Insurance Flashcards
how is healthcare or medical services are paid
healthcare reimbursement
how can claims be denied
inadequate documentation, treatment not covered, or hospilization stay exceeds coverage
who reviews for diagnoses & procedures related to the current episodes of care
medical coders
what describes the diagnosis, services or procedures
codes
a bill for services submitted by a health care provider
claim
people or facilities that provide healthcare services
healthcare providers
those who reimburse healthcare providers for delivering services
third party payer
refers to how hospitals, drs offices, and other providers of medical services get paid?
reimbursment
Healthcare providers to all pple regardless of age, job status, income, and race
universal healthcare
what is healthcare generally reimbursed by
third party payers
what are some 3rd party payers?
private (commercial) or gov based
what is medicare
prospective payment system
what is PPS (prospective payment system)?
amount that is determined before patient gets healthcare services
Which Fees-for-service reimbursment method has the patient or provider submit claim to the third party payer for services
traditional for fee service
Which case is reviewed before services are delivered
prospective review
which case is reviewed for apprt after discharge
retrospective review
What method is when 1 payment is made to compensate providers for ALL services provided to patients for specific period of time?
Episode of care reimbursment
Which method is different from traditional f.f.s methods
Capitations
based off of pre-established payments for specific period of time
Capitations
what means that managed care plan pays the provider a fixed amount on a capita or person.
capitation
what happens when the reimbursed amount is more than services the provider provided?
the physician keeps additional amount
what happens if the services provided cost more than the capita amount
physician doesnt get reimbursed and loses money
list of healthcare services and procedures & the charges associated with them
chargemasters
list of charges for items used or services rendered during a patient’s care
fee schedule
lump sum or bundled payments are made to providers for all services by time period
episode of care reimburshment
what is the first step for claims and reimbursement
coder reviews medical records + documents diagnosis and procedures after discharge
Second step in claims and reimbursement
coder enters diagnosis and procedures into specialized coding computer program
third step in claims and reimbursement
computer program translates diagnosis and procedures into numerical codes
step four in claims and reimbursement
computer program groups all codes into one numerical classifciation system MS-DRG
step five in claims and reimbursement
diagnosis codes/procedures codes + MS-DRG reported on claim form
sixth step for claims and reimbursement
completed claim form sent to insurance for reimbursement
seventh step for claim and reimbursement
insurance co equates # code + MS-DRG to specific reimbursement amount
last step in claims and reimbursement
insurance co reimburses hospital
what are two types of classification systems
ICD-10-CM and HCPCS
what is ICD-10-CM
codes diagnosis and procedures for outpatient services and physician visits
what is HCPCS
current procedure term
what is CPT
5 digits codes used in ambulatory or outpatient settings and physician settings
What are classification groups of disease illnesses and injuries
DRG
payments that hospitals receive from third party payers for providing healthcare services
Accounts Receivable
standard insurance claim form used to report outpatient services to insurance companies
CMS-1500 Claim Form
known as crossover, group policy provision that helps determine the primary carrier in situations in which insured is covered by more than 1 policy.
Coordination of Benefits
What does coordination of benefits prevent
the insured from receiving claims overpayments
Statement sent to a participant in a health plan as well as the healthcare provider that lists services, amounts paid by the plan and total amount billed to patient.
Explanation of Benefits
Insurance co’s contracted by the gov to process claims for gov insurance programs like medicare parts a and b
Fiscal Intermediaries
communication from 3rd party payers to payee that provides a detailed accounting of payments and healthcare services provided
Remittance Advice
UB-92 payment codes for healthcare services or items
Revenue Codes
AKA CMS-1450 form; standardizes processing of billing for hospital inpatient and outpatient services
UB-92 Claim form
way that providers are paid for medical services
Reimbursement
drs, hospitals and healthcare facilities
Healthcare Providers
The process of assigning codes to certain pieces of info in the health record
Medical coding
Illnesses that can prevented before occurring by routine physical exams and immunizations
Preventable Health Threats
responsible for providing insurance arrangement that provides benefits in the form of health care services
3rd party payers
breaking down codes that are normally assigned a set into seperate codes for purpose of obtaining higher reimbursement
Unbundling
assigning codes that aren’t supported by info in health record of patient
Upcoding
info maintained on coding reviews and actions needed for improvement
audit trails
private co that have contract with medicare to process medicare part b bills for physicians and medical suppliers
medicare carriers
institutional claim form used by hospital to receive payment from 3rd party payers;
CMS-1450 or Uniform Bill UB-04
centers for medicare and medicaid service’s profess, universal health claim for used by providers of outpatient health services to bill their fees to health carriers
CMS
a dataset used in home healthcare for patient assessment to help monitor and improve the outcomes of home healthcare
Outcome and Assessment Info set
a facility designed to treat medicare eligible patients
skilled nursing facility
fee paid to physicians for services provided, such as medical consultation and surgery
service fee
fee paid to hospitals for services provided
facility fee
a list of healthcare supplies and services with specific charges assigned for each supply and services
chargemaster
medical expenses that are listed in the benefits section of the insurance policy as being reimbursable by insurance co
covered medical expenses
healthcare provider receives reimbursement based on amount that they charge for service
fee-for-service reimbursement
________ reimbursement means that one payment is made to compensate providers for ALL healthcare services to a patient for specific period of time?
Episode of care
Which of the following situations would CMS-1500 claim form be used?
Physician office services
The ________ is a list of healthcare supplies and services with a specific charges assigned for each supply and service.
chargemaster
________ is a process that evaluates necessity and appropriateness of various healthcare services
utilization management
What is the centers of Medicare and Medicaid services profess universal health claim form?
CMS-1500
_______ for healthcare refers to the way that hospitals, drs, and other healthcare providers providing medical services are paid?
reimbursement
The reimbursement method is based on pre-established payments for a specific period of time?
Capitation
Per diem means that reimbursement is based on services by the
day
What is the computer program that groups all codes into 1 # classification system?
Medicare Severity Diagnosis related group
Skilled nursing facility or SNF is designed for treating
Medicare elgible patients
A ________ is certified facility approved by a health plan to provide services under a contract
home health agency
Who is responsible for updating chargemasters?
Hospital admins
What is known for the accepted profess standards of conduct for the industry when assigning codes and billing for reimbursment?
ethical coding practices
When visiting your dr, the charges accrued for the resources used are reported in a
medical claim
in 1992 ______ the system was implemented to replace the physicians’ medicare fee system
RBRVS
What is considered a 3rd party payer?
insurance co’s
_______ is the practice where codes are normally assigned as a set are broken into separate codes for the purpose of obtaining higher reimbursement for healthcare services provided.
Unbundling
