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MBC 1800
Chapters 1 and 2
| Question | Answer |
|---|---|
| A written policy that states the terms of an agreement between a policy holder and a health plan | Medical Insurance |
| Benefits are | payments for medical services |
| Health plans are referred to as | payers |
| a private or government organization that insures or pays for health care on behalf of beneficiaries | third party payers |
| Insurance policies contain a _____ that summarizes the payments that may be made for medical services | schedule of benefits |
| Payer's definition of ____ determines coverage and payment | Medical Necessity |
| Providers include: | Physicians, Nurse practictioners, physician assistants, therapists, hospitals, laboratories, longe term care facillities, and suppliers (pharamcies and medical supply companies |
| Preventive Medical Services include: | Physical Exams, Pediatric and adolecent immunizations, prenatal care and routine screening procedures |
| Excluded Services may include: | Dental services, Eye Care, Employment-related injuiries, cosmetic procedures, and experimental procedures and Preexisting conditions |
| A medical condition diagnosed before the policy took effect | Preexisting Condition |
| An ____ plan provides protection against loss | Indemnity |
| A formal insurance claim that reports data about the patient and the services provided to the payer on behalf of the patient | Health Care Claim |
| The periodic payment a patient is required to make to keep a policy in effect | Premium |
| The amount that the insured pays on covered services before benefits begin | Deductible |
| The percentage of each claim that the insured pays | Coinsurance |
| A charging method based on each service performed | Fee for service |
| Offers a more resricted choice of providers and treatments in exchange for lower premiums | Mangaged Care |
| ____ establish links between provider, paitent, and payer | Managed Care Organizations (MCO) |
| MCO | Managed Care Organizations |
| ____ combines coverage of medical costs and delivery of health care for a prepaid premium | Health Maintenance Organization (HMO) |
| HMO | Health Maintenance Organization |
| _____ Means that a provider has contracted with a health plan to provide services to the plans beneficiaries | Participation |
| A fixed prepaymetn to a provider for all necessary contracted services provided to each plan member | Capitation |
| ____ is the capitiated rate | Per Member per Month (PMPM) |
| PMPM | Per Member per Month |
| A group of providers having participation agreements with a health plan | Network |
| In HMO's, visits to Out of Network providers are ___ | Not covered |
| HMO's often require _____ before the patient receives many types of services | Preauthorization |
| When HMO members see a provider, they pay a specified charge called a ____ | COpayment |
| HMO Members choose a _____, who directs all aspects of their care | Primary Care Physician (PCP) |
| PCP | Primary Care Physician |
| _____ are those HMO's that allow visits to specailists in the plan's network without a referral | Open-Access Plans |
| A _____ plan permits patients to receive medical services form non-network providers | Point of Service (POS) |
| POS | Point of Service Plan |
| A ____ is an MCO where a network of providers supply discounted treatment for plan members | Preferred provider Organization (PPO) |
| PPO | Preferred Provider Orgainization |
| What is the most popular type of health plan? | PPO |
| What are the 3 types of Savings accounts? | HSA, FSA,and HRA |
| A _____ combines a high deductible health plan with a medical savings plan | Consumer Driven Health Plan (CDHP) |
| CDHP | Consumer Driven Health Plan |
| Three Major Types of Medical Insurance Payers: | Private Payers, Self-Funded Health Plans, and Government Sponsored Health care programs |
| Government spondored health care programs include: | Medicare, Medicaid, TRICARE, and CHAMPVA |
| The _____ is health system reform legislation that introduced sigificant benefits for patients | Patient Protection and Affordable Care Act (PPACA) |
| PPACA | Patient Protection and Affordable Care Act |
| The 10 Steps of the Medical Billing Cycle: | 1. Preregister 2. Establish Financial responsibility 3. Check In 4. Check Out 5. Coding Complicance 6. Billing Complicance 7. Prepare and trasmit claims 8. Monitor payer adjudication 9. Generate patient statements 10. Follow up and Collections |
| A record of a patients financial transactions | Patient Ledger |
| Actions that satisfy offical requirements | Compliance |
| Monies owed to a medical practice | Accounts Receivable (A/R) |
| A/R | Accounts Receivable |
| When checking billing compliance, you must: | ensure you send the claim the way the specific payers wants to see it |
| The process of examining claims and determining benefits | Adjudication |
| A ____ is business software tha organizes and stores a medical practice's financial information | Practice Management Program (PMP) |
| PMP | Practice Management Program |
| CPC | Certified Professional Coder |
| CPC is offered through: | AAPC |
| Acting for the good of the public and the medical practice | Professionalism |
| Medical ___ are standards of behavior requiring _____, ____, and ____ | Ethics; truthfulness, honesty, and integrity |
| ____ is comprised of the standards of professional behavior | Etiquette |
| the recognition of a superior level of skill by an official orgainization | Certification |
| What is done when you preregister | Phone call: Determine the problem, obtain insurance and personal info, schedule appt |
| What is done to establish financial responsibility | Determine who will pay; check with insurer to determne if the service will be covered under the plan and how much they will cover and verify the plan is active |
| What is done when checking in | Get a copy of patient's insurance card, DL and completed demographics, get co-pay and balance (if applicable) |
| What is done when checking out | Collect any balance, schedule next appointment if needed, and get encounter form |
| What is done when reviewing coding complicance | Determine code based on documentation procided by the doctor ~ Data Entry |
| What is done when checking billing compliance | Billing plugs in codes and fees associated with the services and verifies it is all accurate; Verify insurance address, they have the correct insurance, and it is being sent the way that payer needs to see it. |
| What is done to prepare and trasmit claims | After verified all is accurate, submit the claim to the payer for processing ~ Either by paper (mail) or electronic |
| What is done to monitor payer adjudication | Follow up with payers to make sure they got and are processing the claim ~ Manage AR report |
| What is done to generate patient statements | Once the payer has submitted payment ~ Create statement for the patient indicating any outstanding balances |
| What is done in follow up and collections | Follow up with patients to collect monies owed. If they do not pay, send them to collections and right the amount off ~ |
| A medical record contains ____, ____ and ____ about the patient's health | facts, findings and observations |
| The recording of a patients health status in a medical record history | Documentation |
| State specified performance measures for health care delivery | Medical Standards of Care |
| Failure to use professional skill when giving medical services that result in injury or harm | Malpractice |
| An office visit between a patient and a medical professional | Encounter |
| Provider's evaluation of a patient's condition and decision on a course of treatment | Evaluation and Management (E/M) |
| E/M | Evaluation and Management |
| Computerized lifelong health care record with data from all sources | Electronic Health Record (EHR) |
| EHR | Electronic Health Record |
| Computerized record of one physician's encounters with a patient | Electroinc Medical Record (EMR) |
| EMR | Electroinc Medical Record |
| Process by which a patinet authorizes medical treatment after a discussion with a physician | Informed Consent |
| The 4 points of HIPAA | 1. Protects Patient Privacy 2. Ensures Covers (COBRA) 3. Uncovers fraud and abuse 4. Creates Industry Standards (electronic) |
| The main federal government agency responsible for health care is the ______ | Centers for Medicare and Medicaid Services (CMS) |
| CMS: | Centers for Medicare and Medicaid Services |
| The foundation legislation for the privacy of patient's health info is called | Health Insurance Portability and Accountability Act of 1996 (HIPAA) |
| HIPAA | Health Insurance Portability and Accountability Act of 1996 |
| Law with provisions concerning the standards for the electronic transmission of health care data | American Recovery and Reinvestment Act of 2009 (ARRA) |
| ARRA | American Recovery and Reinvestment Act of 2009 |
| The ARRA contains what act | HITECH Act |
| Law promoting the adoption and use of health information technology | HITECH Act |
| System to system exchange of data in a standardized format | Electronic data interchange (EDI) |
| EDI | Electronic data interchange |
| The electronic exchange of health care info is called a | transaction |
| Steps of a EDI trasaction | Dr sends the claim to a clearing house, they scrub the claim and then send it to the insurance company |
| Health care orgainizations that must obey HIPAA regulations are called | Covered Entities (CE's) |
| CE | Covered Entities |
| CE's have ____ contact with patient records | Direct |
| BA's have ____ contact with patient records | Indirect |
| Company that helps providers handle electronic transactions and manage EMR systems | Clearinghouse |
| Orgainizations that work for covered entities but are not themselves CE's | Business Associates (BA) |
| BA | Business Associates |
| CE's can be: ` | Doctors, insurance companies, and clearninghouses |
| BA's can be: | Billing Agencies, Law Firms, and Collection Agencies |
| Law regulating the use and disclosure of patients' protected health information | HIPAA Privacy Rule |
| PHI | protected health information |
| Individually identifiable health info tha tis transmitted or maintained | Protected Health Information (PHI) |
| TPO | Treatment, Payment, and Health Care Operations |
| Taking reasonable safeguards to protect PHI form incidental disclousure | Minimum Necessary Standard |
| CE's records that contain PHI | Designated Record Set (DRS) |
| DRS | Designated Record Set |
| Description of a CE's principles and procedures related to the protection of patients health info | Notice of Privacy Practices (NPP) |
| NPP | Notice of Privacy Practices |
| For use or disclosure other than for TPO, a CE MUST have the patient sign an _____ | authorization |
| DNKA | Did not keep appointment |
| Order of a court for a party to appear and testify | Suponea |
| Order of a court directing a party to appear, testify, and bring specified documents or items | Supoena duces tecoum |
| Medical data form which individual identifiers have been removed | De-identified health info |
| ____ requires CE's to establish safeguards to protect PHI | HIPAA Security Rule |
| Safeguards include: | Encryption and Password |
| Method of converting a message into encoded text | Encryption |
| confidential authentication info | Password |
| The ___ Act required CE's to notify affected individuals following the discovery of a breach of unsecured health info | HITECH |
| Impermissible use or disclousure of PHI that could pose significant risk to the affected person | Breach |
| document notifying an individual of a breach | Breach Notification |
| 4 code sets regulated by HIPAA | ICD-9, HCPCS, CPT, CDT |
| TCS | Transactions and Code Sets |
| Rule governing the electronic exchange of health info | HIPAA Electronic Health Care Transactions and Code Sets |
| Any group of codes used for encoding data elements | Code Sets |
| Identification systems for employers, health care providers, health plans, and patients | HIPAA National Identifier |
| NPI | National Provider Identifier |
| Unique ten digit identifier assigned to each provider | National Provider Identifier (NPI) |
| HIPAA created the _____ ______ ______ and _____ _______ _______ to uncover and prosecute fraud and abuse | Health Care Fraud and Abuse Control Program |
| The HHS ____ of the _____ _____ has the task of detecting health care fraud and abuse and enforcing all the related laws | Office of the Inspector General(OIG)~ FBI of CMS |
| OIG | Office of the Inspector General |
| Formal examination of a physicain's records | Audit |
| Cases in which a relator accuses another party of fraud or abuse against the federal government | Qui Tam |
| Person who makes an accusation of fruad or abuse | Relator |
| An act of deception used to take advantage of another person | Fraud |
| An example of fruad would be | forging another person's signature |
| An action that misuses money that the government has allocated | Abuse |
| An example of abuse would be | billing medicare for an unnecessary ambulance service |
| The difference between fraud and abuse | Fraud is intentional (billing for services not performed) and Abuse is unintentional/sloppy (billing for services that were not medically necessary or upcoding) |
| Law designed to combine the enforcement procedures for privacy and security standards into a single rule | HIPAA final enforcement Rule |
| Government agency that enforces the HIPAA Privacy ACt | Office for Civil Rights (OCR) |
| OCR | Office for Civil Rights |
| Criminal Violations of HIPAA privacy standards are prosecuted by the | Department of Justice (DOJ) |
| DOJ | Department of Justice |
| OCR's can do what? | File Lawsuits |
| DOJ's can do what? | Send to Jail for criminal charges |
| Medical Practice's written plan for complying with regulations | Compliance Plan |
| Doctrine making employers responsible for employee's actions | Respondeat superior |
| Subjective info is what is provided by the ____ | Patient |
| Objective info is what is what the ____ finds during the exam | Physican |
| Assessment, is the conclusion or the physican's ____- | Diagnosis |
| Plan is the course of treatment for the patient, such as: | Antibiotic treatment, surgery, futher tests, etc) |
| Reasons to fire a patietn | Collections, non-compliance, Rude, Disrespectful, non-vacination, insurance issues |
| Medical records should be orgainized ____ using a systematic, logical, and consistent method | alphabetically |
Created by:
iamamandataylor