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Billing & Insurance

Quiz 3 and Mid Term

The concept that every procedure or service reported to a third-party must be linked to a condition that justifies the procedure or service is called medical __________. Necessity.
The type of health care that helps individuals avoid health and injury problems is ________. Preventive.
Which codes supplement procedures, services, and supplies not classified in CPT? HCPCS level II
Payment for medical treatment of an injury will be denied by the liability payer if: it is determined that there was no third-party negligence.
A typical responsibility of a health insurance specialist is: Correcting claims processing errors.
During World War II, the government restricted the wages employers could offer employees; thus employers began offering what to their employees? Benefits.
The World Health Organization originally developed which coding system in 1948? ICD
The automobile insurance policy coverage that can provide for expenses such as lost earnings, rehabilitation, and child expenses, regardless of fault is? Personal Injury Protection
Electronic data interchange is achieved by using? a standardized, machine-readable format.
The percentage of costs a patient shares with the health plan is the: coinsurance
A provider's list of predetermined payments for health care services to patients is: Fee Schedule
A coding consultant who is paid by a practice to assist the coding and billing staff would most likely be classified as an: Independent
What term describes the contractual right of a third-party payer to recover health care expenses from a liable party? Subrogation
Managed care in the United States has been operational: for nearly a century.
The patient's financial record, which can be found in automated or manual format, is the: Patient ledger.
In what year was Kaiser-Permanente created? 1955
The specified percentage of charges the patient must pay to the provider for each service received or for each visit is the: Coinsurance
What term describes the process of developing patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner? Case Management
The financial record source document used to record services rendered in a physician's office is the: Encounter form
Employee and dependents who join a managed care plan are called: Subscribers
Care rendered to a patient that was not properly approved (e.g., preapproved) by the insurance company is known as: Unauthorized services
The maximum amount the payer will allow for each procedure or service, according to the patient's policy is the: Allowed Charge.
A triple option plan can also be known as a cafeteria plan or a: Flexible benefit plan
What combines health care delivery with financing of services provided? Managed Care.
What 2003 legislation allows tax deductions for amounts contributed to a health savings account? Medicare Modernization Act
Managed care plans contract with outside vendor to establish and maintain a utilization management program. The plan can contract with TPA or with: Utilization Review Organization
The voluntary process that a health care facility or organization undergoes to demonstrate that is has met requirements beyond those required by law is called: Accreditation
What document is used to generate the patient's financial and medical record? Patient registration form
The rule stating that the policyholder whose birth month and day occur earlier in the calendar year holds the primary policy for the dependent children is the _____rule. Birth Day
To save the expenses of mailing invoices to patients, the office may ask the patient to: Pay the patient's portion of the bill before treatment or before the patient leaves the office.
How long must providers retain copies of government insurance claims? Seven years
What type of claim is generated for providers who do not accept assignment? Unassigned.
What are laws passed by legislative bodies (e.g., federal Congress and state legislatures)? Statues or statutory laws.
What are guidelines written by administrative agencies (e.g., CMS)? Regulations
A court decision that establishes a precedent is: Case law or common law
What is the legal newspaper that is published every business day by the National Archives and Records Administration (NARA)? Federal Register
What was passed by the federal government in 1863 during the Civil War to regulate fraud associated with military contractors selling supplies and equipment to the Union Army? False Claims Act
Requires carriers and fiscal intermediaries (now called Medicare administrative contractors) to attempt the collection of overpayments. Federal Claims Act of 1966
What forbids the Medicare regional carrier from disclosing the status of any assigned claim beyond the following: date the claim was received by the carrier; date the claim was paid, denied, or suspended; general reason the claim was suspended. Privacy Act of 1974
Storage of documentation for an established period of time, usually mandated by federal and/or state law; its purpose is to ensure the availability of records for use by government agencies and other third parties. Record of retention
Intentional deception or misrepresentation that could result in an unauthorized payment. Fraud
Actions inconsistent with accepted, sound medical, business, or fiscal practices. Abuse
What's the difference between Fraud and Abuse? Intent
Funds a provider or beneficiary receives in excess of amounts due and payable under Medicare and Medicaid statues and regulations. Overpayment
An organization that contracts with CMS to process claims and perform program integrity tasks for Medicare Part A and Part B. Medicare administrative contractors
_________ was developed in 1996 to reduce Medicare program expenditures by detecting inappropriate codes submitted on claims and denying payment for them, promote national correct coding methodologies, and eliminate improper coding practices. NCCI (National Correct Coding Initiative)
An unique identifier, previously called PAYERID, that will be assigned to third-party payers and is expected to have 10 numeric positions, including a check digit in the tenth position. National Health PlanID (PlanID)
An unique identifier to be assigned to health care providers as an 8- or possibly 10-character alphanumeric identifier, including a check digit in the last position. National Provider Identifier (NPI)
An unique identifier assigned to employers who, as sponsors of health insurance for their employees, need to be identified in health care transactions. National Standard Employee Identification Number (EIN)
A mutual exchange of data between provider and payer. Electronic data interchange
ICD is used to code and classify what? Mortality (death)
ICD-9-CM was developed in the US and is used to code and classify what? Morbidity (disease)
Created by: Magyc468
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