Chapter 27: Preparing Insurance Claims and Posting Inurance Payments

Administrative Simplification Compliance Act (ASCA)

identifies limited situations where paper claim forms may be submitted for payment (rather than electronic submission); signed into law on December 27, 2001, as Public Law 107-105.

Centers for Medicare and Medicaid Services (CMS)

previously known as the Health Care Financing Administration (HCFA), CMS is the federal agency within the U.S. Department of Health and Human Services (HHS) responsible for administration of several key federal health care programs (Medicare and Medicaid).

Administrative Simplification Compliance Act (ASCA)

identifies limited situations where paper claim forms may be submitted for payment (rather than electronic submission); signed into law on December 27, 2001, as Public Law 107-105.

Centers for Medicare and Medicaid Services (CMS)

previously known as the Health Care Financing Administration (HCFA), CMS is the federal agency within the U.S. Department of Health and Human Services (HHS) responsible for administration of several key federal health care programs (Medicare and Medicaid).

clearinghouse

a private or public company that often serves as the middleman between physicians and billing groups, payers, and other health care partners for the transmission and translation of electronic claims information into the specific format required by payers.

crossover claim

a claim that is automatically forwarded from Medicare to a secondary insurer after Medicare has paid its portion of a service.

electronic claims tracking (ECT)

computer software designed for monitoring insurance claims.

electronic data interchange (EDI)

refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.

electronic media claims (EMC)

a flat file format used to transmit or transport claims

national provider identifier (NPI)

the name of the standard unique health identifier for health care providers.

secondary insurance

exists when a patient is covered under more than one insurance plan; charges are first submitted to the primary carrier, and any charges not covered are then submitted to the secondary carrier.

scrub

(1) claim scrubbing ensures that claims are correctly coded before being sent to the insurance company, which reduces denials and increases payments to the practice (Ch 27); (2) specific and thorough hand-washing procedure performed for six minutes before taking part in any sterile surgical procedure (Ch 47).

Which term was coined to indicate payment of services rendered by someone other than the patient?

a. Third-party reimbursement

b. Coinsurance

c. Provider reimbursement

d. Copayment

a. Third-party reimbursement

Which of the following is a group insurance that entitles members to services provided by participating hospitals, clinics, and providers; where patients do not have to file a claim, and the provider may not charge a patient directly or send a bill?

a. PPO

b. Medicare

c. HMO

d. IPA

c. HMO

What is the government's method of paying for facility outpatient services for Medicare that is an outpatient prospective payment system applicable only to hospitals?

a. Ambulatory payment classification

b. Diagnosis-related groups

c. Outpatient prospective payment system

d. Relative-value groups

a. Ambulatory payment classification

Initial claims for payment under Medicare must be submitted electronically unless a health care professional or supplier qualifies for a waiver or exception from the ________________ requirement for electronic submission of claims.

a. Outpatient Prospective Payment

b. Administrative Simplification Compliance Act (ASCA)

c. Fee-For-Service

d. Electronic Data Interchange

b. Administrative Simplification Compliance Act (ASCA)

In order to submit claims electronically, which of the following is necessary?

a. Electronic media formatting

b. Electronic data interchange (EDI) must be in place

c. Service-pack for EncoderPro built in

d. Written agreement with the insurance company

b. Electronic data interchange (EDI) must be in place

Which of the following outcomes is usually an advantage of electronic claims tracking (ECT) features?

a. Claims are typically received by the payer in one week.

b. Claims can be entered from anywhere with Internet access with real-time response.

c. Follow-up and phone calls to the insurance company will increase.

d. Errors in claims are overlooked.

b. Claims can be entered from anywhere with Internet access with real-time response.

In many instances, secondary insurance will pay most, if not all, of the balance left over from the primary insurance to your provider and will leave little out-of-pocket expenses for the patient. A patient with Medicare and a secondary insurance that covers 80% of the out-of-pocket amount due will owe _________ for a $200.00 visit cost.

a. $40

b. $32

c. $8

d. $0

c. $8

The contracted amount between the provider and payer (usually substantially less than the amount billed) on the explanation of benefits (EOB) form is referred to as:

a. not allowed amount.

b. coinsurance co-payment amount.

c. billed amount.

d. amount allowed.

d. amount allowed.

The information required to post on the patient account includes the:

a. routing number on the check.

b. date of service.

c. name of the person posting the payment.

d. name of the insurance company sending the payment.

d. name of the insurance company sending the payment.

What form is used for filing paper claims in an inpatient setting?

a. CMS-1500

b. 837P

c. UB-04

d. CMS-1550

c. UB-04

Before contacting an insurer regarding a delinquent claim, which of the following must you have available?

a. The practice's tax identification number

b. The patient's spouse's social security number

c. The patient's social security number

d. The insurance company's NPI

a. The practice's tax identification number

A claim that is automatically forwarded from Medicare to a secondary insurer after Medicare has paid its portion of a service when using an EHR is known as a _____ claim.

a. crossover

b. walkover

c. crosswalk

d. linkover

a. crossover

What is the most common paper claim form or format used in the medical office?

a. UB-04

b. CMS-1500

c. CMS-1450

d. CPT-1450

b. CMS-1500

Which of the following statements best describes the differences between manual and electronic claims tracking?

a. Claims tracking, also known as EFT, is the most efficient.

b. Claims tracking requires a clearinghouse, but manual claims tracking does not.

c. Electronic claims tracking is more efficient than manual claims tracking.

d. Manual claims tracking is more efficient than electronic claims tracking.

b. Claims tracking requires a clearinghouse, but manual claims tracking does not.

What does the acronym NPI stand for?

a. National provider identification

b. National provider identifier

c. National physician identifier

d. National physician information

b. National provider identifier

A company that often serves as the middleman between providers and billing groups, payers, and other health care partners for the transmission and translation of electronic claims information into the specific format required by payers is known as what?

a. A clearinghouse

b. Electronic data interchange

c. Electronic claims tracking

d. A remittance advice

a. A clearinghouse

A remittance advice is a ______.

a. paper check sent to the provider.

b. claim summary sent to the patient.

c. paper check sent to the patient.

d. claim summary sent to the provider.

d. claim summary sent to the provider.

Which of the following statements describes a common error in claims submission?

a. Services that are provided or ordered have been authenticated by the ordering practitioner

b. Services provided or ordered have not been authenticated by the ordering practitioner

c. The EFT code is missing

d. A signature is missing from the provider and patient

b. Services provided or ordered have not been authenticated by the ordering practitioner

What is the main distinction between fraud and abuse?

a. The dollar amount of the overbilling

b. The intent of the overbilling

c. If the patient was aware of the error and did nothing to stop it

d. If the provider, not the billing department overbilled

b. The intent of the overbilling

What is the standard claim form used for billing in medical offices?

a. EDI-1450

b. CMS-1500

c. CMS-1450

d. EDI-1500

b. CMS-1500

Prior to sending any claims to a third party for reimbursement, you should be certain that you have a copy of:

a. the patient's family health history.

b. signed notice of privacy practices from the patient.

c. the patient's lab results.

d. the patient's insurance card.

d. the patient's insurance card.

Which of the following must be in place in order to file a claim electronically?

a. Electronic Data Interchange (EDI)

b. Electronic Claims Tracking (ECT) system

c. Electronic Data Interface

d. HITECH portal

a. Electronic Data Interchange (EDI)

When applying an insurance payment to a patient account on a computerized system, you are not required to post the:

a. amount owed by the patient.

b. check number of the payment.

c. name of the insurance company.

d. payment date.

a. amount owed by the patient.

When would a bill for secondary insurance coverage be created?

a. At the same time as the bill for the primary insurer

b. It is automatically created by the primary insurer

c. Before the bill for the primary insurer is created

d. After the payment is received from the primary insurer

d. After the payment is received from the primary insurer

A book in which a list of insurance claims is kept is known as a:

a. manual-entry system.

b. manual insurance log.

c. continuation sheet.

d. clearinghouse.

b. manual insurance log.

Which of the following means that the doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services?

a. Medicare assignment

b. Medicaid assignment

c. Provider participation

d. HIPAA Privacy Rule participation

a. Medicare assignment

If a doctor, provider, or supplier doesn't accept assignment of Medicare insurance, they are referred to as ________ providers.

Nonparticipating

What type of claim is automatically forwarded from Medicare to a secondary insurer after Medicare has paid its portion of a service in the EHR?

a. Crossover claim

b. Crosswalk claim

c. Primary claim

d. Resubmitted claim

a. Crossover claim

It is recommended that a patient's signature on file be updated:

a. only when the billing office requests.

b. every few years.

c. annually.

d. every time the patient visits the office.

c. annually.

Whose Social Security number is used as the insurance plan ID number?

a. Patient

b. Employer

c. Physician

d. Policy holder

d. Policy holder

The medical assistant would log into the payer's website and enter the information on the visit if the patient is a member of a health insurance plan operated by a payer that supports:

a. real time adjudication.

b. electronic funds transfer.

c. real-time adjustment.

d. quick-check claims.

a. real time adjudication.

Misusing codes on a claim, such as upcoding or unbundling codes, is an example of:

a. improper downcoding.

b. Medicaid fraud and abuse.

c. errors and omissions.

d. Medicare fraud and abuse.

d. Medicare fraud and abuse.

A provider can charge more than the Medicare-approved amount, but there is a limit called ___________, which is up to 15 percent over the amount that nonparticipating providers are paid.

the limiting charge

An insurance adjustment is the difference in amount from what the provider charged and the:

a. explanation of benefits.

b. contracted amount with a particular insurance company.

c. net claim benefit.

d. remittance advice.

b. contracted amount with a particular insurance company.

The amount of a non-covered service, the deductible, or out-of-pocket requirements is noted on the EOB as:

a. claims payment.

b. non-covered charge.

c. not allowed amount.

d. coinsurance amount.

c. not allowed amount.

Providers have been urged to send claims electronically since:

a. 1986.

b. 1996.

c. 2010.

d. 2005.

d. 2005.

In some cases, the patient might have to submit his or her own claim to Medicare, using Form ______________in order to receive reimbursement for the costs.

CMS-1490S