Medical office questions and answers
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| The flow of financial transactions in a business is a | accounting cycle
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| Money that flows into a business | accounts receivable
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| The schedule of sending statements to patients is a | billing cycle
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| a form of translating a description of a condition into a shorter, standardized code is | coding
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| A series of steps that determine whether a claim should be paid | adjudication
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| part of charges that an insured person must pay for health care services after payment of the deductible amount | coinsurance
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| advance payment to a provider that covers each plan member's health care services for a certain period of time | capitation
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| a small fixed fee paid by the patient at the time of an office visit | co-pay
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| list of procedures and charges for a patient's visit | encounter form
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| type of managed care in which a high-deductible/low-premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses, up to the deductible limit | consumer-driven health plan (CDHP)
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| physician's opinion of the nature of the patient's illness or injury | diagnosis
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| standardized value that represents a patient's illness, signs, and symptoms | diagnosis code
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| document from a payer that shows how the amount of a benefit was determined | Explanation of Benefits (EOB)
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| a managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan | Health Maintenance Organization (HMO)
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| type of insurance where the carrier is responsible for both the financing and the delivery of health care | managed care
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| A health plan that repays the policyholder for covered medical expenses | fee-for-service
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| a plan, program, or organization that provides health benefits | health plan
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| treatment provided by a physician to a patient for the purpose fo preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice | medical necessity
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| form that includes a patient's personal, employment, and insurance data needed to complete an insurance claim | patient information form
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| a person who analyzes and codes patient diagnoses, procedures, and symptoms | medical coder
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| person who buys an insurance plan - the insured | policyholder
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| managed care network of providers that agree to perform services for plan members at discounted fees | Preferred Provider Organization (PPO)
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| private or government organization that insures or pays for health care on the behalf of the beneficiaries | payer
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| software program that automates many of the administrative and financial tasks required to run a medical practice | practice management program (PMP)
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| a code that identifies a medical service | procedure code
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| medical treatment provided by a physician or other health care provider | procedure
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| a list of services performed, and charges | statement
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| an EOB transmitted electronically by a payer to a provider | remittance advice (RA)
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| the periodic amount of money the insured pays to a health plan for insurance coverage | premium
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| What is PHI? | Protected Health Information
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| What is TPO? | treatment, payment, and healthcare operations
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| What is a number that the insurance issues to a specialist, admitting hospital or for a particular procedure | preauthorization or certification number
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| What guidelines ensure when a patient has more than one policy, maximum appropriate benefits are paid but, not duplications? | coordination of benefits (COB)
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| What is this an example of: When a child is covered by more than one policy it helps to decide which one is the primary coverage by using the parents birthday. | birthday rule
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| Who gets a walk out receipt or walkout statement? | anyone that made a payment during the visit
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| Why would a practice not want to accept a debit or credit? | they require a processing fee
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| What is PPO? | Preferred Provider Organization
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| What is HMO? | Health Maintenance Organization
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| What are these examples of: Indemnity, Managed Care, HMO, and PPO | health care plans
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| a report that lists errors in a claim | audit/edit report
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| What is the information about a patient's past, present, or future physical or mental health or payment for health care that can be used to identify the person? | Protected Health Information (PHI)
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| What is an organization that receives claims from a provider - checks, and prepares them for processing - transmits them to insurance carriers in a standardized format? | clearinghouse
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| What is the use of computers & handheld devices to write & transmit prescriptions to a pharmacy? | electronic prescribing (e-prescribing)
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| what is the transfer of a business transaction from one computer to another using communication protocols? | electronic data interchange (EDI)
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| national standard identifier for all health care providers, whcih consists of 10 #s | national provider identifier (NPI)
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| What is Information Technology (IT)? | computer hardware and software system
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| What is the electronic format of the claim used by a physicians office to bill for services? | X12-837 Health Care Claim (837P)
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| What regulations require electronic transactions to use standardized formats? | HIPPA electronic transaction & code sets standards
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| regulation guidelines that identify the safeguards required to prevent unauthorized access to electronic health care information | HIPPA security rule
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| What is the section of an EOB that identifies who was paid, how much, and when? | benefit payment information
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| The deductible under many plans applies to each individual each | calendar year
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| If noncovered services are provided, who is responsible for 100% of the costs. | patient
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| The section of an EOB that identifies the total deduction, noncovered charges, and balance the patient may owe is the | coverage determination
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| A provider that is able to balance-bill a patient for the amount over the allowed charge is referred to as a | nonparticipating provider
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| If a claim is found to not be medically necessary at the level reported, the claim will be | downcoded
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| If an a claim is downcoded, the medical office assistant should | appeal to the insurance carrier
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| If the appeal is denied, the medical office assistant can complain to the | state insurance commissioner
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| The submission of additional clinical information to a insurer to overturn a claim denial is known as an | appeal
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| Medicare Part B says the main reason for returning an appeal is due to the lack of a | valid signature
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| If a service is not documented in the medical record... | it didn't happen
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| What is SOAP? | subjective, objective, assesment plan
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| Concerning SOAP, information the patient shares with the doc, is considered to be | subjective
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| Concerning SOAP, the E/M history is considered | subjective
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| When an objective, unbiased group of physicians determines what payment is adequate for services provided, the process is called | peer review
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| Many _____ _____ may see re-billing as a duplicate claim, fraudulent billing, and a notice that payment is delinquent. | insurance carriers
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| What if some services on a claim were over looked by the provider's office; or if charges on the orginal claim were not detailed; or if the medical office specialist made a mistake on the claim? Would these be reasons to re-bill? | yes
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| An examination and verification of claims submitted by a physician is an | audit
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| How do you make sure you have all info from the insurance card? | copy both sides
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| What do you need from the insurance card? | Customer service number #, ID # or policy #, Group #, Co-pay, Co-insurance & Admission certification
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| If an adult has there own policy, plus they are a dependent on another policy, which policy is their primay or secondary? | the policy that names them as the policyholder is the primary policy
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| What are the written or dicated notations of an encounter between a provider and an individual - may be called medical notes or provider's notes. | Physcian's note
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| What is the encounter form that is preprinted with the ICD-9-CM and CPT codes that are most frequently used in that office? (may be called free ticket or routing slip) | superbill
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| Confriming that the services will be covered by the patient's plan is | eligibility
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| Contacting the insurer to verify an active policy is | verfication
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| The #'s or letters that connect an individual to a specific insurance policy is the | policy number or ID number
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| #'s or letters that connect the patient to an individual policy with a specfic group of other insureds is a | group name or number
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| A individual that obtains an insurance policy is a ____. (may be called insured) | policyholder
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| The policy which identifies the patient as the policyholder or the insured party is the | primary Insurance policy
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