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Insurance for Medical Office

MARIA DE LAS NIEVES Inglés 220 fichas

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  1. 1What should be your priority as a billing specialist?An attitude directed at serving the patient's needs.
  2. 2What is the primary goal of a medical insurance billing specialist?Assist in the revenue cycle, both helping patient in obtaining maximum insurance plan benefits and ensuring a cash flow to the health care provider.
  3. 3What is revenue?Regular income
  4. 4What is cycle?the regularly repeating set of events that procues revenue.
  5. 5Two billing components exist:facility billing and professional billing
  6. 6What is facility billing?It is when the medical care is done for hospitals, acute care hospitals, skilled nursing or long term care facilities, rehabilitation centers or ambulatory surgical centers.
  7. 7What is professional billing?Is done for physicians or nonphysician practitioners (NPPs).
  8. 8What a non-physician practitioner (NNP) means?Is an individual who has not obtained medical degree but is allowed to see patients and prescribe medications.
  9. 9A synonym for Non-physician practitioner(NNP)physician extenders.
  10. 10Who can be a NNPAn NPP can be a physician assistant, nurse practitioner, advanced registered nurse practitioner, certified nurse anesthetist, physical therapist, speech therapist, licensed clinical social worker, a certified registered nurse practitioner.
  11. 11Payment schedules for payment of professional services are based onthe payer type( for example, managed care, workers' compensation, or Medicar)
  12. 12Under Medicare, physicians are paid according to relative value units, which are based onthree things: 1.-the cost (overhead) of delivering care; 2.-malpractice insurance, and (3) the physician's work.
  13. 13Several job title names are associated with medical billing personnel. The professional title used depend onregion within the USA.
  14. 14Some of the most popular titles include insurance billing specialist areelectronic claims processor, medical biller, reimbursement specialist, medical billing representative and senior billing representative
  15. 15Cost pressures on health care providers are forcing employers to be more efficient, and hiringmultiskilled health practitioners (MSHPs)
  16. 16What do claims assistance professionals (CAPs) do?work for the consumer. They help patients organizae file, and negotiate health insurance claims of all types;assist the consumer in obtaining maximum benefits; and tell the patient how much to pay to make sure ther is no overpayment.
  17. 17Administrative front office duties have gained in importance for the following reasonsDocumentation is vital to good patient care. It must be done comprehensively for proper reimbursement.
  18. 18Diagnostic and procedural coding must bereviewed for its correctness and completeness.
  19. 19Cash flow isthe amount of actual money available to the medical practive.
  20. 20An insurance billing specialist in a large medical practice may act asan isurance counselor and in a private area can discuss with patient the practice's financial policies and the patient's insurance coverage, as well as to negotiate a reasonable payment plan.
  21. 21The insurance billing specialist discussesclaims processing with contracted and noncontracted third party-payers, the billing of secondary insurance payers and patients once the third party payers pays its portion, self-pay billing, and time payment plans.
  22. 22Insurance billing speciaist knowledge, skills and abilities1.-certificate from one-year insurance billing course, associate degree or equivalente in work experience and continuing education
  23. 23insurance billing specialist knowledge, sikill and abilities2.-knowledge of basic medical terminology, anatomy and physiology, diseases, surgeries, medical especialities and insurance terminology
  24. 24Insurance Biling Specialist (IBS)knowledge, skills and abilities3.-ability to operate computer, printer, photocopy and calculator equipment
    4.-written and oral communication skills including grammar, punctuation, and style
  25. 25IBS knowledge skills and abilities5.-Ability and knowledge to use procudure code books and 6.-diagnostic code books
  26. 26IBS knowledge, skills and abilities7.- knowledge and skill of data entre. 8.- ability to work independently. 9.-certified procedural coder or coding specialist status prefferred.
  27. 27IBS responsabilities1.- abstracts health information from patients records. 2.- Exhibits and understanding of ethical and medicolegal responsabilities related to insurance billing programs
  28. 28IBS responsabilities3.-Operates computer to transmit insurance claims. 4.- Follows employer's policies and procedures. 5.-Transmits insurance claims accurately.
  29. 29IBS responsabilities6.- Enhances knowledge and skills to keep up to date. 7.- Employs interpersonal expertise to provide good working relationship with patients, employer, employees and third-party payers.
  30. 30The American Association of Medical Assistants (AAMA) developed a role delineation study in1997.
  31. 31What do the insurance billing or coding specialist accredited program offers as an additional educationinsurance claims completion, procedural and diagnostic coding, anatomy and physiology, compurter skills, ethics and medicolegal knowledge, and general office skills.
  32. 32For a job as a coder is necessarycompletation of an accredited program for coding certification or an accredited health information technology program.
  33. 33A codificador medical assistance insurance billingis anyone handling medical recods.
  34. 34AHIMAAmerican Health Information Management Association
  35. 35AHIMA has published diagnostic and procedure coding competencies foroutpatient services, and diagnostic coding and reporting requirements for physician billing.
  36. 36IBS can receive a salary depending onknowledge, experience, duties, responsibilities, locale and size of the employing institution.
  37. 37Self-Employment or Independent contracting demandsa full-time commitmet, a lot of hard work, long hours to obtain clients, and the need to advertise and market the business. This means you are responsible for everything: ads, billing, bookkeping and so on.
  38. 38Medical etiquette has to do withhow medical professionals conduct themselves.
  39. 39Customs, courtesy, and manners of the medical profession cam be expressed in 3 wordsconsideration for others.
  40. 40Principles of ethics for the insurance billing specialist:Never critizice physician with a patient or anyone else. Maintain dignity, never belittle patients.
  41. 41Principles of ethics for the insurance billing specialist:In certain circumstances, it may be unethical for two physicians to treat the same patient for the same condition.
  42. 42If you discover that a patient in your practice may have questionable issues of carealways notify your physician
  43. 43Never keep another physician who wants to talk about a medical case to your physician employer waiting longer than necessary in the reception roomUsher him/her into the physician's office as soon as it is unoccupied.
  44. 44Always connect another physician who is calling on the phone to your physician immediately asking a few questions as possible.The only exception is if you know the physician calling is treating one of your patients and you wish to verify the name to pull the cart or other data for your physician.
  45. 45Follow the basic rules of etiquette with co-workers while working in the office.acknowledging people who enter your office or como to your desk by saying, I'will be with you in a moment.
  46. 46Identify yourself to callers and people you callDo not use first name until you know it is appopiate to do so
  47. 47Maintain a professional demeanor and a certain amount of formality when interacting with other.Remember to be courteous, and always project professional image.
  48. 48Observe rules of etiquete when sending e-mail messages an placing or receiving cell phone calls.these rules fall under the Health Insurance Portability and Accountability Act (HIPAA).
  49. 49Medical ethicsare not laws but standards of conductgenerally accepted as moral guides for behavior.
  50. 50The earliest written code of ethical principles and conduct for the medical profession was originates inBabylonia about 2500 B.C.and is called the Code of Hammurabi.
  51. 51In 1980, the American Medical Association (AMA)adopted a modern code of ethics, called the Principles of Medical Ethics
  52. 52Violating guidelines by using code numbers or modifiers to increase payment when the case documentation does not warrant itillegal and unethical
  53. 53Coding services or procudures that were not performed for payment.illegal and unethical
  54. 54Unbundiling services provided into separate codes when one code is available and includes all the servicesillegan and unethical
  55. 55Failing to code a relevant condition or complication when it is documented in the health record, or viceversa, assigning a code without documentation from the provider.illegarl and unethical
  56. 56Coding a service in such a way that it is paid when usually it is not coveredillegal and unethical
  57. 57Coding another condition as the principal or primary diagnosis when most of the patient's treatment is for the preexisting condition.illegal and unethical.
  58. 58Physicians are legally responsible for their own conduct and any actions of their emplyees performed within the context fo their employment.Vicarious liability, also known as respondeat superior
  59. 59An insurance biller always should check with his or her physician-employer to determine whether he or she is included in the medical professional liability insurance policy otherwiseknown as malpractice insurance.
  60. 60Future goals for a insurance IBS1.-Know billing regulations for each insurance programan. 2.-know the aspects of compliance rules and regulatins.3.-State various insurance rules about treatmente and referral of patients.
  61. 61goals for an IBS4.-Become proficient in compuer skills and use of varios medical software packages. 5.-Learn electronica billing software and the variances of each payer. 6.- Develop diagnostic and procedural coding expertise.
  62. 62If IBS change the date of service for get into insurance policy to bill chargeFRAUDE
  63. 63Hay una exclusion para el derecho de privacidadLas heridas por pistola de balas
  64. 64Best practice when you call a patientUse care in the choice of words
  65. 65Who handles the code of ethics for IBS?AAMA
  66. 66AAMAAMERICAN ASSOCIATION OF MEDICAL ASSISTANCE
  67. 67ACAAMERICAN COLLECTORS ASSOCIATION
  68. 68AHIMAAMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION
  69. 69AMAAMERICAN MEDICAL ASSOCIATION
  70. 70ASHDARTERIOSCLEROTIC HEART DISEASE
  71. 71CAPCLAIMS ASSITANCE PROFESSIONALS
  72. 72GEDGENERAL EQUIVALENT DIPLOMA
  73. 73HIPAAHEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
  74. 74listservlist service
  75. 75MSHPMaterial Safety Data Sheet
  76. 76MSOManagement Service Organization
  77. 77NPPnon-physician practitioner
  78. 78ARRAAmerican Recovery and Reivestment Act
  79. 79CERTCompreensive Error Rate Testing
  80. 80CLIAClinical Laboratory Improvement Amedments
  81. 81CMPCivil Moneraty Penalty
  82. 82CMSCenters for Medicare and Medicaid Services
  83. 83DHHSDepartment of Health and Human Services
  84. 84DOJDepartment of Justice
  85. 85FBIFederal Bureau of Investigation
  86. 86FCAFalse Claime Act
  87. 87FDICFederal Deposit Insurance Corporation
  88. 88FTPfile transfer protocol
  89. 89HCFAPHealth Care Fraud and Abuse Control Program
  90. 90HEATHealth Enforcement Action Team
  91. 91HIPAAHealth Insurance Portability Accountability Act
  92. 92HITECHHealt Information Technology for Economics and Clinical Healt
  93. 93IIHIIndividual indentifiable health information
  94. 94MIPMedicare Integrity Program
  95. 95nppnotice of Privacy Practice
  96. 96OCROffice of Civil Rights
  97. 97OIGOffice of the Inspector General
  98. 98ORTOperation Restore Trust
  99. 99OSHAOcupational Safety and Health Administration
  100. 100P&PPolicies and Procedures
  101. 101PHIProtected Health Information
  102. 102POPrivacy Officer
  103. 103RACRecovery Audit Contractors
  104. 104SDPSelf-Disclosure Protocol
  105. 105TPOtreatment, payment or health care operations
  106. 106ZPICZone Program Integrity Contractor
  107. 107COMPLIANCE in the health care industryis the process of meeting regulations, recommendations, and expectations of federal and state agencies that pay for thealth care services and regulate the industry.
  108. 108Title of HIPAA (Health Insurance Portability and Accountability Act) focuses on the health care practice setting and aim to reduce administrative costs and burdensTitle II
  109. 109The HIPAA Title that provede continuous insurance coverage for workers and their insured dependents when they change or lose jobs.Title I
  110. 110What is a clearinghoue?Is an independent organization that receives insurance claims from the physician's office, performs software edits, and redistributes the claims electronically to various third-party payers.
  111. 111What a covered entity may be?1- a health care coverage carrier; 2- a health care clearinghouse through wich claims are submitted; 3- a health care provider, such as the primary care physician.
  112. 112Who is a business associate?Is a person who performs or assists in the performance of a function or activity involving the use of disclosure of individually identifiable health information.
  113. 113A health care provider isa person trained and licensed to provide care to a patient and also a place that is licensed to give health care such as a hospital
  114. 114Is designated to help the provider remain in compliance by setting policies and procudures (P&P) and by training and managing the staff regarding HIPAAPrivacy and Security Officer oversee the HIPAA
  115. 115OCR (Official of Civil Rights)enforces privacy and security rules
  116. 116Confidentialityis using discretion in keeping secret information.
  117. 117PHI (Protected health information)Is any information that indentifies and individual and describes his or her health status, age, sex, ethnicity or other demographic characteristics.
  118. 118Under the HIPAA (Health Information Portability and Accountability Act) what is authorizationAuthorization is an individual's formal, written permission to use or diclose his or her personally identifiable health info for purposes other than treatment, payment, or health care operations.
  119. 119Authorizatin form is necessary foruse and disclosure of PHI (Protected Health Information) that is not included in any existing consent form agreements.
  120. 120Confidentiality between the physician and patient is automatically waived in the following situations:1.-When a patient is memeber of managed care organization (MCO). 2.-If patient have certain communicable diseases that are highly contagious or infectious. 3.-When a medical device breaks or malfunctions.
  121. 121Confidentiality is waived in the following situations:4.- When a patient is suspect in a criminal investigation or to assist in locating a missing person. 5.- When patient's record are subpoenaed and the courts have the right to order to release info.
  122. 122Confidentially physician and patiente is waived in6. when there's a suspicious death or suspected crime victim. 7. when the physician examines a patiente at the request of a third party who is paying the bill, as in workers' compensation cases.
  123. 123Confidiantelly between physician patients waived if8.- When the law requires the release of information to police that is for the good of society, such as reporting cases of child abuse, elder abuse, domestic violence or gushot wounds.
  124. 124Confidential Communicatios isa privileged communication that mayt be disclosed only with the patient's permission.
  125. 125Everything you see, hear, or read about patients remainsconfidential and does not leave the office.
  126. 126Privileged information is related tothe treatment and progress fo the patient.
  127. 127Nonprivileged informationconsist of ordinary facts urelated to treatment of the patient, including the patient's name, city of residence and dates of adminssion or discarge.
  128. 128What do yo have to do if a relative telephones asking about a patient?Have the physician return the call.
  129. 129Unathorized release of information is calledbreach of confidential communication and is considered a HIPAA (health information portavility and accountability act) violation, which may lead to fines.
  130. 130Telephone conversations by provides in front of patientseven in emergency situations, should be avoided.
  131. 131The Security Rule comrises regulations related to thesecurity of electronic protected health information (ePHI) aong with regulations of electronic transactions and code sets, privacy, and enforcement.
  132. 132The Health Information Technology for Economic and Clinical Health Act (HITECH) was a provision ofthe American Recovery and Reinvestment Act (ARRA) pf 2009 signed into law by President Obama.
  133. 133HITECH brought significant compliance changes to three very especific areas1) business associates, 2)notification fo breach, and 3) civil penalties for noncompliance with the provisons of HIPAA
  134. 134HIPAA establishedthe privacy and security responsibilities of covered entities
  135. 135What AAMA (American Association of Medical Assitance) handle?They handle codes of ethics for and Insurance Billing Specialist and any medical assistance.
  136. 136Do's of ConfidentialityDo: 1)properly dispose of notes, papers and memos, 2)be careful when using the copying machine, 3)Use common sense and follow the guidelines to help you keep your professional cedibility and integrity.
  137. 137Don't of Confidentiaity:Don't 1)discuss a patient with acquaintances, yours or the patient's, 2)leave patients'records or appointment books exposed on your desk, 3)Leave a computer screen with patient information visible.
  138. 138The HITECH defines a breach as theunauthorized acquisition, access, use, or disclosure of PHI that compromises the security or privacy fo such information
  139. 139Claim submission is the responsibility foAdministrative Medical Office
  140. 140Medical Ethics includestandars of conduct
  141. 141Report incorrect information to third-partyis unethical
  142. 142If physician charge for innecesary visits isabuse
  143. 143Report false information isunethical
  144. 144The OCR (Office of Civil Rights), overseesprivacy issues and complaints, referring criminal issues to the OIG (Office of Inspector General).
  145. 145The OIG (Office of Inspector General) providesthe workup for referral cases, which may involve the FBI and other agencies.
  146. 146The mission of OIG (Office of Inspector General) isto safeguard the health and welfare of the beneficiaries do DHHS (Department of Health and Human Services) programs and protect the integrity of Medicare and Medicaid.
  147. 147The OIG (Office of Inspector General) was established toidentify and eliminate fraud, abuse, and waste and "to promote efficiency and economy in departmental operations"
  148. 148Billing for services or supplies not provided (phantom billing or invoice ghosting)FRAUD
  149. 149Bill for an office visit if a patient fails to keep an appointment and is not notified ahead of time that this is office policyFRAUD
  150. 150Alter fees on a claim for to obtain higher paymentFRAUD
  151. 151Forgive the deductible or copaymentFRAUD
  152. 152Alter medical records to generate fraudulent paymentsFRAUD
  153. 153Leave relevant information off a claim, as failing to reveal whether a spouse has health insurance coverage through an employerFRAUD
  154. 154Upcode. Submitte a code for a complex fracture when the patient had a simple fracture.FRAUD
  155. 155Shorte. Dispensing less medication than billed forFRAUD
  156. 156Split billing schemes. Billing procedures over a period of days when all treatment occurred during one visitFRAUD
  157. 157Use another person's insurance card in obtaining medical careFRAUD
  158. 158Change a date of ServiceFRAUD
  159. 159Post adjustments to generate fraudulent paymentsFRAUD
  160. 160Solicit, offer or receive a kickback, bribe or rebate in return for refering a patient to a physician or NPPFRAUD
  161. 161Referring a patient to obtain any item or service that may be paid for in full or in part by Medicare or MadicaidFRAUD
  162. 162Restate the diagnosis to obtain insurance benefits or better paymentFRAUD
  163. 163Apply deliberately for duplicate payment. Billing Medicare twice, billing Medicare and the beneficiary for the same service or billing Medicare and another insurer in an attmpt to get paid twiceFRAUD
  164. 164Unbundle or explode charge. Billing a multichannel laboratory test as if individual tests were performedFRAUD
  165. 165Collusion between a physician and an employee of a third-party payer when the claim is assignedFRAUD
  166. 166Physician deliberately overbilled for services, overpayments could be generated with little awareness on the part of the Medicare beneficiaryFRAUD
  167. 167Refer excessively to other providers for unnecessary servicesABUSE
  168. 168Charge excessively for services or suppliesABUSE
  169. 169Perform a baterry of diagnostic test when only a few are required for servicesABUSE
  170. 170Violate Medicare's physician participating agreementABUSE
  171. 171Call patients for repeatd and unnecessary follow-up visitsABUSE
  172. 172Bill Medicare beneficiaries at a higher rate than other patientsABUSE
  173. 173Submit bills to Medicare instead of to third-parthy payers, like claims for injury from an automobile accident, in store, or the workplace.ABUSE
  174. 174Breach assignment agreementABUSE
  175. 175Fail to make required refunds when services are not reasonable and necessaryABUSE
  176. 176Require patients to contract to pay their physician's full charges, in excess of the Medicare charge limitsABUSE
  177. 177Require a patient to waive rights to have the physician submit claims to Medicare and obligate a patient to pay privately for medicare-covered servicesABUSE
  178. 178Require a patients to pay for services not previously billed, including telephone calls with the physician, prescription refills, and medical conferences with other professionalsABUSE
  179. 179Require patients to sign a global waiver agreeing to pay privately for all services that Medicare will not cover, and using these waivers to obligate patients to pay separately for a service that Medicare covers a part of a package or related proceduresABUSE
  180. 180Published the Compliance Program for Individual and Small Group Physician Practices in September, 2000The Office of Inspector General (OIG)
  181. 181The Compliance Program for Individual and Small Group Physician Practices was provided asa means for health care organizations to effectively reduce the rist of legal action and create a good faith effort in combating fraud, waste and abuse.
  182. 182A well-designed compliance program can1)speed the claims processing cycle, 2)optimize proper payment or claims, 3) minimize billing mistakes, 4)reduce the likelihood of government audit, 5)avoid conflict with Stark laus and the Antikickbach statue,6)show a good faith effort that clims will be submitted appropriately and 7) relay to staff that there is a duty to report mistakes and suspected or known misconduct
  183. 183Is the key individual overseeing your organization's compliance program monitoring with the support of the Compliance CommitteAs with the HIPAA Privacy offer, here is the compliance officer
  184. 184"Open door" policies ensurean environment where staff members feel secure to ask about the organization's existing P&P and to report questionable activities.
  185. 185The insurance industry isamong the word's largest businesses
  186. 186Contractis a legar and binding written document that exists between two or more parties.
  187. 187The physician-patient contract begins whenthe physician accepts the patient and agrees to treat him or her.
  188. 188Implied contractis defined as not manifested by direct words but implied or deduced from the circumstance, the general language, or the conduct of the patient.
  189. 189An expressed contractcan be verbal or writte.
  190. 190For a patient who carries private medical insurance, the contract FOR TREATMENT isbetween the physician and the patient
  191. 191PPOpreferred provider organization
  192. 192The patients who belong to a PPO (preferred provider organization)the patient is not liable for the bill if thephysician does not follow his or her contract with the payer.
  193. 193Guarantoris an individual who promises to pay the medical bill by signing a form agreeing to pay or who accepts treatmente.
  194. 194An emancipated minor isperson younger than 18 years of age who lives independently, is totally self-supporting, is married or divorced is a parent even if not married, or is in the military and possesses decision-making rights.
  195. 195Workers' Compensation (WC) casesinvolved a person being injured on job. In these types of cases the contract exists between the physician and the insurance company.
  196. 196Major medical or extended benefits contracts aredesigned to offset large medical expenses caused by prolonged illness or serius injury.
  197. 197The insured is known as asubscriber or in some insurance programs a member, policyholder, or recipient. The subscriber may or may not be the guarantor.
  198. 198Eligibility verification meansto check and confirm that the patient is a member of the insurance plan and that the memeber identification number is correct.
  199. 199In private health insurance, there are five classifications:1)cancelable, 2)optionally renewable, 3)conditionally renewable, 4)guaranteed renewable, and 5) noncancelable
  200. 200Canceleable policygrants the insurer the right to cancel the policy at any time and for any reason.
  201. 201Optionally renewable policy,the insurer has the right to refuse to renew the policy on a date (premium due or anniversary date) specified in the contract
  202. 202Conditionally renewable policesgrant the insurer a limited right to refuse to renew a health insurance policy at the end of a primium payment period.
  203. 203Noncancelable policythe insurer cannot increase premium rates and must renew the policy until the insured reache the age specified in the contract.
  204. 204coinsurance or cost-sharing requirement meansthe insured will assume a percentage of the fee, or pay a especific dollar amount for covered services.
  205. 205copayment (copay)referring to the amount the patient pays at the point of arriving in the office and before he or she sees the physician.
  206. 206COBCoordinator of benefits
  207. 207A COB iswhen the patient has more than one insurance policy (dual coverage or duplication of coverage), this clause requires to determine which carries will be primary and which secondary
  208. 208Birthday lawThe health plan of the person whose birthday month and day, not year, falls earlier in the calendar year pays first, and the plan of the other person covering the dependent is the secondary payer.
  209. 209In the birthday law, if mother and father have the same birthday, who is the primaryWho has had coverage longer is the primary payer.
  210. 210In cases of divorce, consider that you are not an enforcer of court lawsparent who pay the bill must accompanying the child at the time of service.
  211. 211Health insurance policies contain exclusionsIf a person has an injury or illness that is excluded in his or her policy, then there is no insurance coverage for that injury or illness.
  212. 212Preexisting conditionsConditions that existed and were treated before tha policy was issued, these are called preexisting conditions.
  213. 213Precertification refersto discovering wheter a treatment (surgery, hospitalization, tests) is covered under a patient's contract.
  214. 214Preauthorization relatesnot only to whether a service or procudure is covered, buy also to finding out wheter it is medically necesarry.
  215. 215Predetermination meansdiscovering the maximum dollar amount that the carrier will pay for surgery, consulting services, radiology procudures, and so on
  216. 216Blanket contractComprehensive group coverage throughplans sponsored by the professional organiztions to which they belong.
  217. 217What is conversion privilegeWhen a person leaves the employer or organization or the group contract is terminated, and the insured may continue the same or lesser coverage under and individual policy.
  218. 218Usually conversion from a group adventagebecause no physical examination is required, therefore a preexisting condition cannot be excluded.
  219. 219Veterans' Health Administration (CHAMPVA) "Civilian Health and Medical Program of the Department of Veterans Affairs.This federal program shares the medical bills of spouses and children of veterans with total, permant, service-connected disabilities or of the surviving spouses and children of veterans who died as a result of service-contected disabilities.
  220. 220If the person has a condition that would make him or her ineligible for coverage is a case consideredat high risk

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Fichas sobre Insurance for Medical Office, creado por MARIA DE LAS NIEVES el 10/04/2015.
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