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3) Health Care Delivery 1 Set 2 > 6) Coding, Billing, and Payment > Flashcards

6) Coding, Billing, and Payment Flashcards

1
Q

Assignment of Benefits

A

Payment of medical benefits directly to the provider instead of the member/subscriber

  • Requires written release
  • Provider needs to sign off on this if they’re going to bill insurance
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2
Q

Authorization

A

Gatekeeper/PCP approval for medical care or hospitalization

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3
Q

Balance Billing

A

Administrative practice of holding the pt financially responsible for the remained of medical service charges, beyond the insurer’s allowed amount

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4
Q

Does balance billing apply when a managed care contract contains a “hold harmless” clause

A

No

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5
Q

Cost Sharing

A

Methodology to decr utilization where the pt is responsible for a portion/percentage of the total charge

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6
Q

Denial

A

Refusal by insurer to reimburse for services that have already been done

  • Insurance company has to provide a rationale for a denial
  • Obviously bad for the provider bc then they don’t get paid
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7
Q

Explanation of Benefits (EOB)

A

Insurer-provided description of provided services with an explanation of those covered and those that were denied

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8
Q

Policyholder

A

Purchaser of an insurance policy

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9
Q

Pre-Authorization

A

Insurance company reviews the care that will be provided to establish appropriateness of payment/decide if they’re going to pay for it

  • Seeing a pt prior to getting the pre-authorization is a risk for the provider
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10
Q

Pre-Existing Condition

A

Condition that occurs prior to the start of insurance coverage

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11
Q

Profiling

A

Insurance company collects data on provider’s utilization and billing

  • Compares your trends to other providers
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12
Q

What are the basic things that providers need to get paid for services?

A
  • Professional License
  • Business Structure
  • Services Available
  • Business Policies
  • Price List
  • Charge System
  • Billing Processes
  • Reimbursement Contracts
  • Accounting Procedures
  • Collection Procedures
  • Documentation System
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13
Q

When interacting with insurance companies, how should office staff act?

A
  • Courteous
  • Competent
  • Reliable
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14
Q

What three authorizations/consents are needed to tx a pt?

A
  • Informed consent
  • HIPPA
  • Assignment of Benefits
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15
Q

What is the one and only format informed consent can be in?

A

Written

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16
Q

If there’s no assignment of benefits, what is the alternative?

A

Pt pays for services and submits to their insurance for reimbursement

17
Q

What does “clean claims” apply to and why is it important?

A
  • Billing
  • Important bc we need to make sure our documentation is clear→ If they’re not, it can hold up the process and you need $ to keep your practice runnning
18
Q

Are providers allowed to look at other provider’s costs to help them decide what they want to charge and why?

A

No → It’s anti-trust

19
Q

On a claim submission, what needs to be verified?

A
  • Pt info
  • Person responsible for bill
  • Insurance info
  • Coordination of Benefits
20
Q

Coordination of Benefits

A

Generic term for situations where the pt may have coverages under >1 insurance plan

21
Q

True or False: Providers are obligated from collecting copayments from pt’s. Explain.

A

True → If they don’t its fraudulent because then the pt isn’t contributing and then it says to the insurance company that the services can be provided for less

22
Q

Medicare Advanced Beneficiary Notice (ABN)

A

Signed by Medicare pt’s when a service is not going to be covered or not medically necessary

23
Q

National Provider Identifier (NPI)

A

10-digit ID code that can be used to track a provider t/o their career

  • Purpose is to further streamline electronic claims processes already in place
  • Must be put on claim forms when submitted to insurance
24
Q

Describe how the out-of-network model works

A
  • Provider has limited insurance contracts
  • Provider collects payment directly from pt’s at the time of service and gives them an itemized bill which they can submit to their insurance
    • Provider can also submit to their insurance on their behalf
25
Q

Describe the cash practice model

A
  • Provider has no insurance contracts
    • PT’s are not allowed to opt out of Medicare!
  • Pt’s pay in full at time of service OR insurance is billed directly and the pt has to pay the difference
  • Typically comes w/higher pt cost-sharing
26
Q

Diagnosis Billing Codes

A

When billing for services provided by a PT, the medical dx needs to be stated (ICD-10)

27
Q

Intervention Billing Codes

A

CPT-4 Codes

28
Q

What is the purpose of CPT codes?

A

Simplified communication

29
Q

Who “owns”CPT codes?

A

AMA

30
Q

Why did the APTA start billing based on pt-complexity?

A

So PT’s would be paid more for tx’ing complex pt’s

31
Q

How long is each unit of billing?

A

15 minutes

32
Q

What is the deal with billing for supervised modalities?

A

They don’t require direct one-on-one supervision so they can only be billed once per visit

33
Q

What’s the deal with billing for “constant attendance modalities”?

A

Require that a provider have direct one-on-one contact w/the pt (can’t walk away from pt) for all minutes represented by billing

34
Q

CMS 8-Minute Rule

A

Anything done for <8minutes isn’t billable

  • The 1st unit is anywhere from 8-23minutes and incr in 15min increments
    • 8/23/38/53/68/83
  • If you’re doing 3 codes for 30min, bill for the code w/the highest time
35
Q

Group Therapy Code

A

Used when care is provided to >1 pt at the same time

36
Q

How many units will medicare pay for?

A

4 15-minute units in 1hr

37
Q

Modifiers

A

Incr specificity of CPT codes

38
Q

Corrective Coding Initiative

A

Corrects coding methodologies to eliminate improper unbundling of services for Medicare Part B claims

39
Q

Code Pair Edit

A

Combo of 2 CPT codes that can’t be billed together

  • Happens when:
    • Code pair is for services that are mutually exclusive
    • 1 code of the pair is considered a component of another more comprehensive code
  • Reimbursement will occur for only 1 code and the prohibited code will be reported the provider

3) Health Care Delivery 1 Set 2 (4 decks)

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