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Chapter 4 Insurance
| Question | Answer |
|---|---|
| The manual daily accounts receivable is also known as the day sheet is a, | chronological of all transactions posted to individual patient ledgers/accounts on a specific day |
| Insurance claim cycle: | 1. Claims Submission & electronic data interchange (EDI) 2. Claims Processing 3. Claims Adjudication 4. Payment |
| Claims Submission is the | electronic or manual transmission of claims data to payers or clear housing for processing |
| Coordination of Benefits (COB) | is a provision in a group health insurance policies intended to keep multiple insurers from paying benefits covered by other policies |
| Deductible | is the total amount of covered medical expenses a policy holder must pay each year out of pocket before the insurance company is obligated to pay any benefits |
| Coinsurance | is the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid |
| Accounts Receivable | Are the amounts owed to a business for services or goods provided |
| Past-due account or Delinquent account | is one that has not been paid in a certain time frame (also about 120 days) |
| Bad Dept | the accounts receivable that cannot be collected by the provider or the collection agency |
| Litigation (legal action) | to recover dept is a last resort for medical practices |
| Which means that the patient and/or insured has authorized the payer to reimburse the provider directly? | assignment of benefits |
| Providers who do not accept assignment of Medicare benefits do not receive information included on the _____, which is sent to the patient. | Medicare Summary Notice |
| The transmission of claims data to payers or clearinghouses is called claims | submission |
| A series of fixed-length records submitted to payers to bill for health care services is an electronic | flat file format. |
| Which is considered a covered entity? | private-sector payers that process electronic claims |
| A claim that is rejected because of an error or omission is considered a(n) | open claim. |
| The chargemaster | is a document that contains a computer-generated list of procedures, services, and supplies with charges for each. (In Hospitals) |
| Which supporting documentation is associated with submission of an insurance claim? | claims attachment |
| Which is a group health insurance policy provision that prevents multiple payers from reimbursing benefits covered by other policies? | coordination of benefits |
| The sorting of claims upon submission to collect and verify information about the patient and provider is called claims | processing. |
| Which of the following steps would occur first? | Medical practice management software generates electronic claim. |
| Comparing the claim to payer edits and the patient's health plan benefits is part of claims | adjudication. |
| Which describes any procedure or service reported on a claim that is not included on the payer's master benefit list? | noncovered benefit |
| Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider? | common data file |
| Which is the fixed amount patients pay each time they receive health care services? | copayment |
| Which of the following steps would occur first? | Clearinghouse transmits claims data to payers. |
| Which must accept whatever a payer reimburses for procedures or services performed? | participating provider |
| Which is an interpretation of the birthday rule regarding two group health insurance policies when the parents of a child covered on both policies are married to each other and live in the same household? | The parent whose birth month and day occurs earlier in the calendar year is the primary policyholder. |
| Which is the financial record source document usually generated by a hospital? | chargemaster |
| Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions? | Truth in Lending Act |
| Which protects information collected by consumer reporting agencies? | Fair Credit Reporting Act |
| Which is the best way to prevent delinquent claims? | Verify health plan identification information on all patients. |
| Which is a characteristic of delinquent commercial claims awaiting payer reimbursement? | The delinquent claims are resolved directly with the payer. |
| A female patient is properly registered for scheduled blood work and arrives at the hospital's laboratory department. The laboratory technician who performs venipuncture | captures charge data by using an automated system that links to the hospital's chargemaster. |
| During the patient discharge processing stage of revenue cycle management | patient information is verified, discharge instructions are provided, patient follow-up visit is scheduled, consent forms are reviewed for signatures, and patient policies are explained to the patient. |
| Charges for services, procedures, patient personal payments, and third-party payments are entered in the computerized __________. | patient account record |
| Which is a manual-based chronological summary of all transactions posted to individual patient accounts on a specific day? | daily accounts receivable journal |
| Arranging appropriate health care services for discharged patients. | Discharge planning |
| Review for medical necessity of inpatient care prior to admission. | Preadmission review |
| Review for medical necessity of tests/procedures ordered during inpatient hospitalization. | Concurrent review |
| Grants prior approval for reimbursement of a health care service. | Preauthorization |
| Claim rejections | are unpaid claims that fail to meet certain data requirements, such as missing data |
| Claim denials | unpaid claim returned by third-party payers because of beneficiary identification errors, coding errors, diagnosis that does not support medical necessity of procedure/service |
| Preadmission Certification (PAC) | a review for medical necessity of inpatient care prior to the patient’s admission. |
| Preauthorization | a review by health plans to grant prior approval for reimbursement of health care services (e.g., durable medical equipment, prescription medications, surgical procedures, treatment plans |
| Encounter Form | is the financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. |
| Hospitals and other health care facilities generate the ____ claim for inpatient stays and outpatient encounters | UB-04 form |
| Accept Assignment (Box 27) | means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim. The patient is responsible for paying any copayment and/or coinsurance amounts. |
| participating provider (PAR) | contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. PARs are not allowed to bill patients for the difference between the contracted rate and their normal fee |
| nonparticipating provider (nonPAR) (out of network) | doesn't contract w/ the insurance plan, & patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses. patient is usually expected to pay difference between insurance payment and the provider’s fee. (15%) |
| Secondary insurance | must submit Explanation of Benefits (EOB) |
| Patient Ledger/Patient Account record | in a computerized system, is a permanent record of all financial transactions between the patient and the practice. |
| Clean Claim | which contains all required data elements needed to process and pay the claim |
| organized by month and insurance company and have been submitted to the payer, but processing is not complete// include those that were rejected (denied) due to an error or omission (because they must be reprocessed). | Open Claims |
| filed according to year and insurance company and include those for which all processing, including appeals, has been completed. | Closed Claims |
| Accounts Receivable | the amount owed to a business for services or goods provided |
| A past-due account (or delinquent account) | is one that has not been paid within a certain time frame (e.g., 120 days) |
| accounts receivable AGING REPORT | shows the status (by date) of outstanding claims from each payer, as well as payments due from patients. |
Created by:
vlw2861