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Med Office
Medical office questions and answers
| Question | Answer |
|---|---|
| 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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