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Billing and Coding > Insurance > Flashcards

Insurance Flashcards

1
Q

how is healthcare or medical services are paid

A

healthcare reimbursement

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2
Q

how can claims be denied

A

inadequate documentation, treatment not covered, or hospilization stay exceeds coverage

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3
Q

who reviews for diagnoses & procedures related to the current episodes of care

A

medical coders

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4
Q

what describes the diagnosis, services or procedures

A

codes

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5
Q

a bill for services submitted by a health care provider

A

claim

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6
Q

people or facilities that provide healthcare services

A

healthcare providers

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7
Q

those who reimburse healthcare providers for delivering services

A

third party payer

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8
Q

refers to how hospitals, drs offices, and other providers of medical services get paid?

A

reimbursment

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9
Q

Healthcare providers to all pple regardless of age, job status, income, and race

A

universal healthcare

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10
Q

what is healthcare generally reimbursed by

A

third party payers

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11
Q

what are some 3rd party payers?

A

private (commercial) or gov based

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12
Q

what is medicare

A

prospective payment system

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13
Q

what is PPS (prospective payment system)?

A

amount that is determined before patient gets healthcare services

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14
Q

Which Fees-for-service reimbursment method has the patient or provider submit claim to the third party payer for services

A

traditional for fee service

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15
Q

Which case is reviewed before services are delivered

A

prospective review

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16
Q

which case is reviewed for apprt after discharge

A

retrospective review

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17
Q

What method is when 1 payment is made to compensate providers for ALL services provided to patients for specific period of time?

A

Episode of care reimbursment

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18
Q

Which method is different from traditional f.f.s methods

A

Capitations

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19
Q

based off of pre-established payments for specific period of time

A

Capitations

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20
Q

what means that managed care plan pays the provider a fixed amount on a capita or person.

A

capitation

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21
Q

what happens when the reimbursed amount is more than services the provider provided?

A

the physician keeps additional amount

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22
Q

what happens if the services provided cost more than the capita amount

A

physician doesnt get reimbursed and loses money

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23
Q

list of healthcare services and procedures & the charges associated with them

A

chargemasters

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24
Q

list of charges for items used or services rendered during a patient’s care

A

fee schedule

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25
Q

lump sum or bundled payments are made to providers for all services by time period

A

episode of care reimburshment

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26
Q

what is the first step for claims and reimbursement

A

coder reviews medical records + documents diagnosis and procedures after discharge

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27
Q

Second step in claims and reimbursement

A

coder enters diagnosis and procedures into specialized coding computer program

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28
Q

third step in claims and reimbursement

A

computer program translates diagnosis and procedures into numerical codes

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29
Q

step four in claims and reimbursement

A

computer program groups all codes into one numerical classifciation system MS-DRG

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30
Q

step five in claims and reimbursement

A

diagnosis codes/procedures codes + MS-DRG reported on claim form

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31
Q

sixth step for claims and reimbursement

A

completed claim form sent to insurance for reimbursement

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32
Q

seventh step for claim and reimbursement

A

insurance co equates # code + MS-DRG to specific reimbursement amount

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33
Q

last step in claims and reimbursement

A

insurance co reimburses hospital

34
Q

what are two types of classification systems

A

ICD-10-CM and HCPCS

35
Q

what is ICD-10-CM

A

codes diagnosis and procedures for outpatient services and physician visits

36
Q

what is HCPCS

A

current procedure term

37
Q

what is CPT

A

5 digits codes used in ambulatory or outpatient settings and physician settings

38
Q

What are classification groups of disease illnesses and injuries

A

DRG

39
Q

payments that hospitals receive from third party payers for providing healthcare services

A

Accounts Receivable

40
Q

standard insurance claim form used to report outpatient services to insurance companies

A

CMS-1500 Claim Form

41
Q

known as crossover, group policy provision that helps determine the primary carrier in situations in which insured is covered by more than 1 policy.

A

Coordination of Benefits

42
Q

What does coordination of benefits prevent

A

the insured from receiving claims overpayments

43
Q

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.

A

Explanation of Benefits

44
Q

Insurance co’s contracted by the gov to process claims for gov insurance programs like medicare parts a and b

A

Fiscal Intermediaries

45
Q

communication from 3rd party payers to payee that provides a detailed accounting of payments and healthcare services provided

A

Remittance Advice

46
Q

UB-92 payment codes for healthcare services or items

A

Revenue Codes

47
Q

AKA CMS-1450 form; standardizes processing of billing for hospital inpatient and outpatient services

A

UB-92 Claim form

48
Q

way that providers are paid for medical services

A

Reimbursement

49
Q

drs, hospitals and healthcare facilities

A

Healthcare Providers

50
Q

The process of assigning codes to certain pieces of info in the health record

A

Medical coding

51
Q

Illnesses that can prevented before occurring by routine physical exams and immunizations

A

Preventable Health Threats

52
Q

responsible for providing insurance arrangement that provides benefits in the form of health care services

A

3rd party payers

53
Q

breaking down codes that are normally assigned a set into seperate codes for purpose of obtaining higher reimbursement

A

Unbundling

53
Q

assigning codes that aren’t supported by info in health record of patient

A

Upcoding

54
Q

info maintained on coding reviews and actions needed for improvement

A

audit trails

55
Q

private co that have contract with medicare to process medicare part b bills for physicians and medical suppliers

A

medicare carriers

56
Q

institutional claim form used by hospital to receive payment from 3rd party payers;

A

CMS-1450 or Uniform Bill UB-04

57
Q

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

A

CMS

58
Q

a dataset used in home healthcare for patient assessment to help monitor and improve the outcomes of home healthcare

A

Outcome and Assessment Info set

59
Q

a facility designed to treat medicare eligible patients

A

skilled nursing facility

60
Q

fee paid to physicians for services provided, such as medical consultation and surgery

A

service fee

61
Q

fee paid to hospitals for services provided

A

facility fee

62
Q

a list of healthcare supplies and services with specific charges assigned for each supply and services

A

chargemaster

63
Q

medical expenses that are listed in the benefits section of the insurance policy as being reimbursable by insurance co

A

covered medical expenses

64
Q

healthcare provider receives reimbursement based on amount that they charge for service

A

fee-for-service reimbursement

65
Q

________ reimbursement means that one payment is made to compensate providers for ALL healthcare services to a patient for specific period of time?

A

Episode of care

66
Q

Which of the following situations would CMS-1500 claim form be used?

A

Physician office services

67
Q

The ________ is a list of healthcare supplies and services with a specific charges assigned for each supply and service.

A

chargemaster

68
Q

________ is a process that evaluates necessity and appropriateness of various healthcare services

A

utilization management

69
Q

What is the centers of Medicare and Medicaid services profess universal health claim form?

A

CMS-1500

70
Q

_______ for healthcare refers to the way that hospitals, drs, and other healthcare providers providing medical services are paid?

A

reimbursement

71
Q

The reimbursement method is based on pre-established payments for a specific period of time?

A

Capitation

72
Q

Per diem means that reimbursement is based on services by the

A

day

73
Q

What is the computer program that groups all codes into 1 # classification system?

A

Medicare Severity Diagnosis related group

74
Q

Skilled nursing facility or SNF is designed for treating

A

Medicare elgible patients

75
Q

A ________ is certified facility approved by a health plan to provide services under a contract

A

home health agency

76
Q

Who is responsible for updating chargemasters?

A

Hospital admins

77
Q

What is known for the accepted profess standards of conduct for the industry when assigning codes and billing for reimbursment?

A

ethical coding practices

78
Q

When visiting your dr, the charges accrued for the resources used are reported in a

A

medical claim

79
Q

in 1992 ______ the system was implemented to replace the physicians’ medicare fee system

A

RBRVS

80
Q

What is considered a 3rd party payer?

A

insurance co’s

81
Q

_______ 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.

A

Unbundling

Billing and Coding (13 decks)

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