Health Information Technology: Claim Processing and Reimbursement

HIT Classification and Reimbursement Question A payer’s initial processing of a claim screens for Some automated edits are for A claim may be downcoded because Payers should comply with the required What is the next step after the primary payer’s RA has been posted when a patient has additional insurance coverage? Appeals must always be filed Determine what should be verified after an RA has been checked for the patient’s name, account number, insurance number, and date of service. If a patient has secondary insurance under a spouse’s plan, what information is needed before transmitting a claim to the secondary plan? What type of codes explain Medicare payment decisions? Which of the following appears only on secondary claims? A payer may __________ a procedure that it determines was not medically necessary at the level reported. What is the correct order for the basic steps of a payer's adjudication process? During the adjudication process, if there are problems during the automated review, the claim is pulled for The __________ verifies the medical necessity of providers' reported procedures. When a claim is pulled by a payer for a manual review, the provider may be asked to submit A payer's initial claim review may reject a claim due to A payer's automated claim edits may result in claim denial because of Answer basic errors in claim data or missing information. patient eligibility, duplicate claims, and noncovered services. the documentation does not justify the level of service. claim turnaround time. billing the second payer within a specified time. that all billed CPT codes are listed RA data MOA primary payer payment downcode initial processing, automated review, manual review, determination, and payment development. claims examiner clinical documentation. an invalid policy number. any of these. lack of required preauthorization. lack of medical necessity. lack of eligibility for a reported service. Medical situations in which a patient receives extensive care from two or more providers on the same date of service are concurrent care. called to a patient on the same date at the same place of Concurrent care is care provided service by two or more physicians. A payer's decision regarding whether to pay, deny, or determination. partially pay a claim is called What is done by a payer to determine the appropriateness utilization review of medical services? What will a payer do when a claim is submitted with a Payers may deny a claim when outdated codes are diagnosis code that is not valid for the date of service? used. The payer's processing of claims is called adjudication. A payer's determination means it is going to pay, deny, or partially pay the claim. Which of these HIPAA transactions is sent by a payer to 277 answer a question about a submitted claim? the date of claim transmission and receipt of The claim turnaround time is the period between payment. An __________ code indicates that a request for more R information has been sent. A(n) __________ claim status category code is an acknowledgment that the claim has been received. A An insurance aging report lists unpaid claims transmitted to payers by the length of time they remain due. A list of claims transmitted and how long they have been in process with the payer is shown in the Prompt-pay laws govern On an aging report, which category describes a current invoice? A typical aging report groups payments that are due into which of these categories? A pending claim is indicated by which claim status category code? The payer's RA shows Claim adjustment reason codes are used by payers to explain entries on What kind of code appears on payers' electronic reports on the progress of transmitted claims in their adjudication process? The payer sends the medical practice A paper explanation of benefits (EOB) is sent to patients by payers after claims Remittance advice remark codes are maintained by __________ but can be used by all payers. RAs generally have information on any The first step the medical billing specialist should check when reviewing RAs is to The advantage(s) of EFT for practices is(are) insurance aging report. insurance carriers' payments of providers' claims. 0–30 days 0–30 days, 31–60 days, 61–90 days, 91–120 days, and over 121 days P both the amount the provider is allowed and the amount patient pays. RAs. claim status category codes an RA that covers a batch of processed claims. are adjudicated. CMS all of these are correct. errors on the listed claims. denials to the listed claims adjustments to the listed claims. match up claims with the RA using the unique claim control number. funds are available immediately and the transfer is less costly than check deposits. The process of __________ means verifying that the totals on the RA are mathematically correct. reconciliation What does "reconciliation" mean? to double-check that totals are accurate and consistent Funds that are electronically transferred from a payer are directly deposited in the The person filing an appeal is known as a(n) __________, regardless of whether that individual is a provider or a patient. The claimant is the The abbreviation MRN stands for In general, how many levels are there when pursuing an appeal? practice's bank account. When is an appeal sent to third-party payers? after a claim is rejected or paid at less than the expected amount must be returned within 60 days. Medicare overpayments must be reported and the amount Filing a grievance with the state insurance commission requires the __________ to investigate the complaint. If a patient has additional insurance coverage, after the primary payer's RA has been posted, the next step is Which of the following statements is true? If a Medicare beneficiary receives treatment covered by workers' compensation, the Medicare plan is If a Medicare beneficiary is employed and covered by the employer's group health plan, the Medicare plan is The abbreviation MSP stands for If a Medicare beneficiary is covered by a spouse's employer group health plan, the Medicare plan is either the claimant or the appellant patient or provider who appeals the claim. Medicare Redetermination Notice. three state billing the second payer. Medicaid is the secondary payer to Medicare. secondary. secondary. Medicare Secondary Payer. secondary The Medicare Secondary Payer program coordinates the benefits for patients who have both Medicare and When talking with someone other than the patient about an overdue bill, collections specialists will The day sheet produced by the practice management program shows During collections, most practices use Credit bureaus keep records about a patient’s Collection calls are regulated by the guidelines set by Accounts might be considered uncollectible when a patient Skip tracing increases the practice’s chances of The practice will need to pay patient refunds if it has The patient aging report is used to Bad debt is defined as Effective patient billing begins with A good financial policy is clear to When a practice accepts a credit card payment in advance for payments billed after treatment, what does the practice send the patient? A patient statement is any other insurance coverage. not discuss the patient’s debt. the payments and charges that occurred on that date. letters and calls. credit information. FDCPA. files for bankruptcy. locating a patient with an overdue bill. overcharged the patient for a service. collect overdue accounts from patients. uncollectible A/R. sound financial policies. both patients and the practice staff. zero-balance statement a bill that is sent to a patient for medical services that have been provided. Which of the following shows a particular day's day sheet transactions? What document is used by the medical insurance specialist to update the patient billing program with the payer's RA payments and the amount due from the patient? The __________ totals the transactions that were posted to all day sheet patient ledgers on a particular business day. all the transactions that were posted to all patient The day sheet in a medical office summarizes ledgers on a particular business day. What is a printed bill that shows the amount a patient owes? patient statement all of these the balance that a patient owes the The patient statement shows practice. the services provided to the patient. how much the insurance paid. The type of patient billing that spreads out the workload of cycle billing. mailing statements is called In cycle billing, how often does the practice mail all patient at intervals during the month statements? Patients are grouped under the insurance policyholder in guarantor billing what type of billing? Under the Federal Trade Commission's rules, it is illegal to call multiple times daily. For most patients, their first notice that their bill is past due collection letter. is a The law that regulates calling hours and collections methods Telephone Consumer Protection Act. is The __________ report is the start of the process of collecting patient aging payments due from patients. The law that regulates collection practices is FDCPA. Who is responsible for regulating the hours during which both the FDCPA and the Telephone Consumer collection calls may be made? Protection Act Collections from patients are classified as consumer federal collections and are regulated by __________ and state laws. Under the Federal Trade Commission's rules, it is not illegal call a patient at 8 p.m. to FDCPA is the abbreviation for Fair Debt Collection Practices Act. The job of creating and implementing the practice's the billing/collections manager. collections policies is done by Embezzlement is a form of stealing. What term refers to the stealing of funds? What term refers to all the activities that are related to patient accounts and follow-up? The process of following up on overdue accounts is called The job of accurately recording the funds coming into and going out of the practice is done by Which of the following employees learns and applies the correct techniques for effective follow-up of overdue accounts, as well as is most likely to work directly with patients? Patients may agree to a(n)__________ for expensive procedures before the date of service. Which of the following is the cost of a borrower's credit calculated as an annual rate? When patients are scheduled to have major, expensive procedures, the practice's policy may be to set up The __________ process is used to locate a patient who owes an account balance to the practice. Which law modified the Fair Credit Reporting Act to protect the accuracy and privacy of credit reports? A collection agency is usually FACTA is the acronym for FCRA is the abbreviation for Credit bureaus supply information about Collection agencies are outside services that are hired to Which law required consumer reporting agencies to have reasonable and fair procedures? The __________ helps a practice decide whether patients are indigent. __________ is a legal declaration of a person's inability to pay his or her debts. Which of the following requires a practice to follow a specific series of steps before an account can be written off? Uncollectible accounts refer to When a person receives a legal declaration of the inability to pay debts, it is called What is the term for monies owed to a patient from the provider? Bad debt includes all collections that are HIPAA compliance records must be retained for how many years? A __________ is a log of how long various types of documents must be stored for a particular practice. The practice's policy about keeping records is summarized in a __________, a list of the items from a record that are retained and for how long. When the hospital staff collects data on a patient who is being admitted for services, the process is called Which of the following hospital departments has different procedures for collecting patients’ personal and insurance information? Patient charges in hospitals vary according to Which of these rules governs the reporting of hospital inpatient services on insurance claims? Conditions that arise during the patient’s hospital stay as a result of surgery or treatments are called In inpatient coding, the initials CC mean The code 02103D4 is an example of which type of code? embezzlement collections collections. the bookkeeper. collections specialist prepayment plan annual percentage rate prepayment plans. skip tracing FACTA an outside firm the medical practice hires. Fair and Accurate Credit Transaction Act. Fair Credit Reporting Act. how well patients pay their bills. collect overdue accounts. FCRA means test Bankruptcy both Medicaid and Medicare monies owed by patients and payers. bankruptcy. patient refund classified as uncollectible accounts. six retention schedule retention schedule registration emergency department their accommodations and services. UHDDS complications. comorbidities and complications. ICD-10-PCS Under a prospective payment system, payments for services set in advance. are The UB-04 form locator 4 requires the type of bill. Under Medicare rules for patients in car accidents, the primary automobile insurance is situation in which delaying the treatment of a In medical insurance terminology, an emergency is a patient would result in a significant increase in the threat to life or to the viability of the body part. Ambulatory care refers to which kind of care? outpatient What is a special approach to caring for people with terminal hospice care illnesses? ASU is the abbreviation for ambulatory surgical unit. __________ involves a situation that is life-threatening. Emergency care What involves a situation in which a delay in treatment would lead to a significant increase in the threat to a emergency care patient's life or body part? __________ is palliative care for terminally ill patients. Hospice care What type of facility is equipped for patients to stay inpatient overnight? A(n) __________ is a person admitted for services that require inpatient a stay spanning two midnights. either in a special hospice facility or a patient's Hospice care is provided home. ASC is the abbreviation for ambulatory surgical center. HHA is the abbreviation for home health agency. What category of services includes care given at home, such home health care as physical therapy or skilled nursing care? SNF is the abbreviation for skilled nursing facility. What type of care covers all types of health services that do ambulatory care not require an overnight hospital stay? An ambulatory surgical center is a clinic that provides outpatient surgery. At-home recovery care refers to assistance with which of the activities of daily living, such as bathing and the following? eating Ambulatory care is provided in a(n) outpatient facility or setting. The__________ is the main database of a hospital's patients. master patient index Inpatients are admitted to hospitals in a process called registration. A charge master contains a hospital's list of all of the staff. following except patient's personal and insurance information is gathered before or during hospital admission through which process? registration process Patients are listed in a patient register under a unique master patient index. number, which makes up the A __________is the hospital's list of the codes and charges for charge master its services HIM is the abbreviation for health information management. The HIM department in hospitals conducts which of the organizes and maintains patient medical records following The major steps related to hospital claims processing are admission, treatment, and discharge. Which term is generally used for the hospital admission registration process? HINN is the abbreviation for Hospital-Issued Notice of Noncoverage. CC is the abbreviation used by the inpatient coder on the complications and comorbidities medical record for _________. A patient's other conditions at admission that affect care during the hospitalization being coded are called __________, comorbidities meaning coexisting conditions. Which term describes the patient's condition that, after study, is established as the main reason for a hospital principal diagnosis admission? Which of these terms refers to coexisting conditions? UHDDS is the classification system for Which term describes the patient's condition upon hospital admission? Which term describes the main service performed for the condition listed as the principal diagnosis for a hospital inpatient? The principal procedure is assigned by the MS-DRG is the abbreviation for APC is a __________ payment system. __________are complications caused by avoidable conditions that will not be reimbursed. Each MDC is subdivided into __________ MS-DRGs. APC is the abbreviation for DRG is the abbreviation for The DRG system is now called which of the following The IPPS is the Medicare system for payments to institutions for Each hospital's __________ is an average of the DRG weights handled for a specific period of time. Each hospital negotiates a rate for MS-DRGs based on which of the following? A grouper is software used to help calculate and assign The UB-04 form is also identified as the __________ form. Hospitals must submit electronic claims for Medicare Part A reimbursement to MACs using the HIPAA health care claim called comorbidities inpatient health data. admitting diagnosis principal procedure inpatient medical coder. Medicare-Severity Diagnosis Related Group. Medicare Never events medical and surgical ambulatory payment classifications. diagnosis related group. MS-DRGs inpatients. case mix index all of these are factors in the rate supply costs geographic location labor DRGs. CMS-1450 837I.