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CMAA Flashcards

Administrative Office Procedures

Wave booking Patients are scheduled at the same time each hour to create short-term flexibility each hour. Schedule 2 or 3 patients during a designated hourly time period.
Modified wave booking Wave booking can be modified in a couple of different way. One example of this approach is to schedule 2 patients to come in at 9 am and 1 patients at 9:30 am. Hourly cycle repeats
Double booking Two patients are scheduled to come at the same time to see the same physician
Stream/Time-Specific scheduling Scheduling patients for specific time at regular intervals. The amount of the time allotted depends on the reason for the visit.
Open booking (tidal wave scheduling) Unscheduled walk-ins; Patients are not scheduled for a specific time, but told to come in at intermittent times. They are seen in the order in which they arrive.
Cluster or categorization booking Booking a number of patients who have specific needs together at the same time of day.
matrix A grid with time slots blocked out when physicians are unavailable or the office is closed.
screening system Procedures to prioritize the urgency of a call to determine when the patient should be seen.
Health Insurance Portability and Accountability Act (HIPAA) of 1996 Legislation that includes Title II, the first parameter designed to protect the privacy and security of patient information.
electronic medical record (EMR) An electronic record of health information that is created, added to, managed and reviewed by authorized providers and staff within a single health care organization.
Advance directive form Document that spells out what kind of treatment a patient wants in the event that he can't speak for himself/herself. Also known as a living will.
electronic health record (EHR) An electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards that can be created, managed and reviewed by authorized providers and staff from more than 1 health care organization.
birthday rule When a dependent has more than one health insurance plan, the plan of the parent/guardian whose birthday month and day come first in the calendar year is determined to be the primary plan.
reimbursement Payment from insurance companies.
modifiers Added information or changed description of procedures and services and are a part of valid CPT or HCPCS codes.
health history form Form that asks patients to list any illnesses or surgeries they have had, family history, medications taken, chronic health issues, allergies and other physicians they consulted.
Notice of Privacy Practices Document informing a patient of when and how their PHI can be used.
consent A patient's permission.
patient financial responsibility form Form that confirms that the patient is responsible for payments to the provider.
Protected Health Information (PHI) Individually identifiable health information that is inputted, stored and shared relating to the health of patients.
assignment of benefits (AOB) form Form that authorizes health insurance benefits to be sent directly to providers.
living will Document that spells out what kind of treatment a patient wants in the event that he/she can't speak from himself/herself. Also know as an advance directives.
DNR form Form that states that the patient does not want to be revived after experiencing a heart episode or other kind of life-threatening event.
registered nurse (RN) A health care professional who has been licensed by the state to provide and coordinate patient care.
urgent referral When an urgent, but not life-threatening, situation occurs, requiring that the referral be taken care of quickly.
stat referral Needed in an emergency situation, and can be approved immediately over the phone after the utilization review has approved the faxed document.
active files Section of medical charts for patients currently receiving treatment.
inactive files Section of medical charts for patients that the provider has not seen for 6 months or longer.
closed files Section of medical charts for patients who have died, moved away, or terminated their relationship with the physician.
purging The process of moving a file from active to inactive status.
perpetual transfer method Identifying files for purging by marking the outside of the file.
provisional diagnosis A temporary or working diagnosis.
differential diagnosis The process of weighing the probability that other diseases are the cause of the problem.
direct filing system System in which the only information needed for filing and retrieval is a patient's name.
cross-reference Reference to corresponding information in a separate location.
Privacy Rule A HIPAA rule that establishes protections for the privacy of individuals health information.
individually identifiable health information Documents or bits of information that identify the person or provider enough information so that the person could be identified.
bookkeeping Part of the offices accounting functions to include recording, classifying and summarizing financial transactions.
copayment A set amount determined by the plan/payer that the patient pays for specified services, usually office visits and emergency department visits (usually collected at the time of service).
encounter form A document used to collect data about elements of a patient visit that can become part of a patient record or to be used for management purposes.
deductible The amount the patient must pay before insurance pays anything.
coinsurance A form of cost-sharing that kicks in after the deductible has been met.
explanation of benefits (EOB) A record of a patient's fees.
accounts receivable ledger Document that provides detailed information about charges, payments & remaining amounts owed to the providers.
allowable amount The limit that most insurance plans put on the amount that will be allowed for the reimbursement for a service or procedure.
resource-based relative value scale (RBRVS) System that provides national uniform payments after adjustments across all practices throughout the country.
guarantor Person or entity responsible for the remaining payments of services after insurance has paid.
petty cash fund A small amount of company cash available for expenses such as postage, parking fees, small contributions, emergency supplies & misc. small items.
disbursement The record of the funds distributed to specific expense accounts.
daily journal A chronological record of the bills rec'd, bills paid and payments and reimbursements received.
day sheet A daily record of financial transactions and services rendered.
end-of-day summary Document consisting of proof of posting sections, month-to-date accounts receivable proof, and year-to-date accounts receivable proof.
single-entry system A method of bookkeeping that relies on a one-sided accounting entry to maintain financial information.
general journal Document where transactions are entered.
double-entry bookkeeping A system in which every entry to an account requires an opposite entry to a different account.
subsidiary journals A document where transactions are summarized and later recorded in a general ledger.
assets The properties owned by a business.
equities What is left of assets after creditors' liabilities have been subtracted.
liabilities The equity of those to whom money is owed (creditors).
invoice A document that describes items purchased or services rendered and shows the amount due.
statement A request for payment.
first-class mail Sealed or unsealed typed or handwritten material, including letters, postal cards, postcards and business reply mail.
priority mail First-class mail weighing more that 13 ounces.
standard mail Mail that includes advertising, promotional, directory or editorial material, or any combination of such material.
insured mail Mail that has insurance coverage against loss or damage.
registered mail Mail of all classes protected by registering and requesting evidence of it's delivery.
certified mail First-class mail that also gives the mail added protection by offering insurance, tracking and return receipt options.
packing slip A list of items in a package.
covered entities Providers, hospitals, laboratories, facilities, nursing homes, rehabilitation facilities, health plans, health care clearinghouses, and those that supply care, services or supplies to a patient & transmit any protected health information electronically.
non-covered entities Organizations that use, collect, access and disclose individually identifiable health information, but do not transmit electronic data. These do not have to comply with the Privacy Rule.
divulge Make private or sensitive information known.
business associates Individuals, groups or organizations, who are not members of a covered entity's workforce, that perform functions or activities on behalf of a covered entity.
incidental disclosure Secondary use of PHI that cannot be reasonably prevented, is limited in nature, and occurs as a result of another use or disclosure that is permitted.
electronic data interchange (EDI) The transfer of electronic information in a standard format.
National Provider Identifier (NPI) Unique 10 digit code for providers required by HIPAA.
HIPAA Security Rule Rule that describes safeguards that must be in place to protect the confidentiality, integrity and availability of health information stored in a computer and transmitted across computer networks, including the Internet.
firewall Part of a computer system that blocks unauthorized access while allowing outward communication.
audit trail A report that traces who has accessed electronic information.
health information exchange (HIE) System that enables the sharing of health-related information among providers according to nationally recognized standards.
Occupational Safety and Health Administration (OSHA) Part of the U.S. Department of Labor with the mission to ensure workplace safety and a healthy working environment.
exposure control plan Plan that describes tasks employees must perform if there is a risk of exposure to blood or other potentially infectious materials, and what procedures are in place to track employee exposures.
fraud Making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.
upcoding Assigning a diagnosis or procedure code at a higher level than the documentation supports, such as coding bronchitis as pneumonia.
unbundling Using multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure.
program abuse Practices that, either directly or indirectly, result in unnecessary costs to government-funded programs.
medical necessity The documented need for a particular medical intervention.
Healthcare Integrity and Protection Data Bank (HIPDB) A completion of information about fraud and abuse.
Healthcare Fraud and Abuse Program (HCFAP) Program that protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations and inspections.
Medigap Medicare supplemental health insurance for Medicare beneficiaries, which may include payment of Medicare deductibles, coinsurance, balance bills or other services not covered by Medicare. Private health ins. pays for most of the charges not covered by A&B
Healthcare Common Procedures Coding System (HCPCS) A group of codes and descriptors used to represent health care procedures, supplies, products and services.
Patient's Bill of Rights A list of guarantees for people receiving medical care.
referral Written recommendation to see a specialist.
shared decision-making A patient and provider work together to decide on a treatment plan.
abandonment Discontinuing medical care without giving the proper notice or providing a competent replacement.
Blue Cross Blue Shield plan The first prepaid plan in the U.S. that offers health insurance to individuals, small businesses, seniors and large employer groups.
inflection Use and change of tone or pitch in the voice.
jargon Specific words or expressions used by a particular profession or group and that can be difficult for others to understand.
template A sample written correspondence or email that is set up with the correct parts that will be personalized to fit the need. A document with a preset format that is used as a starting point so that it does not have to be recreated each time.
complimentary closing The part of a letter that immediately precedes the signature, such as "very truly yours" or "sincerely."
implied consent A patient presents for treatment, such as an arm to allow a venipuncture to be performed.
verbal consent Consent for treatment given out loud in response to a pointed question.
informed consent An oral or written agreement of mutual communication that ensures the patient has been notified about their health care choice before making them. Providers explain medical or diagnostic procedures, surgical interventions & the benefits & risks involved.
assault and battery Willful and unlawful use of intimidation and physical force or violence on another person.
emancipated minor A person younger than the age of majority (usually 18 to 21 years of age) who is married, in the armed forces, living apart from parents or a guardian, or self-supporting.
Medicare Summary Notice (MSN) Document that outlines all of the services and supplies, the amounts billed by the provider, the amounts billed by the provider, the amounts paid by Medicare and what the patient must pay the provider for the preceding 3 month period.
private health insurance Health insurance subsidized through premiums paid directly to the company.
premium The amount paid or to be paid by the policyholder for the coverage under the contract, usually in periodic installments. A pre-established amount set by the insurance company and paid regularly, usually on a monthly basis, by the patient or an employer.
Medicare Federally funded health insurance provided to all people age 65 or older, people younger that 65 who have certain disabilities and people of all ages with end-stage kidney disease.
benefit period Time during which benefits are payable under a given insurance plan.
Medicare Part A Provides hospitalization insurance to eligible individuals.
Medicare Part B Voluntary supplemental medical insurance to help pay for physicians and other medical professional services, medical services and medical-surgical supplies NOT covered by Medicare Part A.
Medicare Advantage (MA) Combined package of benefits under Medicare Parts A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness or prescription drug coverage.
health maintenance organization (HMO) A medical insurance group that provides coverage of health care services for a period of time and a fixed annual fee.
preferred provider organization (PPO) Plan that allows patients to use physicians, specialists and hospitals in the plan's network and receive a greater discount on services.
private fee-for-service plan Plan that allows patients to go to any physician, other health care professional or hospital as long as the providers agree to treat those patients.
fee-for-service Model in which providers set the fees for procedures and services.
Advance Beneficiary Notice of Noncoverage (ABN) Form provided to a patient if a provider believes that a service may be declined because Medicare might consider it necessary.
Medicare Part D A plan run by private insurance companies and other vendors approved by Medicare to cover the cost of approved prescriptions.
out-of-pocket maximum A predetermined amount after which the insurance company will pay 100% of the cost of medical services.
Medicaid Insurance coverage for families, children, pregnant individuals, older adults who have limited income or access to other health insurance coverage & those who have certain specified medical needs. Funded by federal & state govts & administered by states.
State Children's Health Insurance Program (SCHIP) A program jointly funded by the federal government and the states to cover uninsured children in families with modest incomes too high to qualify for Medicaid.
managed care organization Organization developed to manage the quality of health care and control costs.
capitation A managed care method of monthly payments to the provider based on the number of enrolled patients, regardless of how many encounters a patient may have during a month.
preauthorization Formal approval from the insurance company that will cover the test or procedure. Sometimes required by a payer to determine medical necessity for the proposed services.
preferred provider organization (PPO) A network of physicians, other health care practitioners & hospitals that have joined together to contract with insurance companies, employers or other organizations to provide health care to subscribers for a discounted fee.
employer based insurance Insurance that is tied to an individual's place of employment.
encrypted Electronic data that has been encoded such that only authorized parties can read it.
administrative services only (ASA) contract Contract between employees and private insurers under which employers fund the plans themselves and the private insurers administer the plans for the employers.
Hippocratic Oath Providers promise to do all they can to help patients and "do no harm."
SOAP An approach used for progress notes: S=Subjective O= Objective A=Assessment P=Plans
POMR It divides the medical record into four sections: P=Problem O=Oriented M=Medical R=Record
CHEDDAR An organizational approach to keeping medical records: C=Chief Complaint H=History E=Examination D=Details D=Drugs & Dosages A=Assessment R=Return Visit Info
eponym Term formed from a name.
active listening Engaging with the sender regarding the message and the intended interpretation (focus solely on the conversation, do not interrupt, confirm the message speaker has said, be respectful and professional).
administrative safeguards Administrative policies, procedures, and actions put in place to protect the privacy of the electronic health records.
advance directives Written statements of a person's wishes regarding medical treatment, such as a living will.
aging reports A report that lists outstanding balances that have not been paid by either the patient or the insurance payer.
anatomy and physiology Anatomy is the study of the structures of the human body. Physiology is the study of the function of each body system.
biases Beliefs that are not proven by facts about someone or a particular group of individuals.
block scheduling Grouping similar patient conditions at specific times.
carved out Medical services that are not included in the contracted capitation rate. These services may be billed separately.
certified clinical medical assistant (CCMA) Trained in both clinical and administrative duties.
certified medical administrative assistant (CMAA) Provides administrative support in a variety of health care settings including answering telephones, making appointments, checking patients in and out for examinations, collecting copayment as well as many other duties.
Clearinghouse An organization that accepts the claims data from a health care provider, performs edits comparable to payer edits and submits clean claims to the third-party payer.
communication Sending and receiving information, thoughts, or feelings through verbal words, written words or body language.
compliance Following mandated laws, policies, standards, and guidelines.
contracts Legally binding agreements between parties.
coordination of benefits (COB) A provision in group health insurance that prevents multiple insurers from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim.
cultural differences Various beliefs, languages, and practices that are unique to members of a specified group (ethnicity, race, national origin).
demographics Characteristics of a patient such as name, address, date of birth, contact and insurance necessary for filing.
diversity The impartial perception and inclusion of a variety of people.
downtime Time when the computer system is not functional and other processes must temporarily suffice.
eligibility Meeting the stipulated requirements to participate in the health care plan.
empathy The ability to understand the perspective, drives, and experiences of another person.
established patients Received same provider services within the last 3 years.
ethics Set of principles that differentiate between right and wrong.
health care interoperability Storage, exchange, accessibility and integration of health care records for the overall purpose of optimizing the health of individuals and populations.
Health Insurance Portability and Accountability Act (HIPAA) Federal law that ensures confidentiality of protected health information and sets the standards for health code sets and billing.
health risk assessment A comprehensive patient questionnaire to assess overall well-being by measuring physical and mental health, including lifestyle factors, fall risk, and cognitive function.
hospice The primary goal of hospice is to help relieve uncomfortable symptoms in terminally ill patients. Relieving stress and making the patient comfortable are secondary goals. Hospice usually can be initiated at any stage of the terminal illness.
in-network An insurance plan in which a provider signs a contract to participate. The provider agrees to accept a discounted rate for procedures.
interval A period of time between appointments.
licensed practical nurse (LPN) Provides health management to patients who are sick, injured or need a routine health exam. LPN's are supervised by providers and RN's.
malpractice Any treatment by a medical professional that does not follow the standards of care.
medical law Laws that explain the rights and responsibilities of medical providers and patients.
medical specialist A health care specialist who has a concentration or emphasis on a specific are of medicine.
medical terminology A combination of Latin and Greek language used to describe components and processes of the human body, medical procedures, diseases, disorders and pharmacology.
Medicare abuse Any practice that may result in unnecessary costs to Medicare.
Medicare fraud Intentionally submitting false medical claims for payment, receiving incentives for medical services or devices that are federally funded, or making inappropriate referrals.
National Patient Safety Goals (NPSG) Program that focuses on transforming health care by recognizing patients safety issues and gathering data to support the progress in correcting these issues.
negligence When a patient does not receive adequate and appropriate care, which leads to suffering and harm.
netiquette Courtesy rules for effectively communicating using an online format.
new patients The initial patient appointment or the first encounter after a three year absence from the organization.
non-participating (non-PAR) provider Does not agree to a payer's allowed amount and is not required by contract to do so. This many be referred to as out-of network for managed care plans.
nonverbal communication Communication type that occurs through expressive behaviors and body language rather than oral or written words.
nurse practitioner (NP) A registered nurse who possesses additional preparation and skills and is supervised by a physical examination, order and interpret tests, develop treatment plans, and prescribe medications.
participating (PAR) provider Agrees to accept the payer's allowed amount (regardless of the billed amount). This may be referred to as in-network for managed care payers.
patient abondonment Form of malpractice that occurs when a provider stops treating a patient without a reasonable cause and/or without reasonable notice.
patient-centered medical home (PCMH) A partnership between a patient and their care team in which total health is the focus and not just a single condition. Health care team consists of a provider(physician, NP, PA), CMAA, CCMA, nurses & pharmacists.
pay-for-performance (P4P) A reimbursement model intended to improve the traditional fee-for-service method by changing the focus to value-based care rather than volume-based care.
physical safeguards The policies, procedures, and actions used to protect the computers and equipment from hazards and unauthorized access.
physician assistant (PA) Licensed health care provider who works independently with physicians to diagnose illnesses, conduct physical examination, order and interpret tests, develop treatment plans and prescribe medications.
policyholder A person who signs a contract with a health insurance company and who owns the health insurance policy.
practice management software Software used for the day-to-day administrative business of a health care organization.
practice management system (PMS) An efficient way to electronically manage administrative function, such as scheduling appointment, integrating patient documentation from EHRs, coding, billing, and revenue cycle tasks such a running aging reports and managing the accounts receivable.
precertification A request to determine if a service is covered by the patient's policy.
preferences The medical organizations and provider's norms.
primary care provider Diagnoses and treats illness, injuries and disorders, prescribes medications, makes treatment plans and answers patient's questions.
primary insurance The insurance plan responsible for paying health care insurance claims.
professionalism The attitude, behavior, and work that represent a profession.
protocols A written plan that specifies criteria to be followed in defined situations.
referral An order from a provider for a patient to see a specialist or to obtain specific medical services.
remittance advice A response from the payer of claims payment and an explanation of patient responsibility amounts and any adjustments made to the billed amount by the payer.
revenue cycle A series of administrative functions that are required to capture and collect payment for services provided by a health care organization.
scope of practice A specific set of standards that a medical professional may perform within the limits of the medical license, registration, and/or certification.
screening Gathering pertinent health and insurance information.
secondary insurance The insurance plan that is billed after the primary insurance plan has paid its contracted amount.
technical safeguards Technology and polices that protect electronic protected health information from being accessed by those without permission.
telehealth The virtual delivery of health care services remotely.
telephone etiquette Being respectful using proper verbiage, tone, and manners when conveying information.
tertiary insurance Insurance coverage in addition to primary and secondary insurance. Tertiary insurance covers gaps in primary and secondary insurance coverage.
The Joint Commission (TJC) Accrediting body-focuses on quality improvement & patient safety, certifying health care organizations & programs in the US incl: hospitals & health care organizations providing ambulatory & office-based surgery, behavioral health, home health, labs & NH
therapeutic communication Interaction between a patient and a medical professional focused on improving the physical and emotional well-being of the patient.
time-specified scheduling Scheduling method also referred to as streaming. Set appointment times.
timely filing The length of time from the date of service in which a health care organization may submit a claim to the third-party payer. Timely filing varies by payer and may range from 90 days to one year from D of S. Claims that exceed timely filing are not payable
urgent Medically necessary within 24 hours.
value-based care model Rewards the provider with incentive payments for meeting defined program performance standards.
verification Information validation
workflow Efficient, continuous working pace.
Created by: Danielle Mulhern
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