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Med Office

Medical office questions and answers

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