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Medical Billing and Coding > Medical billing > Flashcards

Medical billing Flashcards

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USMLE® Step 1 flashcards
1
Q

privacy act of 1974

A

prohibits disclosure of certain medical info by government agencies unless the patient gives written consent

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2
Q

healthcare operations

A

certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support the core functions of treatment and payment

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3
Q

Three groups to which HIPAA regulations apply

A
  • Healthcare providers
  • health plans
  • healthcare cleaning houses
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4
Q

protected health information (PHI)

A

any individual identifiable health information

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5
Q

identifiable information

A

data about a specific person

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6
Q

de-identifiable information

A

information stripped of data that may identify an individual

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7
Q

limited data set

A

middle ground between identifiable and de-identifiable information

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8
Q

risk management

A

identifies areas of risk to medical service providers

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9
Q

payment

A

the activities of healthcare providers to obtain payment or be reimbursed for their services

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10
Q

treatment

A

the provision of healthcare and related services

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11
Q

peer review committees

A

consists of healthcare providers who monitor the quality and use of healthcare services

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12
Q

biometrics

A

technologies that identify people through bodily characteristics, such as finger prints, retinal patterns & voice patterns

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13
Q

loss prevention

A

a planned, systematic, and proactive process; in the area of healthcare providers identify those activities, problems, and situations that may result in potential liability

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14
Q

loss reduction

A

the steps taken after an event or incident occurs

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15
Q

virtue theory

A

pertains to the character of a person as displayed by the virtues he or she possesses

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16
Q

duty theory

A

pertains to a persons obligations from the standpoint of morality

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17
Q

consequentialist theory

A

based on the consequences of peoples actions based on their own ethics & morals

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18
Q

false claims act

A

punishes those who knowingly engage in false billing

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19
Q

misdemeanor

A

any crime that’s punishable by imprisonment for less than one year

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20
Q

statues

A

legislation passed by governing bodies on federal and state levels

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21
Q

PPE

A

personal protective equipment

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22
Q

statue of limitations

A

the time period during which a lawsuit must be brought

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23
Q

contributory negligence

A

when a patient contributes to causing themselves harm

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24
Q

arbitration

A

two parties present evidence to an impartial person, who makes a binding decision

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25
Q

appeal

A

during an appeal, the question is whether an error of law was made at the trial court level

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26
Q

perjury

A

false swearing under oath

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27
Q

burden of proof

A

what the plaintiffs are obligated to prove

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28
Q

bench trial

A

a trial in which there’s no jury and the judge serves as the fact finder, weighs the evidence & decides how the law applies to it

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29
Q

expert witnesses

A

people who have skill, experience, training, or education in a specialized field that ordinary people don’t have

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30
Q

types of malpractice

A

failure to diagnose, failure to inform of diagnosis, errors in treatment, lack of informed consent

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31
Q

battery

A

the harmful touching of a patient without consent

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32
Q

product liability

A

the legal responsibility that a manufacturer or distributer of an unreasonably dangerous product has for damages cause by the dangerous condition

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33
Q

Actus Reus

A

latin for “guilty act” or the criminal act

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34
Q

Mens Rea

A

latin for “guilty mind” referring to the state of mind associated with the criminal act

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35
Q

OSHA

A

the occupational safety and health administration

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36
Q

joint commission

A

an external accrediting body for health care facilities

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37
Q

CMS

A

the centers for medicare and medicaid services

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38
Q

Malpractice

A

professional negligence

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39
Q

defensive medicine

A

consists of medical responses that are motivated by a desire to avoid potential liability claims more than by the needs of the patient

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40
Q

mediation

A

occurs when a neutral third party helps the parties in a dispute reach a settlement agreement

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41
Q

ordinances

A

legislation adopted by local legislative bodies

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42
Q

certification

A

refers to a professional organization or institution representing that a certified person has passed a test, completed a course of study, or demonstrated knowledge or skill in some other way

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43
Q

negligence

A

failing to meet a standard of reasonable care

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44
Q

due care

A

the responsibility of a physician to hire qualified personnel and supervise the personnel accordingly

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45
Q

vicarious liability

A

when one person is held responsible for the actions of another

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46
Q

litigation

A

the process of resolving disputes through the court system

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47
Q

alternative dispute resolution (ADR)

A

a process of resolving disputes outside of the court system that may be used before or after litigation has begun

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48
Q

alternative dispute resolution (ADR)

A

a process of resolving disputes outside of the court system that may be used before or after litigation has begun

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49
Q

litigate

A

to begin a legal process involving a court

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50
Q

plaintiff

A

the person who is suing

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51
Q

defendant

A

the person who is being sued

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52
Q

deposition

A

the taking of oral testimony under oath before trial

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53
Q

jury trial

A

a trial in which the jury is the fact finder, and the judge explains the law to the jury and supervises the presentation of evidence

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54
Q

common law

A

a system of law developed on a case by case basis from court decisions

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55
Q

right

A

an individual power, privilege or immunity

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56
Q

duty

A

an individual obligation

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57
Q

three branches of government

A
  • federal
  • state
  • local
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58
Q

civil law

A

concerns the private rights & duties of individuals who live within a society

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59
Q

crime

A

an offense against a locale, a state, or the United States

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60
Q

criminal law

A

prohibits and punishes certain conduct for the benefit of society

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61
Q

law

A

the set of rules that govern our behavior

62
Q

wrongful birth

A

a parents claim against a doctor for damages caused by birth of a child that occur when a doctor fails to detect and disclose a Childs birth defects in time to permit abortion

63
Q

euthanasia

A

occurs when a person takes an action that causes death to another person sometimes called mercy killing

64
Q

assisted suicide

A

occurs when a patient takes actions to terminate his or her life using means supplied by someone else

65
Q

use of biometrics

A

to identify a patient to simplify secure access to records

66
Q

health insurance

A

created important rules regarding safeguarding health information

67
Q

Hippocratic oath

A

taken by physicians and pertains to the ethical practice of medicine

68
Q

durable power of attorney (DPA)

A

authorizes a person to make medical decisions for a patient when the patient is unable to do so

69
Q

do - not - resuscitate (DNR)

A

prevents efforts to resuscitate those who have exhibited the signs of death; doesn’t go into effect until the person is permanently unconscious without realistic hope of recovery

70
Q

advance medical directives

A

instructions people give to others regarding their medical wishes in case they are unable to

71
Q

fetal homicide laws

A

laws that make causing the death of a fetus a crime separate and independent from any crime committed against the woman carrying the fetus

72
Q

etiquette

A

the proper form of social interaction in a given culture or community

73
Q

affordable care act (ACA)

A

signed into law by president Barak Obama in 2010; makes health insurance coverage mandatory

74
Q

ethical theories

A

attempt to systemize, defend, and recommend concepts of right and wrong behavior

75
Q

ethics v. law

A

while moral obligation focuses on an individuals conscience - legal obligations are enforced by the states power w/o regard to conscience

76
Q

meta ethics

A

a branch of ethical theory that considers the origin and meaning of ethical principles

77
Q

normative ethics

A

involves determining the moral standards that regulate right and wrong conduct
3 theories
- virtue theory
- duty theory
- consequentialist theory

78
Q

roe v. wade

A

in 1973, in a landmark decision regarding abortion, the US Supreme Court in roe v. wade applied the right to privacy to abortion

79
Q

amniocentesis

A

a medical technique used to test DNA in amniotic fluid; allows physicians to identify genetic abnormalities before birth

80
Q

negative eugenics

A

limits or discourages reproduction by those considered genetically inferior

81
Q

eugenics

A

a science that deals with “improving” hereditary qualities

82
Q

positive eugenics

A

encourages reproduction by those considered genetically superior

83
Q

methods on conception

A

test tube fertilization artificial insemmination

84
Q

medical paternalism

A

takes away patient autonomy and gives the power to medical personnel or the government for societys benefit

85
Q

patient autonomy

A

requires that the patient give informed consent prior to the start of any medical treatment

86
Q

formulary

A

a list of approved drugs from which doctors must prescribe to have insurance cover the pharmaceuticals

87
Q

doctor-patient privilege

A

a relationship in which a patients medical history, conditions, and related info can’t be made known without the patients consent

88
Q

medical record

A

document that includes a patients history, condition, diagnostic & therapeutic treatment and the results of treatment

89
Q

author of a medical record

A

the provider who has created the data that appear in the record

90
Q

age of maturity

A

when a person becomes an adult

91
Q

certificate of destruction

A

documents that records were properly destroyed in the ordinary course of business

92
Q

substituted consent

A

an authorized person makes a decision for a person who is unable to do so

93
Q

legal basis for confidentiality

A

the right of privacy derived from the U.S. constitution, statues, and the common law

94
Q

accounts receivable (AR)

A

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

95
Q

CMS-1500 claim form

A

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

96
Q

coordination of benefits (COB)

A

also known as crossover; group policy provision that helps determine the primary carrier in situations in which an insured party is covered by more than one policy, thus preventing the insured from receiving claims overpayments

97
Q

explanation of benefits (EOB)

A

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 the patient

98
Q

fiscal intermediaries (FI)

A

insurance companies contracted by the government to process claims for government insurance programs, such as medicare parts A & B

99
Q

remittance advice

A

communication from third party payer to payee that provides a detailed accounting of payments and healthcare services provided

100
Q

revenue codes

A

UB-92 payment codes for healthcare services or items

101
Q

UB-92 claim form

A

also known as the CMS-1450 form; standardizes the processing of billing for hospital inpatient and outpatient services

102
Q

reimbursement

A

the way that healthcare providers are paid for providing medial services

103
Q

healthcare providers

A

doctors, hospitals, and healthcare facilities

104
Q

medical coding

A

the process of assigning codes to certain pieces of information in the health record

105
Q

preventable health threats

A

illnesses that can be prevented before they occur by routine physical examinations and immunizations

106
Q

third-party payers

A

responsible for providing an insurance arrangement that provides benefits in the form of healthcare services

107
Q

fee-for-service reimbursement

A

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

108
Q

covered medical expenses

A

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

109
Q

chargemaster

A

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

110
Q

facility fee

A

fee paid to hospital for services provided

111
Q

service fee

A

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

112
Q

skilled nursing facility

A

a facility designed to treat medicare-eligible patients

113
Q

outcome and assessment information set (OASIS)

A

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

114
Q

CMS

A

centers for medicare and medicaid services’ professional, universal health claim form; used by providers of outpatient health services to bill their fees to health carriers (or third-party payers)

115
Q

CMS-1450

A

institutional claim form used by hospitals to receive payment from third-party payers; also known as the UB-04 or the uniform bill

116
Q

medicare carriers

A

private companies that have a contract with medicare to process medicare part B bills for physicians and medical suppliers

117
Q

audit trails

A

information maintained on coding reviews and the actions needed for improvement

118
Q

upcoding

A

assigning codes that aren’t supported by the information in the patients health record

119
Q

unbundling

A

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

120
Q

coinsurance

A

provision stating that the insured and the insurer will share all losses covered by the policy in porportion agreed upon in advance; for example, an 80-20 policy means that the insurer pays 80 percent and insured pays 20 percent of expenses

121
Q

copayment

A

an arrangement in which the covered person pays a specified amount for various services and the healthcare provider pays the remainder. copayment is usually paid at service.

122
Q

deductible

A

portion of an insured loss paid by the insured before they’re entitled to benefits from the insurer

123
Q

group health insurance

A

health insurance provided to a group, most often a group of employees, providing coverage in the form of lump-sum payment or periodic payments to compensate for income losses due to bodily injury, sickness, or disease as well as medical expenses

124
Q

insured

A

party to an insurance arrangement who’s secured against losses and provided benefits or services; this term is preferred to terms such as policy holder and policy owner

125
Q

insurer

A

party to an insurance arrangement who undertakes to indemnify for losses, provide benefits, or render services. the term insurer is preferred to company or carrier. aka third party payer

126
Q

major medical insurance

A

a type of health insurance that provides benefits up to a high limit for most types of medical expenses incurred, subject to a large deductible. these policies usually pay covered expenses whether an individual is in or out of the hospital

127
Q

out-of-pocket expenses

A

amount not covered by insurance that the covered (or insured) person must pay out of their own pocket, such as coinsurance and a deductible; aka out of pocket costs

128
Q

provider

A

any individual or group of individuals that provide a healthcare service (such as physicians or hospitals)

129
Q

fee-for-service

A

the method by which a physician or provider bills for each service or visit instead of on a prepaid (that is, all-inclusive) basis. this was the initial way that patients received treatment, for which they usually paid cash.

130
Q

managed care

A

a system of healthcare where the goal is to deliver quality, cost of effective healthcare through monitoring and recommending utilization and cost of services

131
Q

prospective payment system (PPS)

A

a system wherein reimbursement is made to the provider based on a predetermined reimbursement level rather than on actual charges after the services have been provided

132
Q

retrospective payment system

A

a system wherein reimbursement is made to providers after healthcare services have been given

133
Q

usual, customary, and reasonable charges (UCR)

A

charges for healthcare services that are based on the physicians “usual” charge for the service, which is the “customary” amount that other physicians in the area charge, and a “reasonable” amount for the service performed

134
Q

prepaid health plan

A

contract that covers specific medical expenses for individuals or groups

135
Q

health insurance

A

protection against income losses for illness or injury, disability income, and accidental death or dismemberment

136
Q

medical insurance

A

coverage for specific medical expenses

137
Q

fee for service basis

A

healthcare providers receive payment for actual charges after healthcare services were provided

138
Q

prospective basis

A

predetermined reimbursement level

139
Q

premiums

A

regular, pre-established amounts paid by private insurance holders

140
Q

government-sponsored healthcare programs

A

healthcare plans that are funded and administered by the federal or state government; examples include Medicare and Medicaid

141
Q

medicare part A

A

hospital insurance coverage for those meeting medicare criteria

142
Q

Medicare part B

A

supplemental insurance coverage for those meeting medicare criteria

143
Q

inpatient hospital care

A

care for patients who are expected to remain in the hospital for at least 24 hours or more to receive care from a physician

144
Q

long term care

A

care for persons with chronic disease or disabilities

145
Q

skilled nursing facility (SNF) care

A

care including rehabilitation, 24 hour nursing coverage, and physical occupational, and speech therapies

146
Q

hospice care

A

an organization that’s primarily designed to provide pain relief symptom management and supportive services for the terminally ill and their families

147
Q

out of pocket expenses

A

expenses that aren’t covered by insurance

148
Q

managed care plan

A

a collection of interdependent systems that integrate the delivery of healthcare services to a specific population

149
Q

Health Maintenance organization (HMO)

A

a prepaid medical service plan that provides services to plan members

150
Q

preferred provider organizations (PPO)

A

represent an organization of hospitals and physicians who, for a set fee, provide services to insurance company clients

151
Q

accountable care organizations

A

groups of doctors, hospitals, and healthcare providers who organize into a group to provide care to medicare patients

Medical Billing and Coding (1 decks)

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