NHA CCMA Exam 2022

Advance Beneficiary Notice (ABN)

A form provided to the patient when the provider believes Medicare will probably not pay for services received

Allowed Amount

The maximum amount a third-party payer will pay for a particular procedure or service

Copayment

a small fixed fee paid by the patient at the time of an office visit

Coinsurance

a provision under which both the insured and the insurer share the covered losses, typically 80:20

deductible

specific amount of money a patient must pay out of pocket before the insurance carrier begins paying

Explanation of Benefits

a form created by the insurance company to explain what charges were covered, denied, or need more documentation based on the claims submitted by the physician's office

Participating provider (PAR)

Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer

Medicare

A federal program of health insurance for persons 65 years of age and older by Part A (hospitalization) or Part B (routine medical office visits)

Tricare

U.S. government health insurance plan for all military personnel

CHAMPVA

covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities

Medicaid

provides health insurance to the medically indigent population through a cost-sharing program between federal and state governments for those who meet specific eligibility criteria

Managed Care

is an umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals

CMS-1500 form

Standard insurance form used by all government and most commercial insurance payers.

- 33 blocks

- divided into three section

CMS-1500 Section 1

Carrier Block: contains the address of the insurance carrier and is located at the top of the form

CMS-1500 Section 2

Patient/insured section: contains information about the patient or insured; includes boxes 1-13

CMS-1500 Section 3

Physician/Supplier Section: contains information about the physician or supplier: boxes 14-33

Supine Position

Dorsal Recumbent Position

Sims' Position

Knee-elbow position

Fowler's Position

Lithotomy Position

Epidural Injection

epidural space of the spine

Intra-arterial Injection

injection into an artery (to break up clots)

Intra-articular Injection

injection into joint space

Intradermal Injection

Skin of the upper chest, forearms, upper pack. 5-15º angle

intramuscular injection

deltoid, vastus lateralis, ventrogluteal muscles

Intraosseous Injection

Bone marrow

Intraperitoneal Injection

within the peritoneal cavity

Intrapleural Injection

pleural space (lungs)

Intrathecal Injection

Subarachnoid space (brain)

Fat soluble vitamins

A, D, E, K

Water Soluble vitamins

B1, B2, B3, B6, Folate, B12, Pantothenic acid, biotin, C.

Erikson's stages of psychosocial development

1. trust vs. mistrust

2. autonomy vs. shame and doubt

3. initiative vs. guilt

4. industry vs. inferiority

5. identity vs. role confusion

6. intimacy vs. isolation

7. generativity vs. stagnation

8. integrity vs. despair

Grief Cycle

denial, anger, bargaining, depression, acceptance

Sagittal Plane

divides body into left and right

Coronal Plane

divides body into front and back

Transverse Plane

horizontal division of the body into upper and lower portions

Right Upper Quadrant (RUQ)

Right lobe of liver, gallbladder, right kidney, portions of stomach, small and large intestine

Left Upper Quadrant (LUQ)

Left lobe of liver, stomach, pancreas, left kidney, spleen, portions of large intestine

Right Lower Quadrant (RLQ)

cecum, appendix, right ovary and tube, right ureter, right spermatic cord

Left Lower Quadrant (LLQ)

contains parts of the small and large intestines, left ovary, left fallopian tube, left ureter

Epigastric Region

located above the stomach

Umbilical Region

hypogastric region

Right Hypochondriac Region

right lateral region just below the ribs

Left Hypochondriac Region

left upper region below the rib cartilage

Right lumbar Region

right middle region near the waist

Left Lumbar Region

Right Iliac Region

Left Iliac Region

Chain of Infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

Wheezing

Difficult breathing with a high-pitched whistling or sighing sound during expiration

Rales

Crackles; wet crackling noise in lungs

Rhonchi

loud rumbling sounds heard on auscultation of bronchi obstructed by sputum

kg -> lbs

1 kg = 2.2 lbs

Trendelenburg position

Intradermal needle gauge

27-28

Intradermal Needle Length

3/8 in

Subcutaneous Needle Gauge

25-26

Subcutaneous Needle Length

1/2 to 5/8 inch

Intramuscular Needle gauge

20-23

Intramuscular Needle Length

1-3 inches

Smaller

the higher the needle gauge number, the ___ the diameter

Precertification

A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure.

EMR

electronic medical record

suffix

word ending

prefix

a syllable or word that comes before a root word to change its meaning

Pancreas

digestion and endocrine

Thymus

endocrine and immune

Upcoding

A fraudulent practice in which provider services are billed for higher procedural codes than were actually performed, resulting in a higher payment.

Usual Fee

Fee for a service or procedure that is charged by a provider for most patients under typical circumstances.

Customary fee

fee typically charged for a service in a particular geographic area

Reasonable Fee

The generally accepted fee a physician charges for an exceptionally difficult or complicated service. A charge is considered reasonable if it is deemed acceptable after peer review even if it does not meet the criteria for a customary fee or prevailing charges.

Capitation

System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan.

Phantom Billing

Billing for services not performed

Who do you report to for Fraud?

Office of Civil Rights (OCR)

Who do you report to for unsecured HPI?

Secretary of Health and Human Services

What is the difference between eHPI and HPI? Who governs both?

HHS

U.S. Department of Health and Human Services

U.S. Department of Health and Human Services

provide essential services, including health care for low-income families, programs for older adults, and child services

CMS

Centers for Medicare and Medicaid Services

OSHA

Occupational Safety and Health Administration

Red Cross

An international organization dedicated to the medical care of the sick or wounded in wars and natural disasters

Legal Aid Society

One of a network of community law offices that provides free or low-cost legal assistance.

The Joint Commission (TJS)

Organization, establishing standards for hospitals/health related facilities

NAACLS

National Accrediting Agency for Clinical Laboratory Sciences

ACS

American Cancer Society

AHA

American Hospital Association

Accountable Care Organization (ACO)

a network of doctors and hospitals that voluntarily share responsibility for managing the quality and cost of care provided to a group of patients

Patient-Centered Medical Home (PCMH)

A model of primary care that provides comprehensive and timely care to patients, while emphasizing teamwork and patient involvement.

ACO vs PCMH

the ACO is primarily a value-based reimbursement model that incorporates "voluntary" collaboration among providers, whereas the PCMH is primarily a care delivery model involving significant collaboration as part of the certification process

Cluster Scheduling

the scheduling of similar appointments together at a certain time of day or week

Wave Scheduling

A certain # of patients are scheduled to arrive at the same time and are seen in which the order they arrive.

Open Scheduling

Patients are seen on a first come first serve basis. Walk-ins

Farenheit to Celsius

(F-32)/1.8

Fomite

A physical object that serves to transmit an infectious agent from person to person

Vector (medical)

an animal that is a carrier of a disease or a medication

Sanitization

removal of pathogens from objects to meet public health standards

Sterilization

The process that completely destroys all microbial life, including spores.