CCMA Quarter 1 Test

Administrative Assisting Medical Law and ethics Patient Care Coordination and Education Health Care Systems and Settings

Scheduling Types

Wave, Modified wave, and Double booking

Wave Scheduling

allows 3 patients to be scheduled at the same time and seen in the order they arrive

Modified Wave Scheduling

Allocates 2 patients to arrive at the same time and the 3rd 30 mins later

Double Booking Scheduling

2 patients are scheduled at the same time to see the same provider, Can be frustrating as patients must wait and first come first serve

Info needed to schedule a new (external) patient

Name, DOB, reason for visit, demographics, address, insurance, consent to treatment form, emergency contacts, SSN, place of employment, medical history, current medications

SOAP Acronym

Subjective impressions (pain), objective findings (vitals), assessment/medical diagnosis, plan for treatment

CHEDDAR Acronym

Chief complaint, (medical) history, examination, details, drugs/dosages, assessment, return visit info

Disadvantages of paper charts

can only be used one person at a time, easily lost, and cannot easily be shared with other providers

Advantages of EMR

decrease medical errors, time spent correcting diagnoses, procedure coding for medical billing, and time needed for insurance reimbursements; is a secure way of communicating with patients (referrals etc.)

Info needed to schedule a returning (internal) patient

patient name, DOB, and reason for visit

Managing EMRs

• Charts never leave the office

• Transcription should be done in a timely manner

• Locked away (password protected)

• Purge records: inactive/transferred/dead patients

• Papers w/ identifying info: (should be shredded by professional service, keep log for liability/HIPAA)

Filing Systems/processes

conditioning, releasing, indexing/coding, sorting, storing/filing

Conditioning

involves grouping related papers together, removing staples/clips, fixing damaged records

Releasing

marking the form to be filed with a mark of designated preference (ready to be filed, the providers initials, using a stamp)

Indexing/coding

determining where to place the original record in the file and whether it needs to be cross-referenced in another section using a chart number

sorting

ordering papers in a filing structure and placing the documents in specific groups

storing/filing

securing docs permanently in the file to ensure medical record docs are not misplaced

What are the filing methods

Alphanumeric, Numeric, and Subject

Methods used to document info on progress sheet

SOAP and CHEDDAR

Copay

a specified sum of $$ based on the patient’s insurance policy benefits due at the time of service

coinsurance

the $$ amount a policyholder is responsible for according to their insurance policy’s provisions (typically 80/20 split)

Deductibles

specific amounts of $$ a patient must pay out of pocket before the insurance carrier begins paying for services, usually on a calendar year accrual basis

Explanation of benefits (EOB)

provided to a patient by insurer as a statement detailing what services were paid, denied, or reduced in payment. includes info regarding amount applied to deductible, coinsurance, or allowed amounts.

Remittance advice (RA)

an explanation of benefits sent to provider from insurer. Contains multiple patients and providers, includes electronic fund transfer info or a check for payment. Statements are used to post payments to patient accounts

Advance Beneficiary Notice (ABN)

a form a Medicare patient will sign when the provider thinks Medicare may not cover a specific item/service

Types of Insurance classifications

Federal and Private

Federal Policies

includes Tricare (military ppl w/ dependents), Medicaid (funded by fed gov/managed via state), Medicare (federal program, 65+), and Workers’ Compensation (state law)

Private Policies

include group policies and individual policies

Premium

similar to a membership fee (monthly)

Group policies

offered through an individual’s employer who will usually pay a portion of the premium and deduct the remainder of the fee from the employee’s paycheck.

Individual policies

an individual funds themselves, patients may pay entire premium if self employed

Insurance Carrier

a company providing insurance plans, helps to protect patients against financial loss when needing health services, pays a portion of costs

Policy

states the terms of the insurance contract, under this patient receives benefits/reimbursements for specified services

beneficiaries

family members covered by the same insurance policy

Info needed to verify insurance coverage

full name, DOB, policy #, SSN

Out-of-pocket expenses

deductible, exclusions, coinsurance/copayments

Insurance Funding (Programs)

Private=enrollees (available to anyone), Public= Federal or state gov (person must meet certain criteria to enroll)

Fee-for-Service Program (Private)

patients pay out-of-pocket and wait for reimbursement from carrier, preventative care NOT covered, can receive care from any provider

Managed Care Program (Private)

carrier pays provider directly for services (including preventative), patients must choose from a specific network of providers, carrier may not cover expenses of external providers

Preventative Care

services provided to prevent future injury/illness, patients may be required to get a 2nd opinion or utilization review for possible procedures

Managed care

an approach to health insurance aimed at cutting costs, accomplished by contracting with a network of providers to offer discounted services. Focuses on preventative care and medical necessity of procedures

Models of Managed Care

HMO, PPO, and POS

HMO (health maintenance organizations)

a plan that contracts with medical center/group of providers to provide preventative/acute care for the insured. Require referrals to specialists, as well as precertification and preauthorization for hospital admissions, outpatient procedures, and treatments, membership based on premium, providers receive reimbursement by capitation

PPO (preferred provider organizations)

insured does not need a PCP, can go directly to specialist w/o referral, patients can see providers in/out of network (internal may cost less), reimburse on fee-for-service basis

POS (point of service)

insured’s PCP must pre-approve visits to specialists (external/internal), deductible/copayment not req for in-network services

How long does it take a regular referral to get approved by the insurance carrier?

3-10 working days

How long does it take an urgent referral to get approved by the insurance carrier?

up to 24 hrs

How long does it take an STAT referral to get approved by the insurance carrier?

immediately by phone

An authorization code is assigned when…

the carrier gives permission to perform a service/procedure

Referral must be authorized via

the insurance carrier

What is the high deductible plan?

the managed care plan is the same, except premiums are lowered in exchange for a high deductible plan. Include savings accounts that patients can put $ in to pay.

All insurance companies are required to…

cover preventive services at no cost (HMO, PPO, and POS plans included)

allowed amount

the maximum amount a third-party payer will pay for a specific service

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

when scheduling new patients assistants should request…

patients arrive 15-20 minutes early

Before providing treatment MA should….

check patient’s insurance eligibility (call # on card or via website)

All insurance/eligibility info must be documented on…

the verification of eligibility and benefits form

who’s responsible for understanding their policy

the patient

If there is more than 1 policy for a patient an MA must…

label one a primary, an other as secondary, and if there’s a third: tertiary

with children who are beneficiaries of both parents, MAs must use the…

birthday rule (the parents’ birthday first in the year will provide the primary policy)

CMS 1500 Form

a form submitted by the provider for reimbursement

Claim

a document sent to an insurance carrier demanding payment for services for the insured. Contains codes detailing provider diagnosis and services

CMS Blocks 1-8

patient/insurance info

• Name/DOB

• Address/phone #

• Insured info

• Insurance info

• Patient signatures

  • Release of info/assignment of benefits

CMS blocks 9-13

• Secondary insurance info, related to work accident, insurance policy #, employer

CMS blocks 14-33

• Info to be taken from healthcare record/encounter form

• Diagnosis codes, CPT 5 digit code, HCPCS

• Produce dates, codes, charges

• NPI info

NPI meaning

National provider identifier (id #)

List the Medical Coding Systems

ICD-10-CM, ICD-10-PCS, CPT codes and modifiers, HCPCS

ICD-10-CM

allows specific reporting of diseases, uses 3-7 characters, 1st: alphabetical, 2nd-3rd: numeric, 4th-6th: either

ICD-10-PCS

medical classifications for procedural codes, used in hospitals that record various health treatments/testing, communicated data on services helping to ensure correct filing of claims and gather statistical data

CPT codes/modifiers (current procedural terminology)

used to document procedures based on services by providers in outpatient settings, all info in medical record must be accurate for correct code to be documented

HCPCS (healthcare common procedure coding sys)

a group of codes that represent procedures, supplies, products, and services NOT covered in the CPT coding sys, are updated every year, designed to make uniform reporting (typically in medicare/medicaid)

modifiers

• Assigned to main code

• Shows one or more special circumstance applies to the service or procedure physician performed.

Category II (CPT)

Track healthcare performance measures

Category III (CPT)

Temporary codes for emerging technology (new services not listed)

Options once a claim has been sent to insurance…

pay, reject, deny, or pend the claim

Rejected claim

a claim requiring investigation and needs further clarification (i.e. wrong DOB, no SSN)

Denied Claim

usually based on a policy issue, (reasons: no covered service, wrong ICD-10 code, procedure and diagnosis don’t match, no coverage during month of service)

What happens to denied claims?

cannot be rebilled, must be filed, may be appealed, may bill patient if they didn’t have coverage

After completing claims forms MAs should….

proofread, take a break, re assess, have coworkers proofread

Encounter Form

a multipurpose form used by most medical practices where name/date of service/diagnosis/procedures are recorded, called a superbill, patient may use this form to bill insurance themselves

Criminal Law

Laws that pertain to crime and the punishments for committing a crime

Plaintiff

The individual who starts legal action by filing a lawsuit

Contract

A legal agreement between two or more parties

Litigation

A legal proceeding that determines the legal rights and remedies of a person or party

Slander

A false spoken statement that causes individuals to have bad opinions about someone

Respondeat Superior

A doctrine in tort law that makes an employer liable for a worker’s wrongs

Nonfeasance

Failure to perform a duty an individual has agreed to perform or is legally obligated to perform

Misdemeanor

A less serious offense than a felony, comes with more lenient punishment: usually a fine or short term imprisonment (less than 1 year)

Defendant

The person being sued for/accused of a crime in a court of law

Breach

The violation of a law, standard, obligation, or tie

Expert Witness

A witness in a court of law that is an expert in a particular field/subject

Libel

A false accusation (written) made to hurt/tarnish the reputation of another person, living or dead.

Felony

A crime more serious than misdemeanor, with harsher punishment, usually convictions result in jail-time greater than 1 year

Subpoena

A written court order that commands a person to be present in court to give evidence/testimony

Negligence

Failure to do something that any reasonable person would do under similar circumstances

Tort

An action that wrongly causes harm to another, but is not addressed in a civil suit

Res ipsa loquitur

A tort law doctrine that allows an inference that the defendant was negligent in an accident that injured the plaintiff, on the basis of circumstantial evidence if the type of accident does not usually occur without negligence

Common Law

Laws that developed from English court decisions and form the foundation of laws in the U.S.

Informed Consent

A clear and voluntary indication of choice, usually written down or orally expressed. Given in circumstances where the available options and consequences have been made clear.

Assault

The crime of threatening to bring physical harm to someone’s life