NURSING

Question 1

The act of unnecessary transfer of patients to another healthcare unit in order to keep medical expenses low in change for incentives.

Answer 1

Turfing

Question 2

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

Answer 2

Contractual Adjustment

Question 3

A service that scrubs and transmits claims electronically to insurance carriers?

Answer 3

Clearinghouse

Question 4

The process of establishing the validity of the patient’s insurance coverage?

Answer 4

Eligibility

Question 5

A managed care clause that prohibits service providers, particularly PCPs or primary care providers from discussing treatment options with patients?

Answer 5

Gag Clause

Question 6

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%

Answer 6

Collection ratio

Question 7

What does DRG stand for?

Answer 7

DIAGNOSIS RELATED GROUP

Question 8

What does DRG stand for?

Answer 8

DIAGNOSIS RELATED GROUP

Question 9

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 ___.

Answer 9

Clean claim

Question 10

The act of billing for services that were not provided ?

Answer 10

Phantom or ghost billing

Question 11

The act of submitting a code for a procedure or service that is more expensive than what was actually performed or provided ?

Answer 11

Upcoding

Question 12

The act of reporting individual codes for services or procedures that are bundled into one code, also known as a la carte coding ?

Answer 12

Unbundling

Question 13

When claim information is automatically sent from Medicare to the secondary insurance such as Medicaid ?

Answer 13

Crossover

Question 14

_____ 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.

Answer 14

Stark I & II regulations

Question 15

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?

Answer 15

Downcoding

Question 16

The checking of insurance claims for errors and missing information and correcting them before submitting to the insurance company is called ___.

Answer 16

Scrubbing

Question 17

The act of ordering excessive tests or providing the same service more than what is necessary in order to bill the insurance company excessively?

Answer 17

Churning

Question 18

The process of confirming that the procedure or service is medically necessary and, therefore, it is covered by the plan?

Answer 18

Preauthorization

Question 19

The process of confirming that the procedure or service is covered by the plan ?

Answer 19

Pre certification

Question 20

The act of making the patient’s condition appear worse in order to collect higher reimbursement ?

Answer 20

Buffing

Question 21

The process of verifying the Dollar amount that the plan is paying for the procedure or service ?

Answer 21

Predetermination

Question 22

A(n) ____ is prepared to group together unpaid balances according to how long they are outstanding

Answer 22

Aging report

Question 23

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 ______

Answer 23

1. Superbill
2. Chargemaster

Question 24

Which of the following good practices and bad practices for a medical biller and coder to do when trying to collect from patients?

Answer 24

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

Question 25

What are the four stages of claims?

Answer 25

1. Claim submission - transmitting of claims
2. Claim processing - checking for errors and missing information; validation of claim.
3. Claim adjudication - decide what benefits to pay; approve or deny the claim; determines how much to pay.
4. Claim payment - prepare and send the payment
5. If the claim is not paid, post the payment. If the claim is denied, file an appeal.

Question 26

Name the different types of claims ?

Answer 26

1. Clean claim - claim without errors and contains complete information.
2. Rejected claim - claim that needs to be corrected; claim that contains missing information.
3. Suspended or pending claim - claim awaiting decision.
4. 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.
5. illogical claim - claim that contains illogical information.

Question 27

What are pre-existing conditions?

Answer 27

Patient condition that has been diagnosed prior to the effectivity date of the insurance.

Question 28

Name at least five reasons for claims denials:

Answer 28

(See answer #4 under question #25)

Question 29

Explain claim appeals ?

Answer 29

The process of getting denied claims paid by a writing a medical report to explain why the procedure or service is medically necessary.

Question 30

What is an EOB/RA?

Answer 30

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

Question 31

What are accounts receivables?

Answer 31

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

Question 32

What are accounts receivables?

Answer 32

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