Insurance for Medical Office

Question	Answer
What should be your priority as a billing specialist?	An attitude directed at serving the patient's needs.
What 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.
What is revenue?	Regular income
What is cycle?	the regularly repeating set of events that procues revenue.
Two billing components exist:	facility billing and professional billing
What 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.
What is professional billing?	Is done for physicians or nonphysician practitioners (NPPs).
What a non-physician practitioner (NNP) means?	Is an individual who has not obtained medical degree but is allowed to see patients and prescribe medications.
A synonym for Non-physician practitioner(NNP)	physician extenders.
Who can be a NNP	An 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.
Payment schedules for payment of professional services are based on	the payer type( for example, managed care, workers' compensation, or Medicar)
Under Medicare, physicians are paid according to relative value units, which are based on	three things: 1.-the cost (overhead) of delivering care; 2.-malpractice insurance, and (3) the physician's work.
Several job title names are associated with medical billing personnel. The professional title used depend on	region within the USA.
Some of the most popular titles include insurance billing specialist are	electronic claims processor, medical biller, reimbursement specialist, medical billing representative and senior billing representative
Cost pressures on health care providers are forcing employers to be more efficient, and hiring	multiskilled health practitioners (MSHPs)
What 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.
Administrative front office duties have gained in importance for the following reasons	Documentation is vital to good patient care. It must be done comprehensively for proper reimbursement.
Diagnostic and procedural coding must be	reviewed for its correctness and completeness.
Cash flow is	the amount of actual money available to the medical practive.
An insurance billing specialist in a large medical practice may act as	an 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.
The insurance billing specialist discusses	claims 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.
Insurance billing speciaist knowledge, skills and abilities	1.-certificate from one-year insurance billing course, associate degree or equivalente in work experience and continuing education
insurance billing specialist knowledge, sikill and abilities	2.-knowledge of basic medical terminology, anatomy and physiology, diseases, surgeries, medical especialities and insurance terminology
Insurance Biling Specialist (IBS)knowledge, skills and abilities	3.-ability to operate computer, printer, photocopy and calculator equipment 4.-written and oral communication skills including grammar, punctuation, and style
IBS knowledge skills and abilities	5.-Ability and knowledge to use procudure code books and 6.-diagnostic code books
IBS knowledge, skills and abilities	7.- knowledge and skill of data entre. 8.- ability to work independently. 9.-certified procedural coder or coding specialist status prefferred.
IBS responsabilities	1.- abstracts health information from patients records. 2.- Exhibits and understanding of ethical and medicolegal responsabilities related to insurance billing programs
IBS responsabilities	3.-Operates computer to transmit insurance claims. 4.- Follows employer's policies and procedures. 5.-Transmits insurance claims accurately.
IBS responsabilities	6.- 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.
The American Association of Medical Assistants (AAMA) developed a role delineation study in	1997.
What do the insurance billing or coding specialist accredited program offers as an additional education	insurance claims completion, procedural and diagnostic coding, anatomy and physiology, compurter skills, ethics and medicolegal knowledge, and general office skills.
For a job as a coder is necessary	completation of an accredited program for coding certification or an accredited health information technology program.
A codificador medical assistance insurance billing	is anyone handling medical recods.
AHIMA	American Health Information Management Association
AHIMA has published diagnostic and procedure coding competencies for	outpatient services, and diagnostic coding and reporting requirements for physician billing.
IBS can receive a salary depending on	knowledge, experience, duties, responsibilities, locale and size of the employing institution.
Self-Employment or Independent contracting demands	a 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.
Medical etiquette has to do with	how medical professionals conduct themselves.
Customs, courtesy, and manners of the medical profession cam be expressed in 3 words	consideration for others.
Principles of ethics for the insurance billing specialist:	Never critizice physician with a patient or anyone else. Maintain dignity, never belittle patients.
Principles 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.
If you discover that a patient in your practice may have questionable issues of care	always notify your physician
Never keep another physician who wants to talk about a medical case to your physician employer waiting longer than necessary in the reception room	Usher him/her into the physician's office as soon as it is unoccupied.
Always 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.
Follow 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.
Identify yourself to callers and people you call	Do not use first name until you know it is appopiate to do so
Maintain a professional demeanor and a certain amount of formality when interacting with other.	Remember to be courteous, and always project professional image.
Observe 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).
Medical ethics	are not laws but standards of conductgenerally accepted as moral guides for behavior.
The earliest written code of ethical principles and conduct for the medical profession was originates in	Babylonia about 2500 B.C.and is called the Code of Hammurabi.
In 1980, the American Medical Association (AMA)	adopted a modern code of ethics, called the Principles of Medical Ethics
Violating guidelines by using code numbers or modifiers to increase payment when the case documentation does not warrant it	illegal and unethical
Coding services or procudures that were not performed for payment.	illegal and unethical
Unbundiling services provided into separate codes when one code is available and includes all the services	illegan and unethical
Failing 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
Coding a service in such a way that it is paid when usually it is not covered	illegal and unethical
Coding another condition as the principal or primary diagnosis when most of the patient's treatment is for the preexisting condition.	illegal and unethical.
Physicians 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
An 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 otherwise	known as malpractice insurance.
Future goals for a insurance IBS	1.-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.
goals for an IBS	4.-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.
If IBS change the date of service for get into insurance policy to bill charge	FRAUDE
Hay una exclusion para el derecho de privacidad	Las heridas por pistola de balas
Best practice when you call a patient	Use care in the choice of words
Who handles the code of ethics for IBS?	AAMA
AAMA	AMERICAN ASSOCIATION OF MEDICAL ASSISTANCE
ACA	AMERICAN COLLECTORS ASSOCIATION
AHIMA	AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION
AMA	AMERICAN MEDICAL ASSOCIATION
ASHD	ARTERIOSCLEROTIC HEART DISEASE
CAP	CLAIMS ASSITANCE PROFESSIONALS
GED	GENERAL EQUIVALENT DIPLOMA
HIPAA	HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
listserv	list service
MSHP	Material Safety Data Sheet
MSO	Management Service Organization
NPP	non-physician practitioner
ARRA	American Recovery and Reivestment Act
CERT	Compreensive Error Rate Testing
CLIA	Clinical Laboratory Improvement Amedments
CMP	Civil Moneraty Penalty
CMS	Centers for Medicare and Medicaid Services
DHHS	Department of Health and Human Services
DOJ	Department of Justice
FBI	Federal Bureau of Investigation
FCA	False Claime Act
FDIC	Federal Deposit Insurance Corporation
FTP	file transfer protocol
HCFAP	Health Care Fraud and Abuse Control Program
HEAT	Health Enforcement Action Team
HIPAA	Health Insurance Portability Accountability Act
HITECH	Healt Information Technology for Economics and Clinical Healt
IIHI	Individual indentifiable health information
MIP	Medicare Integrity Program
npp	notice of Privacy Practice
OCR	Office of Civil Rights
OIG	Office of the Inspector General
ORT	Operation Restore Trust
OSHA	Ocupational Safety and Health Administration
P&P	Policies and Procedures
PHI	Protected Health Information
PO	Privacy Officer
RAC	Recovery Audit Contractors
SDP	Self-Disclosure Protocol
TPO	treatment, payment or health care operations
ZPIC	Zone Program Integrity Contractor
COMPLIANCE in the health care industry	is the process of meeting regulations, recommendations, and expectations of federal and state agencies that pay for thealth care services and regulate the industry.
Title of HIPAA (Health Insurance Portability and Accountability Act) focuses on the health care practice setting and aim to reduce administrative costs and burdens	Title II
The HIPAA Title that provede continuous insurance coverage for workers and their insured dependents when they change or lose jobs.	Title I
What 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.
What 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.
Who 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.
A health care provider is	a 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
Is designated to help the provider remain in compliance by setting policies and procudures (P&P) and by training and managing the staff regarding HIPAA	Privacy and Security Officer oversee the HIPAA
OCR (Official of Civil Rights)	enforces privacy and security rules
Confidentiality	is using discretion in keeping secret information.
PHI (Protected health information)	Is any information that indentifies and individual and describes his or her health status, age, sex, ethnicity or other demographic characteristics.
Under the HIPAA (Health Information Portability and Accountability Act) what is authorization	Authorization 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.
Authorizatin form is necessary for	use and disclosure of PHI (Protected Health Information) that is not included in any existing consent form agreements.
Confidentiality 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.
Confidentiality 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.
Confidentially physician and patiente is waived in	6. 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.
Confidiantelly between physician patients waived if	8.- 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.
Confidential Communicatios is	a privileged communication that mayt be disclosed only with the patient's permission.
Everything you see, hear, or read about patients remains	confidential and does not leave the office.
Privileged information is related to	the treatment and progress fo the patient.
Nonprivileged information	consist of ordinary facts urelated to treatment of the patient, including the patient's name, city of residence and dates of adminssion or discarge.
What do yo have to do if a relative telephones asking about a patient?	Have the physician return the call.
Unathorized release of information is called	breach of confidential communication and is considered a HIPAA (health information portavility and accountability act) violation, which may lead to fines.
Telephone conversations by provides in front of patients	even in emergency situations, should be avoided.
The Security Rule comrises regulations related to the	security of electronic protected health information (ePHI) aong with regulations of electronic transactions and code sets, privacy, and enforcement.
The Health Information Technology for Economic and Clinical Health Act (HITECH) was a provision of	the American Recovery and Reinvestment Act (ARRA) pf 2009 signed into law by President Obama.
HITECH brought significant compliance changes to three very especific areas	1) business associates, 2)notification fo breach, and 3) civil penalties for noncompliance with the provisons of HIPAA
HIPAA established	the privacy and security responsibilities of covered entities
What AAMA (American Association of Medical Assitance) handle?	They handle codes of ethics for and Insurance Billing Specialist and any medical assistance.
Do's of Confidentiality	Do: 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.
Don'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.
The HITECH defines a breach as the	unauthorized acquisition, access, use, or disclosure of PHI that compromises the security or privacy fo such information
Claim submission is the responsibility fo	Administrative Medical Office
Medical Ethics include	standars of conduct
Report incorrect information to third-party	is unethical
If physician charge for innecesary visits is	abuse
Report false information is	unethical
The OCR (Office of Civil Rights), oversees	privacy issues and complaints, referring criminal issues to the OIG (Office of Inspector General).
The OIG (Office of Inspector General) provides	the workup for referral cases, which may involve the FBI and other agencies.
The mission of OIG (Office of Inspector General) is	to 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.
The OIG (Office of Inspector General) was established to	identify and eliminate fraud, abuse, and waste and "to promote efficiency and economy in departmental operations"
Billing for services or supplies not provided (phantom billing or invoice ghosting)	FRAUD
Bill for an office visit if a patient fails to keep an appointment and is not notified ahead of time that this is office policy	FRAUD
Alter fees on a claim for to obtain higher payment	FRAUD
Forgive the deductible or copayment	FRAUD
Alter medical records to generate fraudulent payments	FRAUD
Leave relevant information off a claim, as failing to reveal whether a spouse has health insurance coverage through an employer	FRAUD
Upcode. Submitte a code for a complex fracture when the patient had a simple fracture.	FRAUD
Shorte. Dispensing less medication than billed for	FRAUD
Split billing schemes. Billing procedures over a period of days when all treatment occurred during one visit	FRAUD
Use another person's insurance card in obtaining medical care	FRAUD
Change a date of Service	FRAUD
Post adjustments to generate fraudulent payments	FRAUD
Solicit, offer or receive a kickback, bribe or rebate in return for refering a patient to a physician or NPP	FRAUD
Referring a patient to obtain any item or service that may be paid for in full or in part by Medicare or Madicaid	FRAUD
Restate the diagnosis to obtain insurance benefits or better payment	FRAUD
Apply 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 twice	FRAUD
Unbundle or explode charge. Billing a multichannel laboratory test as if individual tests were performed	FRAUD
Collusion between a physician and an employee of a third-party payer when the claim is assigned	FRAUD
Physician deliberately overbilled for services, overpayments could be generated with little awareness on the part of the Medicare beneficiary	FRAUD
Refer excessively to other providers for unnecessary services	ABUSE
Charge excessively for services or supplies	ABUSE
Perform a baterry of diagnostic test when only a few are required for services	ABUSE
Violate Medicare's physician participating agreement	ABUSE
Call patients for repeatd and unnecessary follow-up visits	ABUSE
Bill Medicare beneficiaries at a higher rate than other patients	ABUSE
Submit bills to Medicare instead of to third-parthy payers, like claims for injury from an automobile accident, in store, or the workplace.	ABUSE
Breach assignment agreement	ABUSE
Fail to make required refunds when services are not reasonable and necessary	ABUSE
Require patients to contract to pay their physician's full charges, in excess of the Medicare charge limits	ABUSE
Require a patient to waive rights to have the physician submit claims to Medicare and obligate a patient to pay privately for medicare-covered services	ABUSE
Require a patients to pay for services not previously billed, including telephone calls with the physician, prescription refills, and medical conferences with other professionals	ABUSE
Require 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 procedures	ABUSE
Published the Compliance Program for Individual and Small Group Physician Practices in September, 2000	The Office of Inspector General (OIG)
The Compliance Program for Individual and Small Group Physician Practices was provided as	a 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.
A well-designed compliance program can	1)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
Is the key individual overseeing your organization's compliance program monitoring with the support of the Compliance Committe	As with the HIPAA Privacy offer, here is the compliance officer
"Open door" policies ensure	an environment where staff members feel secure to ask about the organization's existing P&P and to report questionable activities.
The insurance industry is	among the word's largest businesses
Contract	is a legar and binding written document that exists between two or more parties.
The physician-patient contract begins when	the physician accepts the patient and agrees to treat him or her.
Implied contract	is defined as not manifested by direct words but implied or deduced from the circumstance, the general language, or the conduct of the patient.
An expressed contract	can be verbal or writte.
For a patient who carries private medical insurance, the contract FOR TREATMENT is	between the physician and the patient
PPO	preferred provider organization
The 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.
Guarantor	is an individual who promises to pay the medical bill by signing a form agreeing to pay or who accepts treatmente.
An emancipated minor is	person 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.
Workers' Compensation (WC) cases	involved a person being injured on job. In these types of cases the contract exists between the physician and the insurance company.
Major medical or extended benefits contracts are	designed to offset large medical expenses caused by prolonged illness or serius injury.
The insured is known as a	subscriber or in some insurance programs a member, policyholder, or recipient. The subscriber may or may not be the guarantor.
Eligibility verification means	to check and confirm that the patient is a member of the insurance plan and that the memeber identification number is correct.
In private health insurance, there are five classifications:	1)cancelable, 2)optionally renewable, 3)conditionally renewable, 4)guaranteed renewable, and 5) noncancelable
Canceleable policy	grants the insurer the right to cancel the policy at any time and for any reason.
Optionally 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
Conditionally renewable polices	grant the insurer a limited right to refuse to renew a health insurance policy at the end of a primium payment period.
Noncancelable policy	the insurer cannot increase premium rates and must renew the policy until the insured reache the age specified in the contract.
coinsurance or cost-sharing requirement means	the insured will assume a percentage of the fee, or pay a especific dollar amount for covered services.
copayment (copay)	referring to the amount the patient pays at the point of arriving in the office and before he or she sees the physician.
COB	Coordinator of benefits
A COB is	when 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
Birthday law	The 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.
In the birthday law, if mother and father have the same birthday, who is the primary	Who has had coverage longer is the primary payer.
In cases of divorce, consider that you are not an enforcer of court laws	parent who pay the bill must accompanying the child at the time of service.
Health insurance policies contain exclusions	If 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.
Preexisting conditions	Conditions that existed and were treated before tha policy was issued, these are called preexisting conditions.
Precertification refers	to discovering wheter a treatment (surgery, hospitalization, tests) is covered under a patient's contract.
Preauthorization relates	not only to whether a service or procudure is covered, buy also to finding out wheter it is medically necesarry.
Predetermination means	discovering the maximum dollar amount that the carrier will pay for surgery, consulting services, radiology procudures, and so on
Blanket contract	Comprehensive group coverage throughplans sponsored by the professional organiztions to which they belong.
What is conversion privilege	When 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.
Usually conversion from a group adventage	because no physical examination is required, therefore a preexisting condition cannot be excluded.
Veterans' 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.
If the person has a condition that would make him or her ineligible for coverage is a case considered	at high risk

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	Created by MARIA DE LAS NIEVES about 9 years ago