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FINAL

Reimbursement and HIPAA

QuestionAnswer
T/F: When a managed care patient is admitted for a non-emergency to a hospital without a managed care contract, the managed care program needs to be notified by the hospital within 48 hours. False. Next business day.
T/F: Under HIPAA guidelines, an outside billing company that manages claims and accounts for a medical clinic is known as a covered entity. False. Clearinghouses, Providers and Third party payers are "Covered Entities".
Insurance companies are rated according to the number of complaints received about them. True. Remember, the state Insurance Commissioner tracts this data and is published in the public domain.
When a physician offers a discount, it must apply to the total bill, not just the portion that is paid by the patient. True.
A personal check is a guarantee of payment. False.
Standard policy should be to reduce fees of any patient who dies after receiving medical care. False. Perception on part of the family is that an element of guilt is implied.
In the UCR system of payment, "Usual" is the fee that the physician usually charges for a given serive to a private patient. True.
Ambulatory Payment Classifications are based on diagnoses. False. Based on Procedures.
A patient always has the right to obtain a copy of his/her confidential health information. False.
A collection rate of 80-85% should be a goal for the practise administrator in charge of collections in the physician's office. False.
The exchange of data in a standardized format through computer connections is known as electronic data interchange. True.
Statements should not be sent to a patient who has filed for bankruptcy. True.
The purpose of the DRG based system is to hold down rising health care costs. True.
Confidentiality between the physician and the patient is automatically waived when the patient is being treated in a worker's compensation case. True.
The cash factor is used to translate the abstract units (RVUs) in the scale to dollar fees for each serivce or procedure. False. It is the Conversion Factor.
Confidential data should be stored only in the computer's hard drive. False.
Appeal decisions on Medicare unassigned insurance claims are sent to the patient. True.
If the provider is notified by a commercial carrier that an overpayment has been made, investigate the refund request. True.
When a physician continues to treat an established patient with an overdue account, patients who fall into this delinquent status should be referred elsewhere. False.
The physician's office uses ICD-9-CM Volumes 1,2, and 3 to code diagnoses and procedures. False. Volume 1 and 2 only in the private office.
M/C:Confidential information includes:1. Everything heard about a patient.2. Everything that is read about a patient.3. Everything that is seen regarding a patient.4. All the above. All the above.
M/C: The claim form transmitted to the insurance carrier for reimbursement for inpatient hospital services is called? UB-04
M/C: A group of insurance claims sent at the same time from one facility is known as a: Batch
The most important function of a practise management system is: Accounts Receivable.
M/C: A clearinghouse performs:1. Transmits claims to the insurance payer.2. Performs software edits.3. Separates claims by carrier.4. All of the above. All the above.
When a medical practise has it's own computer and transmits claims electonically directly to the insurance carrier, this system is known as: Carrier-direct
The significant reason for which a patient is admitted to the hospital is coded using the: Principal diagnosis.
The form that accompanies the billing claim for inpatient hospital services is called a/an: Detailed or itemized statement.
Nonprivilged information about a patient consists of the patient's: City of residence. Remember, the only thing that is privilged is "health information" that can be connected to an individual.
The focus on the health care practise setting and reducing administrative costs and burdens are the goals of which HIPAA Title: HIPAA Title II Adminstrave Simplification.
What is the correct response when a relative calls asking about a patient? Have the physician return the phone call.
The rule stating that when a patient receives outpatient services within 72 hours of admission, then all outpatient services are combined with inpatient services and become part of the diagnostic-related group for the admission, is called the____? 72 Hour Rule.
Professional services billed by the physician include? Hospital consultations; Hospital visits; Emergency department visits.
Pending or resubmitted insurance claims may be tracked through a_______? Tickler file.
The document togethar with the payment voucher that is sent to a physician who has accepted assignment of benefits is referred to as a/an? EOB (Explanation of Benefits)
An example(s) of a technical error on an insurance claim is? Duplicate dates of service; Transposed numbers; Missing "Place of service" codes.
The correct method to send documents for a Medicare reconsideration (Level 2) is by what method? Certified mail with return receipt requested.
The average amount of accounts receivable should be? 1.5 to 2.0 times the charges for 1 month of services.
What is the name of the Act designed to address the collection practises of third party debt collectors and attorneys who regularly collect debts from others? Fair Debt Collection Practises Act (FDCPA)
What does RVU stand for? Relative Value Unit
What does PAT stand for? Pre Admission Testing
What does CCI stand for? Correct Coding Initiative.
What does DRG stand for? Diagnosis Related Group
What does APC stand for? Ambulatory Payment Classification
What does RBRVS stand for? Resource Based Relative Value Scale(System)
What does GAF stand for? Geographic Adjustment Factor
What does UCR stand for? Usual, Customary and Reasonable
What does HL7 stand for? Health Level 7
What does EIN stand for? Employer's Identification Number.
Assigning a code to represent data is known as? Encryption
When keying data, it is wise to _______ frequently to save information. Back-up
If the medical practise receives payment from an insurance company that is more than the contracted rate, it is called a/an ____? Overpayment
If inadequate payment was received from an insurance company for a complicated procedure, the insurance billing specialist should file a/an ____ on behalf of the physician. Appeal
The relationship of the amount of money owed to a physician and the amount of money collected on the physician's accounts receivable is called the _____? Collection Ratio
How the physician's office handles the retention, removal, and disposal of paper records is a/an _________ safeguard. Physical
The hospital department that conducts an admission and concurrent review on all cases and prepares a discharge paln to determine whether admissions are justified is the _____ department. Utilization Review.
A 3 to 4 digit code representing a specific accomodation ancillary service or billing calculations related to a service is a/an? Revenue Code
DRG's are based on what two elements? Diagnosis and Treatment
The range of usual fees charged by providers of similar training and experience in a geographic area is called? Customary (UCR)
Stealing money that has been entrusted to one's care is known as? Embezzelment.
Billing for services or supplies not provided is? Fraud
A billing practise such as excessive referrals to other providers for unnecessary services is considered? Abuse
The procedure of systematically arranging the accounts receivable by age from the date of service is called? Age analysis
The statement "This bill is now 30 days past due. Please remit payment." This is known as what kind of message? Dun
A formal regulation of law setting time limits on legal action is known as what? Statue of Limitations.
In dealing with an estate claim, a call to the ___ can be made periodically to check on the status of the estate. Executor
A/an _____ is a claim on the property of another as seurity for a debt. Lien
Employees should be required to attend a compliance training session at least? Annually
The maximum time during which a legal collection suit may be rendered against a debtor is referred to as a/an? Statue of Limitation
What are the three names for the form used by inpatient billing services? UB-04; CMS 1450; 837i
Explain the following formula. Not only what the abbrevations stand for, but also their meaning: RVU X GAF X CF= MEDICARE REIMBURSEMENT The sum of the three individual RVUs (Relative Value Units) times the Geographic Adjustment Factor times the Conversion Factor= Reimbursement
What are 5 of the 8 disciplinary standards for employee misconduct? Verbal warning; Written warning; Written reprimand; Suspension or probation; Demotion; Termination; Restitution of damages; Referral for prosecution.
What does the abbreviation HIPAA stand for? Health Insurance Portability and Accountablity Act. (1996 signed into law by Pres. Clinton)
Created by: douelt on 2009-01-22



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