NURSING Flashcards
The act of unnecessary transfer of patients to another healthcare unit in order to keep medical expenses low in change for incentives.
Turfing
The amount of charges a provider or hospital agrees to write off and not change the patient per the contract terms with the insurance company
Example :
Actual amount = $600. 00
Allowed amount = $450.00
Adjustment = $150.00 to be written off
Contractual Adjustment
A service that scrubs and transmits claims electronically to insurance carriers?
Clearinghouse
The process of establishing the validity of the patient’s insurance coverage?
Eligibility
A managed care clause that prohibits service providers, particularly PCPs or primary care providers from discussing treatment options with patients?
Gag Clause
The percentage in reference to the providers accounts receivable. It is the ratio of the payments received to the total amount of money owed on the providers accounts ?
Example:
Amount owed = $100,000.00
Amount collected = $80,000.00
Collection ratio = 80%
Collection ratio
What does DRG stand for?
DIAGNOSIS RELATED GROUP
What does DRG stand for?
DIAGNOSIS RELATED GROUP
A complete insurance claim that has all the necessary correct information without any omissions or mistakes and is submitted in a timely manner is referred to as ___.
Clean claim
The act of billing for services that were not provided ?
Phantom or ghost billing
The act of submitting a code for a procedure or service that is more expensive than what was actually performed or provided ?
Upcoding
The act of reporting individual codes for services or procedures that are bundled into one code, also known as a la carte coding ?
Unbundling
When claim information is automatically sent from Medicare to the secondary insurance such as Medicaid ?
Crossover
_____ are laws that prohibit physicians from giving self-referrals or refer patients to laboratories, specialists, and other healthcare providers with whom they have financial interests.
Stark I & II regulations
When the insurance company reduces the code and reimbursement amount for a claim when there is no documentation to support the level of service submitted by the provider, what is the insurance company doing?
Downcoding
The checking of insurance claims for errors and missing information and correcting them before submitting to the insurance company is called ___.
Scrubbing
The act of ordering excessive tests or providing the same service more than what is necessary in order to bill the insurance company excessively?
Churning
The process of confirming that the procedure or service is medically necessary and, therefore, it is covered by the plan?
Preauthorization
The process of confirming that the procedure or service is covered by the plan ?
Pre certification
The act of making the patient’s condition appear worse in order to collect higher reimbursement ?
Buffing
The process of verifying the Dollar amount that the plan is paying for the procedure or service ?
Predetermination
A(n) ____ is prepared to group together unpaid balances according to how long they are outstanding
Aging report
The form that shows the patient’s name, account number, date of service, name of provider, diagnoses and ICD codes, procedures and CPT codes, charges and payments made after an outpatient encounter is called the_____. In an inpatient setting it is called the ______
- Superbill
- Chargemaster
Which of the following good practices and bad practices for a medical biller and coder to do when trying to collect from patients?
a. Call the patient between 8am and 9pm only. ☑
b. Call the patient on holidays and weekends. ý
c. Threaten to file a lawsuit against the patient if he or she does not pay at a certain date. ý
d. Call the patient multiple times a day. ý
e. Turn the patient’s account over to the collection agency after 30 days. ý
f. Leave a detailed message about the patient’s debt on the answering machine. ý
g. Send details of the patient’s account on a postcard. ý
What are the four stages of claims?
- Claim submission - transmitting of claims
- Claim processing - checking for errors and missing information; validation of claim.
- Claim adjudication - decide what benefits to pay; approve or deny the claim; determines how much to pay.
- Claim payment - prepare and send the payment
- If the claim is not paid, post the payment. If the claim is denied, file an appeal.
Name the different types of claims ?
- Clean claim - claim without errors and contains complete information.
- Rejected claim - claim that needs to be corrected; claim that contains missing information.
- Suspended or pending claim - claim awaiting decision.
- Denied claim - claim that will not be paid due to lack of medical necessity, pre-existing conditions, fraudulent claim, termination of coverage/lack of eligibility.
- illogical claim - claim that contains illogical information.
What are pre-existing conditions?
Patient condition that has been diagnosed prior to the effectivity date of the insurance.
Name at least five reasons for claims denials:
(See answer #4 under question #25)
Explain claim appeals ?
The process of getting denied claims paid by a writing a medical report to explain why the procedure or service is medically necessary.
What is an EOB/RA?
RA - Remittance Advice - used to notify the provider that the claim has been denied or approved (with amount of payment); sent to the provider.
EOB – Explanation of Benefits – more detailed than the RA; includes the patient’s name, date of service, name of provider, procedures and CPT codes, charges, allowed amounts, disallowed, payments, patient’s responsibilities, and remark codes; sent to the patient and provider
What are accounts receivables?
money that the provider expects to receive from the insurance companies and the patients; amount owed to the provider; amount owed by insurance companies and patients to the provider; used to assess or measure the financial viability of the provider
What are accounts receivables?
money that the provider expects to receive from the insurance companies and the patients; amount owed to the provider; amount owed by insurance companies and patients to the provider; used to assess or measure the financial viability of the provider
