CPB Chapter 9 - Fee schedules Flashcards
What is a fee schedule
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
payment schedule
what medicare or other payers approve as the reimbursement amount for the service provided.
two most common methods to calculate a fee schedule
cost-based fee schedule and based off RVU’s (CMS FS)
what was developed in 1992
standardized physician payment schedule utilizing RVU value scale - RBRVS
actions to reduce payment delay
verify insurance, submit clean claims, submit electronic claims, check status reports, submit documentation
Post contractural adjustments
the amount that the provider agrees to accept as a participating provider with the insurance carrier
what happens when the post contractural adjustment is not taken
it leaves a balance on the patients account and can possibly keep any deductibles and copays from being billed to a secondary insurance carrier
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
prior authorization
when is the best time to obtain prior authorization
when the service or surgery is being scheduled
information required for a prior authorization
patients name
DOB
insured’s ID number
CPT/HCPCS codes
ICD-10 codes
location of service
ordering MD
DOS
software program that reviews claims for key components and flags any detected errors before claims are sent to an insurance company
claim scrubber
A/R
accounts receivable = money owed to the practice for services rendered and billed
direct deposit for claim payment
payer sends the remittance advice (RA) to the provider and an explanation of benefits (EOB) to the patient.
benefits of electronic claim submission
-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
what are the average annual savings per physician from electronic claim submissions in place of paper
$23,000
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
electronic claims
very high-speed connection that uses the same wires as a telephone line during electronic claim submission
digital subscriber line - DSL
private computer network allowing controlled access to the payers system . limited access to payer and patients of theirs only
extranet
process of transferring data between providers and insurance payers
electronic data interchange
electronic data interchange specific flat file format
ANSI ASC X12
an entity that processes or facilitates the processing of claims for providers and healthcare plans
clearing house
clearinghouse actions
capability to convert nonstandard data received from payers to standard transaction data to meet HIPAA reqs
charge providers for the service with a start-up fee, a monthly service fee, and/or per-claim transaction fee based on the volume
clearinghouse
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