time Flow, minimize
If it is not _______________, it did not happen. Documented
Name 5 date elements that may be required in the registration system: Patient name, address, phone number, Advance Directive, Employer info.
Patient medical record number is assigned on their ______ visit First
Medical records must be maintained for a minimum of ___ years. 10
Patients can request copies of medical records ________. Anytime
Financial clearance is also known as "financial pre-determination" and is where the provider identifies _________ sources to assist the patient in determining their expected _______________ costs, reimbursement, and alternative _______ sources. Payment, Out of Pocket, Funding
Patient must understand their financial obligation or portion of the final bill _____ to receiving services. Prior
Avoiding financial _________ promotes good customer service. Surprises
The EMTALA act is especially relevant to patients in the __________. Emergency Department
According to it, patients must be medically screened and stable before asking for _________, Payment
Doing so prevents discrimination of treatment based on ___________ status. Economic
Before screenng/stabilization takes place, patients can be asked if they have ________ and to make a copy of their card. Insurance
You CANNOT discuss ________ or __________. Payment or Coverage.
You CANNOT accept payment before treatment even if the patient __________. Volunteers
Patients must give _________ authorization before discussing payment with a third-party payer. Written
The goal of a PATIENT CENTERED ENVIRONMENT is creating an experience the patient will___________. Recommend
Customer satisfaction is measured by the patient's _________ of the staff member's effort to understand their _________ situation. Perception, Unique
The federal act designed to protect patient's privacy is known as ______. HIPAA
It also encourages ___________ transactions. electronic
Registration personnel are required to treat patients differently in relation to their ____. Age
________ _________ know their address and phone number and like to ask "Why?" a lot. School Children
______________ are able to discuss problems but are often afraid to do so because they may be afraid/embarrassed to ask/share. Adolescents
The nonverbal cues of their _____ language often signal how they feel. Body
_______ are at the peak of mental, verbal, reasoning, and information recall abilities. They have many responsibilities (Children, aging parents, act.) Adults
________ have decreased memory and a slower ability to process information. Address as Mr./Mrs. "Last Name". Seniors
Waits and delays in service, proper room and food temperature, noise levels, and pleasant smiles are known as ____________ concerns that customer satisfaction. Traditional
_______ on behalf of the hospital staff also has a major impact on a patient's impression of the hospital according to a Press-Ganey Study. Empathy
According to the study, patients may put up with __________ amenities, but they have a low tolerance for ___________ or _____________ care. Marginal, Impersonal, Uncompassionate
Registration staff should be experienced in working with __________ agencies and _____________ companies and be able to assist patients in determining how accounts should be paid. Government , Insurance
Patients with insurance will depend on you to verify ____________, check ______________, and to verify ________ if hospital is out of network. Coverage, Benefits, Cost
You should acknowledge all walk ins, even if you are with another patient with an approximate ______ ________ of when you will be able to assist them. wait time
According to EMTALA, patients must be _________ and ____________ before asking for payment. Doing so prevents discrimination of treatment based on __________ status. Screened, Stabalized, Economic
CMS guidelines mandate that policies for __________ patients be consistent with the policies for all the other patients. Medicare
Point of Service Collection non-negotiables include selecting the _______ patient when posting payments. Correct
Posting all payments received on daily ____ ____: giving patients a ______ after paying, and making relevant ________ regarding the patients account in the appropriate place. Cash sheet, receipt, comments
Promoting consideration of patient values and preferences includes informing the patient that they can _____________ treatment. Discontinue
The Regulatory agencies provides accreditation by setting standards concerning health care which providers must follow in order to receive Medicare and Medicaid Joint Commission
Regulatory agencies are similar to the _______ in making sure hospitals take care of patients. Police
Providers seek accreditation from this agency by paying a ____ and agreeing to be measured by ____________ ____________. Fee, National Standards
Accreditation by this agency enhances _____________ confidence, encourages ________ improvement efforts, provides staff ___________ tools, could help meet _______ _______ requirements, expedites _______ ________ payments, etc. Community, Quality, Education, Medicare Certification, Third Party
____________ refers to a hospitals ability/willingness to "follow the law" set by the Regulatory Agencies (police). Compliance
Doing so improves ________ care, reduces _______, ______, and also reduces the cost of healthcare to federal, state, and private health insurers. Patient, Fraud, Waste
In order to do so, hospitals must hire a __________ officer. Compliance
Communicate standards through _________ programs, perform _______ audits to prevent noncompliance within the hospital, develop lines of communication for reporting ______, and enforce standards through well ______ guidelines and procedures. Education, Internal, Violations, Publicized
_________ is the health insurance portability act of 1996. HIPAA
Portability means once a person has insurance coverage, when they change health plans (most commonly when changing jobs) the previous coverage may be used to reduce or eliminate ____________ condition exclusions. Pre-Existing
The act also attempted to reduce the cost and administration burden of providing healthcare by promoting standardized electronic _______ and _________ transactions. administrative and financial
It also ensures that protected health information (PHI) is _________ and that no personally __________ health information is disclosed. Protected, Identifiable
Hospitals must ______ all employees who will access to protect health information soon after they begin work. They must ______ a statement saying they have received training and must do so every ___ years. Train, Sign, 3
___ refers to all things information technology or computer related. IT
This department helps provide a ________ identity to patient records, provides easier access to _________ and _______________ data. Unique, Clinical, Administrative
It also helps ensure ______ integrity. Data
_________ refers to keyboard, monitor, central processing unit (CPU), printers, servers, cables, cord, etc. Hardware
_________ refers to system programs that make the computer run (Windows, Microsoft Word, Excel, Active Dashboard, SMS Invision, AccuRet, etc.) Software
_______ ____________ is a software application that transmits data on a pre-scheduled or demand basis (Novell email). Batch Processing
__________ is a software application that takes data from one system and sends to another. Interface
Data integrity is an essential part of Access Services because errors made in registration are ____________ to all other systems. Transmitted
The ___________ ___________ _______ stores the health systems entire population and can uniquely identify each patient based on certain key data. Master Patient Index
The __________ ______ ____________ provides ready access patient data from different areas of the healthcare network. Such data can be integrated into a single long term record for the patient. Clinical Data Repository
A __________ is coverage for a certain type of medical condition. Benefit
Another name for the policy holder is ________________. Subscriber
The policy holder will not _______ be the person whose name appears on the card. Always
For most Blue Cross, Commercial, and PPO insurance, the policy holder is the person whose name is on the _______. Card
Most ________ give each insured person his or her own card. This means the person whose name is on the card may not be the policyholder. HMOs
______ identify a policy holder by two digit suffix of 00 or 01. Spouses are usually 01 or 02, and dependents are 03, 04, etc. HMOs
The policy holder will be the sponsor or the person who is active or retired military with __________. Tricare
The policy holder will always be the patient with _________ and __________. Medicare and Medicaid
The employer is usually the policy holder for __________ ____________. Workmans Compensation
CMS refers to the _______ ___ ________ and ________ ________. Centers For Medicare and Medicaid Services
CMS is a __________ agency responsible for administering the largest federal health program. They are responsible for implementing federal _________ assurance standards in all facilities that participate in Medicare or Medicaid programs. Government, Quality
They are also involved in the CHiPs program for uninsured ________. Children
An organization administered by CMS to improve quality of care for Medicare beneficiaries to review complaints, cse review,s, outreach activities, and disease prevention campaign is a ____ ______ ____________. Peer Review Organization
CMS leads the healthcare industry in the use of __________ ___________ for all phases of claims processing. electronic Transactions
CMS combats fraud and abuse to protect ________ dollars and to help guarantee security for ________, ________, and _____ ______ ________. Medicare, Medicaid, and Child Health Programs
The department of _______ and the office of _________ _______ work with local and state agencies to protect CMS funds. Justice, Inspector General
Funding to combat fraud is provided through _____. HIPAA
A private agency that helps out with Medicare Part A is a ______ ____________. Fiscal Intermediary
A private agency that helps out wit Medicare Part B is a _______. Carrier
In order for private agencies to handle Government money they are charged to protect taxpayer money by determining _______ _________, detecting and deterring _____, and conducting ______ to ensure the proper amount was paid for service. Medical Necessity, Fraud, Audits
Medicare is for people at or over the age of ___, those of any age with ____, and certain disabled people under the age of __. 65, ESRD, 65
Medicare cards identify if the patient has Part A and B and will list the date these benefits became _________. Effective
Medicare claim numbers are usually the patient or spouse's ___ with a ______/______ prefix. SSN, Letter/Number
Common Codes: a. Primary Wage Earner ___. b. Retired Railroad Employee ___. c. Entitled through spouse ___. d. Child ___. e. Widow ___. f. Widower___. g. Disabled Widow ___. h. Disabled ____. a. A b. A c. B. d. C e. D f. D1 g. W h. W1
Medicare beneficiaries are automatically eligible on their ____ birthday but must apply __ months beforehand. 65th, 3
Inpatient hospital services are covered under Part ____; Outpatient services Part ___. Inpatient Part A, Outpatient Part B
Beneficiaries can pay private insurance companies to offer HMO and PPO coverage instead of traditional Medicare coverage through Part ___. Part C
This is also known as ________ _________. Medicare Advantage
Part ___ helps cover prescription drug plans. Part D
Part A helps pay for inpatient ________ care, ______ ________ __________ home health agencies and _______. Hospital, Skilled Nursing Facilities, Hospice
Inpatient Hospital Care is for up to ___ days each benefit period. 90
The ___ day or ___ hour rule allows all pre-admission or diagnostic services provided within this time prior to admission to be included with the inpatient payment. Doesn't cover _________ services. 3 day or 72 hr, Ambulance
Medicare's BENEFIT PERIOD for inpatient hospital and skilled nursing home facilities care is ___ days. 60
The BENEFIT PERIOD begins on the ____ day of services and ends ____ days following discharge if those days aren't interrupted by skilled care in another facility. First, 60
Medicare beneficiaries can have an _________ number of BENEFIT PERIODS but they must pay the inpatient ___________ for each period. Unlimited, Deductible
LIFETIME RESERVE DAYS refer to ___ additional days of hospitalization when beneficiary is an inpatient for a period greater that ___ days. These days can be used inly _____ in a lifetime. 60, 90, Once
IMPORTANT MESSAGE FROM MEDICARE (IMM) is given to all inpatient ________ recipients and explains their rights to care and follow up care after discharge. It also gives them a number to call if they are being discharged too _____. Medicare, Early
Hospitals cannot force beneficiaries to leave while their case is being ________. Reviewed
SKILLED NURSING FACILITY CARE - if medically ________ Part A pays for up to 100 days for each benefit period. Medicare pays all of the first ___ days, and patients pay a coinsurance for days ___ - ___. Necessary, 20 days, 21-100.
HOME HEALTH CARE - Medicare covers full ________ cost of covered HHC services. Patients pay only 20% co-insurance on equipment such as wheelchairs/walkers. Approved
MEDICARE (PART B) INSURANCE - helps pay for _______ services, _________ hospital services (including ER visits), ambulance transportation, diagnostic tests, lab, some preventative care, etc. It pays ___% of approved charges for most covered services. Doctor, Outpatient, 80%
Beneficiaries are responsible for paying ____ deductible per calendar year and the remaining ____ % approved charges. $100, 20%
MEDICARE (PART C) INSURANCE - Medicare beneficiaries can elect to assign their benefits to a ______ insurance company that has special coverage for seniors .... usually an HMO/PPO. Private
MEDICARE (PART D) INSURANCE - helps cover __________ drugs and may lower prescription costs. Prescription
Be sure to mention to all Medicare recipients that their yearly MEDICARE ENROLLMENT REVIEW is ________ through ________. They can make changes during this time. November through December
Except for certain limited cases in _______ and _______, Medicare does not pay for treatment outside the US. Canada and Mexico
Medicare Part A does not pay for convenience items such as _______ and ______,private rooms(unless _______ _____),or private duty nurses.Skilled nursing facilities are for _________ purposes only. Medicare does not pay for ______services (bathing,eating) Telephones, Televisions, Medically necessary, Rehabilitation, Custodial
Medicare Part B usually doesn't pay for ________ _____, physical examinations or services not related to treatment of an _____ or ______. It doesn't pay for dental care, cosmetic surgery, foot care, hearing aids, eye exams, or eyeglasses. Prescription Drugs, Illness or Injury
The ADVANCED BENEFICIARY NOTICE should be given to Medicare recipients if Medicare may not consider the service _______ _______ and there is a good chance the patient will have to pay. Medically Necessary
If the ABN isn't ______ before service is rendered and Medicare doesn't pay, the patient ________ be held responsible for the services. If ABN was signed, then the patient may be billed. Signed, Cannot
Many Fiscal Intermediaries are using _________ that compares the diagnosis code with a list of medically necessary services. Therefore it is extremely important that the correct code is assigned to the diagnosis. Software
Medicare is the secondary payer when another insurance is _________ and therefore Medicare is the __________. Primary, Secondary
A MEDICARE SECONDARY PAYER _____________ must be completed on all _________ patients each time service is provided because this information can _______ from visit to visit. Failure to do so can result in ______. Questionnaire, Medicare, Change, Fines
Medicare is the Secondary Payer if: a. Patient is 65 years old or older and is covered by Group Health Insurance provided by an employer with ____ or more employees for whom they or their _______ works. 20, Spouse
Medicare is the SECONDARY PAYER if: b. Patient is under the age of 65 and ________ and they or a family member currently works at an employer with _____ or more employees who covers them under Group Health Insurance. Disabled, 100
Medicare is the SECONDARY PAYER if: c. Patient has Medicare due to permanent kidney failure, known as _____. ESRD
Medicare is the SECONDARY PAYER if: d. Patient has Medicare, but is suffering from an illness or injury covered under _______ compensation, the federal ______ lung programs, no fault insurance, or any _____ insurance. Workers, Black, Liability
If patient retired before their Medicare entitlement date, but can't remember their exact retirement date, then their entitlement date can also serve as their ________ date. Retirement
If a Medicare beneficiary worked beyond their retirement date but cannot remember their exact date of retirement, and it has been at least ___ years since they retired, you can subtract ___ years from date of service as the retirement date. 5, 5
CMS regulations state that for recurring visits, where one account is reated and the patient has several visits related to the same service (such as physical therapy), all hages for each visit are entered into ____ account. One
But, you must verify the patient's MSP information every ___ days. 90
Medicare avoids excessive INPATIENT stays by paying only a fixed amount according to the patient's diagnosis. It will pay the _______ _______ ______ rate regardless of actual hospital charges or lenght of stay . Diagnostic Related Group
The only conditions where Medicare will pay more are f the hospital serves a great percentage of ___ income patients or is an approved _____ hospital. This extra amount is known as an ____ ___. Low, teaching, Add-On
This DRG payment is important to keep in mind when a patient questions the total amount of their inpatient bill because Medicare's reimbursement is rarely influence by the _____ _______. Total Charges
Medicare reimbursement amounts for professional and most OUTPATIENT services are based on ______ _______ ___________, which are tied to Current Procedural Terminology (CPT) codes and are based on national average costs. Ambulatory Payment Classification
The amount the patient is responsible for when APCs are the method of payment will vary until the amount can be set at a standard ___ % of the APC payment. This change will gradually be phased in to prevent the patient from being hit with a large ___pay. 20%, Co
For lab and physical therapy, Medicare pays according to a ___ schedule. Fee
Unintentional failure to follow CMS guidelines carries severe _____ and _______. In cases of intentional fraud, Medicare will not only pursue the hospital, but the _______ as well. Fines and Penalties, Employee
The three tyoes of Medicare SUPPLEMENTAL Insurance coverage includes: ___________ (employer or union), __________ (from a former employer or union) or _________ (from a private company or group). Employee, Retiree, Medigap
MEDIGAP is a private insurance designed to help pay Medicare _____ sharing amounts such as co_______, _________, and uncovered services. Cost, Insurance, Deductibles
MEDICARE SELECT is a type of supplemental insurance that generally has lower premiums than other policies because each insurer has specific _______ and often specific ________ that participants must use. Hospitals, Doctors
Except in _______, in order to receive full benefits. It is similar to an ____ Emergency, HMO
MEDICARE BENEFICIARY NOTICES (MBN) - an easy to read monthly __________ that clearly lists claims information. Statement
MEDICARE + CHOICE-plan that manages the Medicare coverage for its members and may provide benefits like coordination of care or reduce out of _____ expenses. Pocket
Members may also get prescription drug benefits or additional days in the hospital. Medicare pays a set amount of _____ for your care every month to these private health plans. Patient must have Part __ and __ to be eligible. Money, A and B
MEDICARE MANAGED CARE PLAN PROCESS - in most cases, patients can only go to certain ______ that agree to treat members of the plan a. Doctors can join or leave Managed Care Plans __________. Providers, anytime
b. Patients usually need a _______ from a Primary care Physician to see a specialist and risk higher co-pays without one. Referral
c. Patients pay _____ if they go outside the network, unless it's an emergency or urgent care. More
d. Dome Managed Care Plans offer a POint of Service option which allows patients the option to go to doctors _______ the network, but pay more. Outside
PRIVATE FEE FOR SERVICE - in this case the private company rather than __________ determines how much it pays and how much the patient pays for services. Medicare
a. Patients can go to any _______ that accepts the terms of plan's payment. Provider
b. Private company pays a ____ for each service, and patient my also have a __ ____. Fee, Co Pay
c. Patients could pay _____ if the plan lets provider bill more than the plan pays for service. More
In order to receive Medicare through other health plan choices, the beneficiary must have Part __ and Part __, continue to pay the monthly part B _____ , live in the plan's service ______, and not have _______. A and part B, Premium, Area, ESRD
Medicare beneficiaries in managed care plans should have a Medicare card as well as a _____________ card. They still receive Medicare _______ services and retain all Medicare _______ and protections. Insurance, Covered, Rights
If a patient has Medicare HMO and is in an automobile accident, who should be the primary payer? Auto Insurance
MEDICAID was established in 1965 to provide health care for certain low income people. Each state can determine _________ standards, which benefits and _______ to cover, and to set payment rates. Eligibility, Services
MEDICAID QUALIFICATIONS are certain low income families with ______, aged, blind, or disabled people on Supplemental Security Income, certain low income ______ women and children, and certain people who qualify due to _________ medical expenses. Children, Pregnant, Catastrophic
MEDICAID COVERED SERVICES must include ______ and outpatient hospital services, lab and x-rays, skilled nursing and home health services, family planning and periodic health check-ups, diagnosis, and treatment for __________. Inpatient, Children
TRADITIONAL MEDICAID eligibility is evaluated on a _______ basis. The Medicaid card is issued to the _____ of each family, which will list the names and ______ ID numbers for each person covered. Regular, Head, Individual
HMO MEDICAID contracts are determined by the State and contracts are usually arranged so that claims are submitted to and paid by the ___, which is reimbursed by Medicaid. HMO
Medicaid is a _______ payer with respect to Medicare. Secondary
WORKER'S COMPENSATION - services related to the result of ____ related accidents or injuries and are paid by the employer or the employer's workers compensation insurance company. work
a. The ________ must authorize worker compensation services. Employer must be contacted for __________. For billing, a claim number and the name of ______ authorizing the service is required. Employer, Authorization, Person
b. Key information to obtain in Worker's Comp. cases: _____ and date of injury, type of _____, name of ______ and ______ person, their ________ supervisor, Employee insurance information (in case injury is determined ____ to be work related). Time, Injury, Employer, Contact, Immediate, NOT
AUTO INSURANCE - usually primary for ___ victims of auto accident's. a. If patient has no health insurance, then auto insurance would be ______. b. If patient has Medicare or Medicaid, then auto insurance is _______. All, Primary, Primary
c. Whenever possible, obtain the claim ______, ________ address, and ___________ name and phone number. Number, Billing, Adjusters
LIABILITY - coverage for injuries resulting from ______ of another party. If the patient slipped and fell on a freshly mopped floor in a business and a sign was not posted that the floor was wet, the business would be liable. There is no ins. _____. Negligence, Card
COMMERCIAL INSURANCE - Insurance that is ____ Medicare, Meicaid, Federal State or County Programs. Blue Cross, Auto, PPO, HMO are considered ________ Insurance. Typically commercial beneficiaries are not required to select a _____or go to a specific ____. NOT, Commercial, Primary Care Physician, Hospital
PREFERRED PROVIDER ORGANIZATIONS (PPOS) - PPOS are contracts between employers, _______, and _________. a. Doctors and hospitals provide services at a __________ in return for receiving large volume of _______ who are PPO Members. Doctors, and Hospitals, Discount, Patients
b. These doctors/hospitals are known as participating ____________. Providers
c. Members do not have to select a PCP but must use a participating provider to obtain _____ coverage. Full
d. Choosing to go to a non-participating provider results in a coverage ________ and the member has to pay more out of _________. Decrease, Pocket
e. Not all PPOs have PPO written on the _______. Healthcare facilities usually have a _____ of PPOs that the facility has contracts with available to the staff. PPO cards usually have the co-pay amounts for ER/UC office visit. Card, List
HEALTH MAINTENANCE ORGANIZATION (HMO) - insurance plans that strive to __________ health care costs by requiring members to receive services at designated ___________. Control, Facilities
a. Therefore, all services except those in ______ _________ situations must be provided or _________ by a participating physician. b. Members typically select a _____ who is responsible for overseeing their healthcare and approves non-emergency service Lie Threatening, Approved, PCP
c. Not all cards have ____ on them. Most HMOs issue cards to each family member with their name instead of the policyholder's. Many add a suffix to the end of the policy holder to identify the cardholder's relationship to the subscriber. HMO
d. So if I am the policy holder, my suffix would be 00, my wife's would be __, my oldest child would then be __, and my youngest child would be ___. 01, 02, 03
e. Many HMO cards display the ____'s name and phone number as well as co-pay information. Some HMOs specify that non-participating claims be sent to a different _____ than participating claims. PCP, Address
TRICARE - healthcare program overseen by the ______ of ______ in cooperation with regional civilian contractors. Department of Defense
FOUR TRICARE OPTIONS: A. Tricare _____ is similar to an HMO. B. Tricare _____, is similar to a PPO that saves money for patients. Prime, Extra
FOUR TRICARE OPTIONS; C. Tricare ______, a fee for service option the same as the former CHAMPUS. D.Tricare _____ provides expanded medical coverage for Medicare eligible beneficiaries. Standard, For Live
CHAMPVA - health benefit program for families (the surviving spouse or children) of ________ who died or were 100% disabled from a service connected injury. Veterans
All active duty service members are automatically enrolled in Tricare ______. Prime
Tricare Standard is a cost sharing program for military families (and retirees) that shares most of the cost of treatment rom civilian providers when beneficiaries cannot get care from a ________ hospital or clinic. Military
Tricare has a series of rules to determine the ______payer. Generally Tricare is the ______ payer to coverage from other health plans (HMO/PPO).Tricare is the ____ payer if the other coverage is Medicaid or when a pt. is eligible for Indian Health Service Primary, Secondary, Primary
Tricare for Life provides expanded medical coverage for: ________ eligible retirees, Medicare eligible ________ members and widow/widowers, and certain former _______ if they were eligible for Tricare before age 65. Medicare, Family, Spouses
Patients must have Medicare Part ___ to be eligible for TFL. B
You can usually verify basic information such as date coverage began, active/inactive status, and is the patient the policyholder or a dependent, what are deductibles, and copay information by ________ ____ ___________. Visiting the website
Accurat coverage information regarding specific services and if preauthorization/certification is needed should be handled ___________ . Why? Over the phone, so you can get the name and contact information of the person you spoke with to ensure accuracy and accountability.
The COMMON WORKING FILE (CWF) is a tool used to verify Medicare __________. Coverage
It verifies: A. If a patient has ___ and ___, their effective dates, whether they have switched from Medicare to Medicare Advantage (________). B. If the patient or spouse is _______ and if they are covered by _____ ______. A and B, C, Employed, Employer Insurance
C. If the patient was involved in an _______ where the car is still open. D. The number of full and partial days remaining in the _______ _____. E. The number of ____ ____ ____ days remaining, and if the patient is on _______ care. Skilled Nursing Facility, Hospital
Medicaid can be verified through your _____ website or their CWF Verification System. State
A. Subscriber _____ s important concerning admission out of network. B. The ____ phone number is also important in case a referral is required. County, PCP
__________ ___________ refers to the person being entitled to benefits and covered. The date they became eligible for the plan is important to know since info can change from month to month. Insurance Eligibility
Cerain services need authorizations and others do not. Some insurance companies require a CPT code, so have it available. This is referred to as ___________ ____________. Authorization Requirement
Certain insurance companies require ___-_____________/_____________ from the PCP prior to services being performed. Pre-Certification/Authorization
The TOTAL amount of money policyholder will pay for medical services for himself and all dependents in a GIVEN TIME PERIOD is known as ____ of ______ _______. Once this limit is reached, benefits increase to ___%. _____may or may not contribute to this. Out of Pocket Maximum, 100%, Deductibles
The amount of eligible expenses a covered person must pay each year out of pocket before the plan pays for eligible benefits is known as ____-_____________. Co-Payments
___-___________ is the percentage from amount of money a subscriber must pay toward medial costs once the deductible has been met, usually 80%/20%. Co-Insurance
____ ____refers to purchasing a service o medical device separately which is typically a part of an HMO plan.For example, an HMO may ___ ____behavioral health benefits,select a specific vendor to supply these services,and offs them on a stand alone basis. Carving Out , Carve Out
________ _________ refers to a limit that once reached, prevents any further funds from being available for coverage or any further services. Could be for a calendar year or a lifetime. Lifetime Maximum
Procedures hat are not included and covered on a plan are known as _____________. Exclusions
Be sure to ______ ______ _______ to insure he/she is on the panel of providers or the patients insurance. This is especially important when a patient comes in unassigned and is treated by the physician ___ _____. Verify The Physician, On-Call
______________ of _____________ - refers to the way of determining the order in which benefits are paid and the amounts that are payable when a patient is covered by more than _____ health care plan. The intention is to avoid ________ of payments. Coordination of Benefits, One, Duplication
BIRTHDAY RULE - when a child is covered under both parent's insurance, then the parent whose birthday (using month and day) occurs _______ in the year is primary. Earlier
A. Ex.,if Steven's son is covered by his and his wife Kathy's insurance, and her birthday is in June and his is in November, then ________ insurance will be primary. Kathy's
B. If both of their birthdays are in April and Steve's is on the 11th and Kathy's on the 21st, then ______ will be primary. Steve
When parents are not together and a court decree exists, then: A. the plan of the parent with ________ is primary. B. the plan of the _________ (spouse with custody) is primary. Answer, Stepparent
C. The plan of the parent who does not have ________. D. the plan of the ___ _______ stepparent. Custody, Non Custodial
The primary plan is contacted _____ for authorization and billed for all services rendered. First
A. The _______ plan is billed after the primary plan has made the _________ payment allowed. Secondary, Maximum
B. The secondary carrier calculates benefits as though there were _____ other coverage. Then they pay the lesser of the calculated amount and the balance the primary carrier has submitted. No
__________ is when a payer agrees that condition have been met based on the information given that all requirements have been satisfied to reimburse for medically necessary services. Authorization
Pre-Encounter refers to _____________________________________. Before patient arrives to the hospital
Encounter refers to __________________________________. The time while the patient is at the hospital
The responsibilities of the Access Representative are to: A. _________ information B. Appropriately identify the ___________ C. Insure ____________ for services D. communicate information concerning patients _________ Gather, Patient, Reimbursement, Rights
E. obtain consents from ______ and authorizations from _________ F. collect co-pays and ________ G. direct the patient to the _____ of _______ H. make the patient feel comfortable and __________ Patients, Payers, Deductibles, Point of Service, Important
The Medicare form relating to medical necessity is know as the _______ __________ ________. Advance beneficiary notice
First impressions are imprinted in the patients mind during the _________ because they can observe the staff's __________ and attitudes. Encounter, Behavior
The MOST IMPORTANT task undertaken by patient access is proper _____________ ______________. Patient Identification
Proper patient identification includes obtaining the patient's ________ name, ______, and additional identifying information. Legal, DOB
A massive list containing the names of all patients who have ever received service at a medical facility is known as the __________ ________ __________. Master Patient Index
Patient identification information is matched against the ______ ______ _______ for matched. Master Patient Index
The Joint Commission's number ONE goal is to improving patient __________ which improves patient _________. Identification, Safety
all healthcare workers must use a minimum of ____ identifiers (name, date of birth, etc.) when providing care treatment, and services. Two
In addition to accurately identifying the patient, patient access staff should follow the facility directed guidelines to secure the patient's __________ and _________ information. Demographic and Financial
Doing so helps prevent _____ _______ and _________ _________. Identity theft and insurance fraud
The _________ _________ is a good source of information to determine if the patient has a special needs. Physician's Order
According to Title III of the Americans with Disabilities Act, __________ _________ must be identified and accommodated/addressed for those with Limited English Proficiency. Language Barriers
Reasonable steps must be taken to communicate effectively with patients, family members, and ________. This also included those who are _______ of ________. Visitors, Hard of Hearing
The Joint Commission requires that hospitals provide a ____ reduction program because if a patient falls on an unmarked wet floor, UMHC will be _____ for the medical bills. Fall, Liable
Hospitals must also provide waiting room chairs, special beds, and large wheelchairs to preserve the dignity and safety of ______ patients. Obese
Also known as "bed control" or "bed placement", hospitals must provide the most _________ location and level of service necessary for ______ clinical care. CHAA refers to this as _____ ________ . Optimum, Patient Placement
An important factor to consider in patient placement is _____ _____. A. In acute care hospitals, infected patients should be placed in a _____ rooms when available. B.When not available, patients with the same MRSA should be placed in the ______ room. Private, same
Staph infections, including MRSA occur most frequently among persons in hospitals and healthcare facilities with _________ immune systems. Weakened
The Center for Disease Control And Prevention (CDC) identified these standard precautions as crucial to preventing the spread of disease: A. _____ _______ B. _______ ________ Equipment C. ________/_________ etiquette Hand Hygiene, Personal Protective, Cough/Respiratory
If hands are not soiled, the preferred methos of documentation is an ______ based hand rub. If hands are visibly soiled, use only after removing visible materials with ____ and ______. Alcohol, Soap and Water
Alcohol-based rubs kill germs more _________ and __________. A. are less _______ to the skin B. requires less __________ C. and are more _________ than soap and water. Effectively and Quickly, Damaging, Time, Accessible
Medical Attention given for a sudden onset of an illness that demands urget (quick) attention of limited duration (time) when the patients health and wellness would deteriorate without treatment is known as _______ ________. Active Care
OBSERVATION care is limited to: A. the use of ___ and periodic ________ by hospital staff. B. Services should e reasonable and necessary to _________ the need for a possible hospital admission. C. Care USUALLY doesn't exceed ___-____ hours. Bed, monitoring, evaluate, 24-48
_________ ______ is treatment received at a hospital, clinic, or dispensary but the patient is not hospitalized. Outpatient Care
A scheduled or non-scheduled service such as radiology, laboratory, or other services performed in a hospital or clinic where patient leaves the facility once services are completed is known as ________ _______. Ancillary Services
In EMERGENCY SERVICES, patients are examined on an _________ _______ basis for ________ treatment in the emergency facilities at a hospital. Unscheduled emergent, Immediate
A. Depending on diagnosis, patient could be admitted as an __________ _________, or transferred to another facility. Observation Inpatient
____________ ____________/Same Day Surgery is where patient receives surgical treatment and is discharged within ___ to ____ hours of procedure.. Ambulatory Services, 4 to 6
____________ SERVICES are known as physical/occupational therapy, cardiac or pulmonary rehab that occurs over time based on doctor's order. Recurring
LONG TERM CARE is generally provided to the ______________ ill, _________ or those in a nursing home. A. Services include 24 hour ______ care. Chronically, Disabled, Nursing
B. Occupational/Physical/Speech _______ as well as assistance with daily living. C. Medicare beneficiaries are eligible for ____ days and Medical is available for those who have ____ their own resources. Therapy, 100 days, Exhausted
________ _______ is short term care provided to people caring for elders/mentally/physically dependent family members. A. It gives the care givers ____ ___ from taking care of their loved ones. B. It is not ________ through Medicare or Medicaid. Respita Care, Time Off, Reimbursed
________ is a non-profit organization dedicated to families and patients facing ________ illness or _____. A. It alows patients to share their last days together in their own ____ or hospice designated facility. B. It is _______ under Medicare. Hospice, Chronic, Death, Home, Reimbursed
Demographic information has both a ______ and _______ purpose and must be __________ and complete. Clinical and Financial, Accurate
Demographic information is verified by obtaining positive _____________ of the patient in combination with a A. ______ _____ conducted using B. ____ _____ questions. Identification, Verbal Interview, Open Ended
In patient access, the patient or _____ ____ is required to sign the consent form Patient Representative
A. _______ prior to obtaining signature and the patient should be given B. ___ to ____ the document and ask ______ C. Most facilities include on this form a release of information for _________ purposes. Explained, Time to Review, Questions, Financial
The patient representative must _____ and _____ the form and may be required to list their: A. ______ to the patient. B. Patient Access Staff must also sign the form as a ________. Sign and date, Relationship, Witness
If a patient's condition prevents them from signing and no patient representative is available, the patient access rep should ___ that on the form and ___ as a witness.Of course,they must also follow up with the pt. or rep to obtain consent when available Document, sign
When patient refuses to sign consent form in a scheduled, elective, or walk in clinic, ________ or _______ involvement may be required to address patient concerns. Supervisory or Clinical
Some patients may be unable to sign because they are ______. A. If so, there is usually a guardian or durable ____ of _____ assigned. B. Patient access should obtain a ____ of the power of attorney form to be included in the medical record proving the
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