Reimbursement and HIPAA
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| 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.
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| 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".
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| 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.
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| When a physician offers a discount, it must apply to the total bill, not just the portion that is paid by the patient. | True.
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| A personal check is a guarantee of payment. | False.
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| 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.
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| In the UCR system of payment, "Usual" is the fee that the physician usually charges for a given serive to a private patient. | True.
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| Ambulatory Payment Classifications are based on diagnoses. | False. Based on Procedures.
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| A patient always has the right to obtain a copy of his/her confidential health information. | False.
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| A collection rate of 80-85% should be a goal for the practise administrator in charge of collections in the physician's office. | False.
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| The exchange of data in a standardized format through computer connections is known as electronic data interchange. | True.
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| Statements should not be sent to a patient who has filed for bankruptcy. | True.
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| The purpose of the DRG based system is to hold down rising health care costs. | True.
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| Confidentiality between the physician and the patient is automatically waived when the patient is being treated in a worker's compensation case. | True.
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| 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.
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| Confidential data should be stored only in the computer's hard drive. | False.
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| Appeal decisions on Medicare unassigned insurance claims are sent to the patient. | True.
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| If the provider is notified by a commercial carrier that an overpayment has been made, investigate the refund request. | True.
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| 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.
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| 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.
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| 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.
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| M/C: The claim form transmitted to the insurance carrier for reimbursement for inpatient hospital services is called? | UB-04
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| M/C: A group of insurance claims sent at the same time from one facility is known as a: | Batch
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| The most important function of a practise management system is: | Accounts Receivable.
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| 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.
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| 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
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| The significant reason for which a patient is admitted to the hospital is coded using the: | Principal diagnosis.
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| The form that accompanies the billing claim for inpatient hospital services is called a/an: | Detailed or itemized statement.
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| 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.
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| 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.
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| What is the correct response when a relative calls asking about a patient? | Have the physician return the phone call.
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| 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.
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| Professional services billed by the physician include? | Hospital consultations; Hospital visits; Emergency department visits.
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| Pending or resubmitted insurance claims may be tracked through a_______? | Tickler file.
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| 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)
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| An example(s) of a technical error on an insurance claim is? | Duplicate dates of service; Transposed numbers; Missing "Place of service" codes.
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| The correct method to send documents for a Medicare reconsideration (Level 2) is by what method? | Certified mail with return receipt requested.
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| The average amount of accounts receivable should be? | 1.5 to 2.0 times the charges for 1 month of services.
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| 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)
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| What does RVU stand for? | Relative Value Unit
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| What does PAT stand for? | Pre Admission Testing
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| What does CCI stand for? | Correct Coding Initiative.
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| What does DRG stand for? | Diagnosis Related Group
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| What does APC stand for? | Ambulatory Payment Classification
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| What does RBRVS stand for? | Resource Based Relative Value Scale(System)
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| What does GAF stand for? | Geographic Adjustment Factor
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| What does UCR stand for? | Usual, Customary and Reasonable
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| What does HL7 stand for? | Health Level 7
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| What does EIN stand for? | Employer's Identification Number.
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| Assigning a code to represent data is known as? | Encryption
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| When keying data, it is wise to _______ frequently to save information. | Back-up
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| If the medical practise receives payment from an insurance company that is more than the contracted rate, it is called a/an ____? | Overpayment
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| 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
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| 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
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| How the physician's office handles the retention, removal, and disposal of paper records is a/an _________ safeguard. | Physical
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| 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.
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| A 3 to 4 digit code representing a specific accomodation ancillary service or billing calculations related to a service is a/an? | Revenue Code
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| DRG's are based on what two elements? | Diagnosis and Treatment
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| The range of usual fees charged by providers of similar training and experience in a geographic area is called? | Customary (UCR)
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| Stealing money that has been entrusted to one's care is known as? | Embezzelment.
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| Billing for services or supplies not provided is? | Fraud
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| A billing practise such as excessive referrals to other providers for unnecessary services is considered? | Abuse
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| The procedure of systematically arranging the accounts receivable by age from the date of service is called? | Age analysis
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| The statement "This bill is now 30 days past due. Please remit payment." This is known as what kind of message? | Dun
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| A formal regulation of law setting time limits on legal action is known as what? | Statue of Limitations.
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| In dealing with an estate claim, a call to the ___ can be made periodically to check on the status of the estate. | Executor
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| A/an _____ is a claim on the property of another as seurity for a debt. | Lien
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| Employees should be required to attend a compliance training session at least? | Annually
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| The maximum time during which a legal collection suit may be rendered against a debtor is referred to as a/an? | Statue of Limitation
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| What are the three names for the form used by inpatient billing services? | UB-04; CMS 1450; 837i
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| 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
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| 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.
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| What does the abbreviation HIPAA stand for? | Health Insurance Portability and Accountablity Act. (1996 signed into law by Pres. Clinton)
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