Medical Insurance: An Integrated Claims Approach Process
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| *What are the 3 parts for Processing encounter for billing purposes | 1. Info about patients and insurance is gathered/verified.
2. Data about diagnoses/procedures are documented by the provider and used by the medical insurance specialist to update patients account.
3. Collection of time-of-service charges from patients.
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| New Patient (NP) | Someone who has not received services from the provider in a particular practice withing the past 3 years.
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| Established Patient (EP) | This patient has scene the provider withing the past 3 years.
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| *What is a referring physician? | a Dr. that sends a patient to another physician for treatment.
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| *MCO | Managed Care Organization
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| *What are some MCO's appointment regulations? | 1. Physician must see patient in a short period of time after patient calls for apt.
2. Emergencies need to be handled in the office instead of the ED.
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| Participating Provider (PAR) | An In-network physician contracted with an insurance company to provide lower rates for the patient.
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| Nonparticipating Provider (nonPAR) | An Out-of-Network physician not contracted with an insurance company.
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| *What are other common words used to mean Policyholder? | Subscriber, Insured, or Guarantor
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| Patient Info./Reg. Form | Used to collect demographic info about the patient.
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| *What does it mean by Matching Patient Name? | The patient's name on a claim should be exactly the same as it is on the insurance card.
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| Direct Provider | physician who directly treats the patient must sign an acknowledgment.
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| Do Indirect Providers have to secure additional acknowledgment? | No, though they must have a privacy policy.
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| What is a chart number? | Is a Unique # that identifies the patient.
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| Why is good communication with patients so essential? | Because satisfied customers are essential to the financial heath of every business.
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| Why is it important to be aware of a patients plan information? | So that you know what co-payments, precertification, referral requirements, and non-covered services are in a plan.
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| *How do you help secure preauthorization? | 1. Be Specific with the payer about the planned procedure.
2. Collect and have all diagnosis information available related to the procedure.
3. Query the provider and then request preauthorization for all procedures potentially treated.
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| *What does it mean to process a patient financial agreement? | It means that patients are given copies of their financial agreement while the practice files the original in the health record.
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| *Do you bill Supplemental Insurance Plans before or after you have received payment from the primary? | Afterward
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| *What is the Birthday Rule? | When both parents of a dependent child have primary insurance the parent whose day of birth is earlier in the calender year is primary.
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| How does an insurance specialist determine what is primary insurance when there are 2 plans present? | The plan that pays first.
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| *What are encounter forms? | is either electronic or paper and summarizes billing information for a patient's visit.
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| What are encounter forms called in hospitals? | Hospital Charge Tickets
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| What is charge capture? | Prenumbering of encounter forms makes sure all days' appointments jibe with the forms. This checks that all visits have been entered into the PMP.
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| What financial transactions are recorded in the PMP? | 1.Charges
2.Payments
3.Adjustments
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| What does the Collection of Time-of-Service payment entail? | 1.Co-payments
2.Non-covered or over-limit fees
2. Charges of non-participating providers.
3.Charges for self-pay patients
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| *Direct Provider | The provider who treats the patient
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| *Assignment of Benefits | Authorization by a policyholder that allows a payer to pay benefits directly to a provider.
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| *New Patient | A patient who has not received professional services from a provider, or another provider in the same practice with the same specialty, in the past 3 years.
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| *Secondary Insurance | The Insurance plan that pays benefits after payment by the primary payer when a patient is covered by more than one medical insurance plan.
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| *Encounter Form | Form used to summarize the treatments and services patients receive during visits.
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| *Established Patient | A patient who has received professional services from a provider, or another provider in the same practice with the same specialty, in the past 3 years.
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| *Insured | Policyholder, guarantor, or subscriber
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| *Coordination of benefits | A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
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| *Walkout Receipt | Document given to a patient who makes a payment.
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| *Patient information Form | Form completed by patients that summarizes their demographic and insurance information.
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| *T/F The HIPAA Health Care Claims or Equivalent Encounter Information/Coordination of Benefits transaction is used for both health care claims and coordination of benefits b/c secondary payer information goes along with the claim to the primary payer. | True
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| *T/F If both Gary's parents have primary medical insurance, his father's dob is 02-13-69, and his mother's dob is 03-04-68, his mother's plan is Gary's primary insurance. | False
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| *T/F Accepting assignment of benefits means that the physician bills the payer on behalf of the patient and receives payment directly. | True
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| *T/F The provider may not treat a patient unless the patient has first signed an Acknowledgment of Receipt of Notice of Privacy Practices | True
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| *T/F The provider does not need authorization to release a patient's PHI for treatment, payment, or operations purposes | True
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| *T/F The HIPAA Eligibility for a Health Plan transaction may be used to determine a patient's insurance coverage. | True
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| *T/F Patient's dates of birth should be recorded using all four digits of the year of birth | True
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| *T/F Patient's insurance benefits are usually verified after provider encounters. | False
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| *T/F The policyholder and the patient are always the same individual | False
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| *T/F Co-payments are collected at the time-of-service | True
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| *nonPAR | Out-of-Network physician
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| *COB | Coordination of Benefits
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| *PAR | Participating Provider
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| *NP | New Patient
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| *EP | Established Patient
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| *A Patient's group insurance number written on the patient information or update for must match: | B. The # on the patient's insurance card
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| *If a health plan member receives medical services from a provider who does not participate in the plan, the cost to the member is: | B. Higher
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| *What information does a patient information form gather? | A. The patient's personal information, employment data, and insurance information.
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| *If a husband has an insurance policy but is also eligible for benefits as a dependent under his wife's insurance policy, the wife's policy is considered_________for him. | C. Secondary
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| *A certification number for a procedure is the result of which transaction and process? | D. referral and authorization
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| *A completed encounter for contains: | C. both A and B
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| *The encounter form is a source of______information for the medical insurance specialist. | A. Billing
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| *Under HIPAA, what must be verified about a person who requests PHI? | D. both A and B
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| *Which charges are usually collected at the time of service? | B. Co-pays, non-covered or overlimit fees, charges of nonparticipating providers, and charges for self-pay patients
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| *The Tertiary insurance pays: | A. After the first and second payers
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