Encounter, Billing, and Revenue Cycle

Question 1

Capitation

Answer 1

Payment method of an HMO in which a contractually fixed payment paid by the payer covers the provider’s services to a plan member for a specified period

Question 2

What are the two types of insurance plans?

Answer 2

Indemnity Plan and Managed Care Plans

Question 3

Indemnity Plan

Answer 3

Type of medical insurance that provides the freedom to choose the providers and hospitals you want to attend and reimburses a policyholder for medical services under the terms of its schedule of benefits; may require you to pay upfront and then submit a claim for reimbursement

Question 4

Managed Care Plan

Answer 4

a plan that has contracts with various healthcare providers and medical facilities and members must see one of these in-network providers to avoid higher fees; premiums and deductibles are lower

Question 5

Types of Managed Care Plans

Answer 5

Health maintenance organizations (HMOs)
Point-of-service plans
Preferred Provider organizations (PPOs)
Consumer-driven health plans

Question 6

Health Maintenance Organizations (HMO plans)

Answer 6

an MCO that agrees to offer healthcare to members for fixed periodic payments from the plan to the provider; members must have a PCP and receive referrals for specialists; regulated by the state to provide certain services to members and dependants, such as preventative care

Question 7

Point-of-Service (POS) plan, or Open HMO

Answer 7

Payment method of an HMO which reduces restrictions and allows members to choose providers who are out of network; Typically, the patient must pay 20 to 30% of the charge for out-of-network service, and the deductible can be very high. The HMO pays out-of-network providers on a fee-for-service basis.

Question 8

Preferred Provider Organizations (PPO)

Answer 8

an MCO that is structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge

Question 9

Consumer-driven Health Plan (CDHP)

Answer 9

an MCO that combines a high deductible with low premiums and a medical savings plan that covers some out-of-pocket expenses; the idea that patients who themselves pay for healthcare services become more careful consumers and believe that asking patients to pay a larger portion of medical expenses reduces costs

Question 10

Private Payers

Answer 10

A small number of large insurance companies dominate the national market and offer all types of health plans. There are also several nonprofit organizations

Question 11

Emergency Medical Treatment and Active Labor Act (EMTALA)

Answer 11

hospital emergency departments must provide care for all patients in need of medical services, regardless of their ability to pay

Question 12

Self-funded Health Plans

Answer 12

Rather than paying premiums to an insurance carrier, the organization “insures self”. It assumes the risk of paying directly for medical services and sets up a fund from which it pays for claims. Most are set up as PPOs; fewer than 10% are set up as HMOs.

Question 13

Government-Sponsored Healthcare Plans

Answer 13

Medicare - covers people who are 65 and over and those who, regardless of age, are disabled or have permanent kidney failure

Medicaid - jointly funded by federal and state governments and covers low-income people who cannot afford medical care

TRICARE - covers active duty members of the Uniformed Services and their spouses children and other dependents, retired military personnel and their dependents, and family members of deceased active duty personnel.

CHAMPVA - covers the spouses and dependents of veterans with permanent service-related disabilities, and spouses and dependent children of veterans who died from service-related disabilities

Question 14

10 Steps of the Revenue Cycle

Answer 14

Before the Encounter
1. Preregister patients

During the Encounter
2. Establish financial responsibility
3. Check in patients
4. Review coding compliance
5. Review billing compliance
6. Check out patients

After the Encounter
7. Prepare and transmit claims
8. Monitor payer adjudication
9. Generate patient statements
10. Follow-up payments and collections

Question 15

HIPAA 270

Answer 15

transaction to determine if a patient or service is covered by their health insurance plan; can also be used to inquire about Medicare eligibility

Question 16

Advanced Beneficiary Notice (ABN)

Answer 16

forms the patient must sign to prove that patients have been told about their obligation to pay the bill before uncovered services are given

Question 17

Preauthorization

Answer 17

process to determine coverage for medical services; focuses on the medical necessity of a service or treatment

Question 18

Precertification

Answer 18

process to confirm coverage for certain healthcare services or procedures before they are performed

Question 19

X12 278

Answer 19

HIPAA Referral Certification and Authorization; a referral document that describes the services the patient is certified to receive (referral)

Question 20

Referral Waiver

Answer 20

Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending (eg, patient for got to bring in the referral)

Question 21

Coordination of benefits (COB)

Answer 21

A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim

Question 22

Birthday Rule

Answer 22

The guideline that determines which of two parents with medical coverage has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary

Question 23

Gender Rule

Answer 23

Coordination of benefits rule for a child insured under both parents’ plans under which the father’s insurance is primary (less common, but some states have regulations that require a plan that uses this rule)

Question 24

COB Guidelines for a child of divorced parents

Answer 24

Joint custody - Birthday Rule applies

Sole custody (unless otherwise directed by a court order) 1) The plan of the custodial parent; 2) The plan of the spouse of the custodial parent, if the parent is remarried; 3) The plan of the parent without custody

Question 25

Encounter Form

Answer 25

Lists the medical practices most frequently performed procedures with their procedure codes which must be updated as new codes are released; superbill, charge slip, routing slip

Question 26

Acceptance of assignment

Answer 26

A participating physician’s agreement to accept the insurance plan’s allowed charge as payment in full

Question 27

Claims form even non-PAR providers must still submit as a courtesy

Answer 27

Even these providers file Medicare forms as a courtesy

Question 28

Collections made at the time of service

Answer 28

Previous balances
Co-payments
Coinsurance
Non-covered or over-limit fees
Charges of non-participating providers
Charges for self-pay patients
Deductibles for patients with CDHPs

Question 29

Real-Time Adjudication

Answer 29

An insurance claim processed at patient check-out; allows the practice to know what the patient will owe for the visit

1) Informs the practice if there are any errors in the claim so they can be fixed and the claim immediately resent for adjudication
2) States whether the patient has met the plan’s deductible
3) Provides the patient’s financial responsibility
4) Supplies an explanation of benefits

Question 30

CCOF

Answer 30

Credit Card on File

Question 31

Upcoding

Answer 31

The code does not reflect the actual procedure provided

Intentional - fraud
Unintentional - abuse

Question 32

Downcoding

Answer 32

Payer reduces level of procedure

Question 33

Unbundling Codes

Answer 33

Incorrect billing practice

Instead of one CPT code for a package of codes, two or three codes are used

Question 34

MUEs

Answer 34

Medically Unlikely Edits

CMS unit of service edits that check for clerical or software-based coding or billing errors, such as anatomically-related mistakes

Question 35

Code Linkage

Answer 35

Connection between service and condition/illness; indicates why the service was provided

Question 36

Allowed charge

Answer 36

Maximum amount that a health plan will pay

Maximum Allowable Fee, Maximum charge, Allowed amount, Allowed Fee

Question 37

Balance Billing

Answer 37

Difference between fee and allowed amount; NonPAR may be allowed to charge the patient

Question 38

Write Off

Answer 38

Difference between amount charged and amount allowed; the difference is deducted from the patient’s account; due to payer agreement to accept allowed amount as payment in full

Question 39

Adjustment

Answer 39

Change in a patient’s account whether it is pos or neg

Question 40

Compliant Billing

Answer 40

Correct claims report the connection between a billed service and a diagnosis

Question 41

OIG’s LEIE

Answer 41

Office of the Inspector General’s List of Excluded Individuals/Entities

Individuals or companies that, because of reasons bearing on professional competence, professional performance, or financial integrity, are not permitted by OIG to participate in any federal healthcare programs

Question 42

CCI

Answer 42

Correct Coding Initiative

Medicare’s national and local coverage and payment policies; private payers develop code that is similar to those of the CCI

Question 43

Compliance Errors

Answer 43

Healthcare payers often base their decisions to pay or deny claims only on the diagnosis and procedure codes; Errors relating to code linkage and medical necessity

Question 44

Truncated Coding

Answer 44

Using diagnosis codes that are not as specific as possible

Question 45

Assumption Coding

Answer 45

Reporting items or services that are not actually documented but that the coder assumes were performed

Question 46

Global Period

Answer 46

a period of time starting with a surgical procedure and ending some period of time after the procedure

Question 47

Unrelated work during the global period

Answer 47

visits during a post-operative period that are not related to the patient’s surgical procedures are billable, use modifier 79 to indicate the situation

Question 48

Global period for minor procedures

Answer 48

their preoperative is just the day of the procedure; post-operative period is 0 or 10 days

Question 49

Global period for major procedures

Answer 49

a one-day preoperative with a 90-day postoperative