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What is the correct order for the basic steps of a payer's adjudication process?

1. Initial processing
2. Automated review
3. Manual review
4. Determination
5. Payment

What is the claim status when the payer is developing the claim?

Suspended

Minor errors found by the practice on transmitted claims require which of the following?

corrections by asking the payer to reopen the claim and make the changes

Concurrent care is care provided

to a patient on the same date at the same place of service by two or more physicians.

What may result from a lack of clear, correct linkage between the diagnosis and the procedure?

medical necessity denial

Which of the following is an example of concurrent care?

a case in which a nurse practitioner sees the patient and then transfers the care to a physician

Noncovered service at a primary care medical office

employment-related injuries

What kind of medical services are annual physical examinations and routine screening procedures?

preventive

Under an insurance contract, the patient is the first party and the physician is the second party. Who is the third party?

insurance plan

In what ways can insurance policies be written?

an individual or group

Determine which of the following entities is not considered a provider.

insurance companies

Dependents of a policyholder may include his/her

spouse and children.

The key to receiving coverage and payment from a payer is the payer's definition of:

medical necessity.

A health plan will not pay for:

noncovered services

Where do medical insurance companies summarize the payments they may make for medically necessary medical services?

schedule of benefits document

Which type of provider service would most likely NOT be covered by a health plan?

a medical procedure that is not included in a plan's benefits

Under a written insurance contract, the policyholder pays a premium, and the insurance company provides:

payments for covered medical services.

Out-of-pocket expenses must be paid by:

the insured.

Which of the following conditions must be met before payment is made under an indemnity plan?

payment of premium, deductible, and coinsurance

Under an indemnity plan, typically a patient may use the services of

any provider.

Accounts payable

The practice’s operating expenses, such as for overhead, salaries, supplies, and insurance

Cash flow

Movement of monies into or out of a business

Accounts receivable

Monies owed to a medical practice by its patients and third-party payers

Revenue cycle

All administrative and clinical functions that help capture and collect patients’ payments for medical

Medical insurance

A healthcare plan that covers the cost of hospital and medical care.

Health information technology (HIT)

Computer hardware and software information systems that record, store, and manage patient information

Electronic health record (EHR)

A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual

PM/EHR

A software program that combines both a PMP and an EHR into a single product

Medical insurance

A written policy stating the terms of an agreement between a policy-holder and a health plan

Policyholder

Person who buys an insurance plan AKA insured

Health plan

Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans

Benefits

The amount of money a health plan pays for services covered in an insurance policy

Payer

Health plan or program

Schedule of benefits

List of the medical expenses that a health plan covers

Provider

Person or entity that supplies medical or health services and bills for, or is paid for, the services in the normal course of business. A provider may be a professional member of the healthcare team, such as a physician, or a facility, such as a hospital or skilled nursing home.

Covered services

Medical procedures and treatments that are included as benefits under an insured’s health plan.

Preventive medical services

Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests.

noncovered services

Medical procedures that are not included in a plan’s benefits.

Excluded service

A service specified in a medical insurance contract as not covered.

Indemnity plan

Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits.

Healthcare claim

An electronic transaction or a paper document filed with a health plan to receive benefits.

Premium

Money the insured pays to a health plan for a healthcare policy.

copayment

A specified (fixed) amount that a beneficiary must pay at the time of a healthcare encounter is called

Capitation

fixed prepayment to a medical provider for services to a plan member for a specified period

AKA open HMO

Point-of-service (POS) plan

Under a fee-for-service plan, the third-party payer makes a payment:

after medical services are provided.

When is a deductible paid?

before benefits begin

How is coinsurance defined?

the percentage of each claim that the insured pays

What is a premium?

the periodic payment the insured is required to make to keep a policy in effect

Identify the advantages offered to patients in managed care plans, as compared to indemnity insurance.

lower premiums, charges, and deductibles

Choose the entity(ies) that may form agreements with an MCO.

the patient and provider

Name a benefit a provider usually gets from participation with a health plan:

an increased number of patients

Health care claims report data to payers about __________ and __________.

the patient; the services provided by the physician

In what format are health care claims sent?

electronic or hard copy

What is the formula for calculating an insurance company payment in an indemnity plan?

charge − deductible − coinsurance

Latin for head

*Capit*

A capitated payment amount is called a

prospective payment; paid *before* the patient visit.

Identify the type of HMO cost-containment method that limits members to receiving services from the HMO's physician network.

restricting patients' choice of providers

Formulary

Providers must prescribe drugs for patients only from HMO’s list of selected pharmaceuticals and approved dosages.

Identify the type of HMO cost-containment method that requires providers to use a formulary.

controlling drug costs

Identify the type of HMO cost-containment method that requires the patient to pay a copayment.

cost-sharing

Cost-sharing

Also called copayment

Identify the type of HMO cost-containment method that requires patients to obtain approval for services before they receive the treatment.

requiring preauthorization for services

If a POS HMO member elects to receive medical services from out-of-network providers they usually

pay an additional cost.

Which term best describes medical services that meet professional medical standards?

medical necessity.

Describe the role of a primary care physician (PCP) in an HMO.

coordinating patients' overall care

PPO members who use out-of-network providers may be subjected to

higher copayments.

Employers that offer health plans to employees without using an insurance carrier are:

self-funded (insured) health plans.

**consumer-driven health plan (CDHP)**

Type of medical insurance that combines a %%high-deductible health plan%% with a @@medical savings plan@@ that covers some out-of-pocket expenses.

Which of the following is an example of a private-sector payer?

insurance company

A patient ledger records

the patient's financial transactions.

Imagine you are a medical insurance specialist; identify the impact your ability to prepare accurate, timely claims can have on the practice.

Preparing accurate and timely claims generally leads to full and timely reimbursement from the health plan.

Practice management programs may be used for

scheduling appointments, financial record keeping, and billing.

**practice management program (PMP)**

Business software designed to organize and store a medical practice’s financial information; often includes:

* Scheduling
* Billing
* Electronic medical records features.

The statement that “coding professionals should not change codes. . .to increase billings” is an example of:

professional ethics.

Courteous treatment of patients who visit the medical practice is an example of medical:

etiquette.

Pick the most accurate definition of certification.

recognition of a superior level of skill by an official organization

What is typically required of professional organizations?

continuing education sessions

An encounter is defined as a

face-to-face meeting between a provider and a patient.

Electronic health records are considered to have significant advantages, including all of the following *except:*

reduced costs.

The electronic equivalent of a business document is called a:

transaction

Which of the following can be used by providers to transmit claims in the proper format for carriers?

clearinghouse

Which of the following are organizations that work for covered entities but are not themselves covered entities?

business associates

When are covered entities required to give patients their Notice of Privacy Practices?

at the first contact or encounter

HIPAA Privacy Rule

Regulates the use and disclosure of patients' protected health information.

Which of the following require(s) CEs to establish safeguards to protect PHI?

HIPAA Security Rule

The minimum necessary standard means to:

take reasonable safeguards to protect PHI.

Encryption

The process of encoding information in such a way that only the person (or computer) with the key can decode it.

A __________ is an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI.

breach

NPI is the abbreviation for

National Provider Identifier.

Fraud

Deception with intent to benefit from the behavior.

Which of the following is an action that misuses money that the government has allocated?

abuse

Which of the following terms means using the expertise reasonably expected of a medical professional?

medical standards of care

When a provider injures a patient due to failure to follow medical standards of care, it is called

malpractice.

HIPAA identifies three types of covered entities:

* Health plans
* Clearinghouses
* Providers

When personal identifiers have been removed, protected health information is called

de-identified.

What is the most important strategy a medical practice can use to ensure regulations are being followed?

having a compliance plan in place

An important part of a compliance plan is a commitment to keep both physicians and medical office staff current by providing

ongoing training on coding and billing.

An established patient is defined as one who has seen the provider within the last

three years.

Ms. Lowell arrives for an appointment on February 8, 2017. She last visited the practice on May 14, 2016, and is scheduled to see the same physician. What should you, medical office receptionist, ask Ms. Lowell to do upon arrival? 

Review and update the information on file, in case there are changes.