CPB Chapter 9 - Fee schedules

Question 1

What is a fee schedule

Answer 1

list of fees physicians established as the fair price for the services the provide. The service is reported with a HCPCS Level II or CPT code with associated fee

Question 2

payment schedule

Answer 2

what medicare or other payers approve as the reimbursement amount for the service provided.

Question 3

two most common methods to calculate a fee schedule

Answer 3

cost-based fee schedule and based off RVU’s (CMS FS)

Question 4

what was developed in 1992

Answer 4

standardized physician payment schedule utilizing RVU value scale - RBRVS

Question 5

actions to reduce payment delay

Answer 5

verify insurance, submit clean claims, submit electronic claims, check status reports, submit documentation

Question 6

Post contractural adjustments

Answer 6

the amount that the provider agrees to accept as a participating provider with the insurance carrier

Question 7

what happens when the post contractural adjustment is not taken

Answer 7

it leaves a balance on the patients account and can possibly keep any deductibles and copays from being billed to a secondary insurance carrier

Question 8

requirement imposed by the insurance payers to determine the medical necessity and benefit coverage eligibility before the patient receives a service or undergoes a procedure

Answer 8

prior authorization

Question 9

when is the best time to obtain prior authorization

Answer 9

when the service or surgery is being scheduled

Question 10

information required for a prior authorization

Answer 10

patients name
DOB
insured’s ID number
CPT/HCPCS codes
ICD-10 codes
location of service
ordering MD
DOS

Question 11

software program that reviews claims for key components and flags any detected errors before claims are sent to an insurance company

Answer 11

claim scrubber

Question 12

A/R

Answer 12

accounts receivable = money owed to the practice for services rendered and billed

Question 13

direct deposit for claim payment

Answer 13

payer sends the remittance advice (RA) to the provider and an explanation of benefits (EOB) to the patient.

Question 14

benefits of electronic claim submission

Answer 14

-minimize claim rejections and resubmissions
-deliver the claims to health insurers in real time
- expedite payer responses and boost the cash flow
- reduce cost of claim submission

Question 15

what are the average annual savings per physician from electronic claim submissions in place of paper

Answer 15

$23,000

Question 16

claims that can be submitted to a carrier from a providers office using a computer with software that meets electronic filing requirements as per HIPAA standards

Answer 16

electronic claims

Question 17

very high-speed connection that uses the same wires as a telephone line during electronic claim submission

Answer 17

digital subscriber line - DSL

Question 18

private computer network allowing controlled access to the payers system . limited access to payer and patients of theirs only

Answer 18

extranet

Question 19

process of transferring data between providers and insurance payers

Answer 19

electronic data interchange

Question 20

electronic data interchange specific flat file format

Answer 20

ANSI ASC X12

Question 21

an entity that processes or facilitates the processing of claims for providers and healthcare plans

Answer 21

clearing house

Question 22

clearinghouse actions

Answer 22

capability to convert nonstandard data received from payers to standard transaction data to meet HIPAA reqs

Question 23

charge providers for the service with a start-up fee, a monthly service fee, and/or per-claim transaction fee based on the volume

Answer 23

clearinghouse

Question 24

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