B&C Chapter 1: Health Insurance Specialist Career

Question 1

AAPC

Answer 1

professional association, previously known as the American Academy of Professional Coders, established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to networks, and to increase and promote national recognition and awareness of professional coding.

Question 2

American Association of Medical Assistants (AAMA)

Answer 2

enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients, as well as protect medical assistants’ right to practice.

Question 3

American Health Information Management Association (AHIMA)

Answer 3

founded in 1928 to improve the quality of medical records, and currently advances the health information management (HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM and ICD-10-PCS in 2013.

Question 4

bonding insurance

Answer 4

an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer.

Question 5

business liability insurance

Answer 5

protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising.

Question 6

Centers for Medicare and Medicaid Services (CMS)

Answer 6

formerly known as the Health Care Financing Administration (HCFA); an administrative agency within the federal Department of Health and Human Services (DHHS).

Question 7

claims examiner

Answer 7

employed by third-party payers to review health-related claims to determine whether the charges are reasonable and medically necessary based on the patient’s diagnosis.

Question 8

coding

Answer 8

process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters (called codes) on the insurance claim.

Question 9

Current Procedural Terminology (CPT)

Answer 9

published by the American Medical Association; includes five-digit numeric codes and descriptors for procedures and services performed by providers (e.g., 99203 identifies a detailed office visit for a new patient).

Question 10

embezzle

Answer 10

the illegal transfer of money or property as a fraudulent action; to steal money from an employer.

Question 11

errors and omissions insurance

Answer 11

see professional liability insurance

Question 12

ethics

Answer 12

principle of right or good conduct; rules that govern the conduct of members of a profession.

Question 13

explanation of benefits (EOB)

Answer 13

report that details the results of processing a claim (e.g., payer reimburses provider $80 on a submitted charge of $100).

Question 14

HCPCS level II codes

Answer 14

national codes published by CMS, which include five-digit alphanumeric codes for procedures, services, and supplies not classified in CPT.

Question 15

health care provider

Answer 15

physician or other health care practitioner (e.g., physician’s assistant).

Question 16

health information technician

Answer 16

professionals who manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for health care services provided to patients.

Question 17

health insurance claim

Answer 17

documentation submitted to an insurance plan requesting reimbursement for health care services provided (e.g., CMS-1500 and UB-04 claims).

Question 18

health insurance specialist

Answer 18

person who reviews health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider; see also reimbursement specialist.

Question 19

Healthcare Common Procedure Coding System (HCPCS)

Answer 19

coding system that consists of CPT, national codes (level II), and local codes (level III); local codes were discontinued in 2003; previously known as HCFA Common Procedure Coding System.

Question 20

hold harmless clause

Answer 20

policy that the patient is not responsible for paying what the insurance plan denies.

Question 21

independent contractor

Answer 21

defined by the ‘Lectric Law Library’s Lexicon as “a person who performs services for another under an express or implied agreement and who is not subject to the other’s control, or right to control, of the manner and means or performing the services. The organization that hires and independent contractor is not liable for the acts or omissions of the independent contractor.”

Question 22

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

Answer 22

coding system to be implemented on October 1, 2015, and used to report diseases, injuries, and other reasons for inpatient and outpatient encounters.

Question 23

International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)

Answer 23

coding system to be implemented on October 1, 2015, and used to report procedures and services on inpatient claims.

Question 24

internship

Answer 24

nonpaid professional practice experience that benefits students and facilities that accept students for placement; students receive on-the-job experience prior to graduation, and the internship assists them in obtaining permanent employment.

Question 25

medical assistant

Answer 25

employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly

Question 26

medical malpractice insurance

Answer 26

a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment

Question 27

medical necessity

Answer 27

involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service.

Question 28

national codes

Answer 28

commonly referred to as HCPCS level II codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT (e.g., J-codes are used to assign drugs administered).

Question 29

professional liability insurance

Answer 29

provides protection from liability as a result of errors and omissions when performing their professional services; also called errors and omissions insurance.

Question 30

professionalism

Answer 30

conduct or qualities that characterize a professional person.

Question 31

property insurance

Answer 31

protects business contents (e.g., buildings and equipment) against fire, theft, and other risks.

Question 32

reimbursement specialist

Answer 32

see health insurance specialist

Question 33

remittance advice (remit)

Answer 33

electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/thru date), type of bill (TOB), charges, payment information, and reason and/or remark codes.

Question 34

respondeat superior

Answer 34

Latin for "let the master answer"; legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment.

Question 35

scope of practice

Answer 35

health care services, determined by the state, that an NP and PA can perform.

Question 36

workers' compensation insurance

Answer 36

insurance program, mandated by federal and state governments, that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders.