STUDY GUIDE Flashcards
INFORMED CONSENT
IS REQUIRED IN WRITING AFTER EXPLANATION OF A PROCEDURE WITH TIME TO ASK QUESTIONS
IMPLIED CONSENT
CONSENT THAT IS ASSUMED
CONSENT
IS USED ONLY WHEN THE PERMISSION IS FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS
AUTHORIZATION
IS PERMISSION GRANTED BY THE PATIENT OR THE PATIENT’S REPRESENTATIVE TO RELEASE INFORMATION FOR REASONS OTHER THAN TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS.
AUDITING
REVIEW CLAIMS FOR ACCURACY AND COMPLETENESS
DOCUMENTATION
A COMPLETE, ACCURATE, UP TO DATE RECORD OF THE CARE A PATIENT RECEIVES AT A HEALTH CARE FACILITY
DISCLOSURE
THE WAY HEALTH INFORMATION IS GIVEN TO AN OUTSIDE PERSON OR ORGANIZATION.
FRAUD AND EXAMPLES
INTENTIONAL MISREPRESENTATION OF INFORMATION FOR THE PURPOSE OF RECEIVING HIGHER PAYMENT
-FALSE STATEMENTS OF FATS TO OBTAIN OF PAYMENT NOT ENTITLED TO
-BILLING FOR SERVICES NOT RENDERED
ABUSE
UNINTENTIONAL, OFTEN BECAUSE OF POOR BUSINESS PRACTICES.
UPCODING
ASSIGNING A ODE THAT WILL DELIBERATELY RESULT IN A HIGHER PAYMENT
STARK LAW STATES
PHYSICIANS CANNOT REFER PATIENTS TO PRACTITIONER WITH WHOM THEY HAVE A FINANCIAL RELATIONSHIP
OFFICE OF THE INSPECTOR GENERAL IS RESPONSIBLE FOR
FIGHTING FRAUD
FACTORS THAT AFFECT BILLING
-NUMBER OF INSURANCE PLANS
-COORDINATION OF BENEFITS: AVOID DUPLICATION
-PRIMARY PAYS FIRST
-IF SERVICE COVERED UNDER SECONDARY, PRIMARY PAYS BALANCE
-CANNOT COLLECT MORE THAN CHARGED FOR SERVICE
BIRTHDAY RULES
APPLIES TO DEPENDENT CHILDREN WHOSE PARENTS HAVE MORE THAN ONE INSURANCCE POLICY.
-PARENT BIRHTDAY COMES 1ST IS PRIMARY
-IF BOTH HAVE SAME BIRTHDAY, PLAN THAT HAS COVERED THE LONGEST IS PRIMARY
-PARENT WITH CUSTODY IS PRIMARY
-PLAN OF ACTIVE EMPLOYEE IS PRIMARY
MEDICAID
PAYER OF LAST RESORTS
WHY IS IT IMPORTANT TO VERIFY INSURANCE INFORMATION?
BEFORE SUBMITTING CLAIM IT IS IMPORTANT TO MAKE SURE THAT THE INSURANCE IS VALID, AND THE SERVICES ARE A COVERED BENEFIT
MEDICARE
-65 AND OLDER
-YOUNGER THAN 65 WITH DISABILITIES
-END STAGE RENAL KIDNEY DISEASE
MEDICAID
-LOW INCOME
-NON-GOVERNMENT CARRIERS
PRIVATE INSURANCE
SUBSIDIZED THROUGH PREMIUMS
EMPLOYER HEALTH INSURANCE
-SELF INSURED
-USUALLY LESS EXPENSIVE
MEDICARE PART A
HOSPITALIZATION COVERAGE
-INPATIENT HOSPITAL CARE
-SKILLED NURSING FACILITY CARE
-HOME HEALTH CARE
-HOSPICE CARE
-INPATIENT CARE
-BENEFITS PERIODS
-LIMITATIONS ON PAYMENT
MEDICARE PART B
VOLUNTARY SUPPLEMENTAL INSURANCE
-CALENDAR DEDUCTABLE 20% COINSURANCE
———–COVERS————
-EMERGENCY, OUTPATIENT, HOME HEALTH CARE
-LABORATORY, DIAGNOSTIC TEST
-AMBULATORY SURGERRY
-PHYSICAL, SPEECH, OCCUPATIONAL THERAPY
-RADIATION
-KIDNEY DIALYSIS, TRANSPLANTS
———–NOT COVERED———–
-LONG TERM NURSING CARE
-COSMETIC SURGERY
-DENTAL
-ACUPUNCTURE, HEARING AIDS, EXAMS
MEDICARE PART D
DRUG BENEFITS
-RUN BY PRIVATE INSURANCE COMPANIES
-VARY IN COST, COVERAGE
-BENEFICIARIES CHOOSE BASED ON NEEDS
———–OUT OF POCKET EXPENSES———-
-PATIENTS RESPONSIBLE FOR CHARGES
-COST SHATRING FOR PART B
MEDICARE PART C
MEDICARE ADVANTAGE
COMBINATION PACKAGE
-EXTRA COVERAGE
-VISION
-HEARING
-DENTAL
-HEALTH, WELLNESS
-PRESCRIPTION DRUGS
-REQUIREMENTS FROM CMS
MEDICARE ADVANTAGE OPTIONS
HMO: APPROVED LIST OF PROVIDERS EXCEPT IN EMERGENCY
PPO: PROVIDERS IN NETWORK, EXTRA FEE FOR OUT OF NETWORK
PRIVATE FEE FOR SERVICE: ANY PROVIDER WITH AGREEMENT, PLAN DETERMINES PAYMENT
MEDICARE SPECIALTY:SPECIALIZED CARE FOR SPECIFIC GROUPS, MEDICARE AND MEDICAID, NURSING HOME, CHRONIC MEDICAL CONDITIONS
MEDIGAP
PRIVATE HEALTH INSURANCE, PAYS FOR MOST CHARGES NOT COVERED BY PART A AND B, MEDICAID CAN PAY SOME OUTSTANDING EXPENSES.
PREMIUMS
-PRE-ESTABLISHED AMOUNT SET BY INSURANCE COMPANY
-PAID REGULARLY
-GO INTO FUND THT PAYS FOR CLAIMS
-COMPANY REVIEWS CLAIMS FOR COVERAGE
-REVIEWERS CHECK DIAGNOSIS CODE
-PAYMENT TO PROVIDER OR POLICY HOLDER
-INFO POLICYHOLDER RECEIVES UP FRONT
COVERED SERVICES
-WHEN COMPANY PAYS
-HOW MUCH, LONG COMPANY PAYS
-CORRECT PROCESS
EMPLOLYER BASED SELF INSURANCE PLANS
-SAVES COMPANIES MONEY
-ELIMINATES PRIVATE INSURER FEES
-VARY IN DESIGN, SERVICES
-COST SHARING
-USUALLY CHEAPER THAN INDIVIDUAL PLANS
FUNDING FROM ASO CONTRACTS (ADMINISTRATIVE SERVICES ONLY)
-EMPLOYERS FUND PLANS
PRIVATE INSURERS ADMINISTER PLANS
BLUE CROSS AND BLUE SHIELD PLANS
-FIRST PREPAID PLANS IN US
-BLUE CROSS HOSPITAL CARE
-BLUE SHIELD PHYSICIAN SERVICES
-MERGED 1982
-INCLUDES 60 COMPANIE
——OFFERED TO———
-INDIVIDUALS
-SMALL BUSINESSES
-SENIORS
-LARGE EMPLOYER GROUPS
-GOVERNMENT BC/BS FEDERAL EMPLOYEE PROGRAM
3 MAJOR GOVERNMENT INSURANE PLANS
-MEDICARE
-MEDICAID
-STATE CHILDREN’S HEALTH INSURANCE PROGRAMS (SCHIP)
PRIOR AUTHORIZATION
REQUIRED BY SOME SERVICES:
-SURGERY
-HOSPITAL STAYS
DETERMINES:
-MEDICAL NECESSITY
-LIKELY LENGHTH STAY
PRIVATE HEALTH INSURANCE VS EMPLOYER SELF-INSURED PLANS
PRIVATE HEALTH INSURANCE IS PAID BY INDIVIDUALS IN THE FORM OF PREMIUMS TO THE INSURANCE COMPANY.
VS
EMPLOYER SELF-INSURED PLANS ARE PURCHASED IN MASSE BY THE EMPLOYER AND ARE SOMETIMES MORE COST EFFECTIVE.
-ADDITIONAL COSTS ADDED TO PREMIUMS ARE LARGELY ELIMINATED
-EMPLOYERS FUND THE HEALTH INSURANCE PLANS
-OFTEN, EMPLOYERS ENTER INTO AGREMENTS WITH PRIVATE INSURERS TO MANAGE THE PLANS
PRECERTIFICATION
-BEFORE PROCEDURES, SURGERY
-ASKS IF SAFER, CHEAPER AS OUTPATIENT
-PLAN CAN DENY COVERAGE
-PRECERTIFICATION NUMBER IS APPROVED
PREDETERMINATION
-WRITTEN REQUEST FOR VERIFICATION OF BENEFITS
-REPLY IN WRITING
-USUALLY NOT NECESSARY
WHO IS USUALLY THE GATEKEEPER AND WHAT IS ROLE?
USUALLY THE PRIMARY CARE PHYSICIAN, THE GATEKEEPER DETERMINES IF REFERRALS TO SPECIALISTS, SERVICES, OR FACILITIES ARE NEEDED AND THEN SELECTS THE PROVIDER THE PATIENT SHOULD GO TO.
PREAUTHORIZATION
APPROVAL FROM THE HEALTH PLAN FOR AN INPATIENT HOSPITAL STAY OR SURGERY.
BEFORE GIVING APPROVAL, THE HEALTH PLAN WILL ASSESS WHETHER THE PROCEDURE IS MEDICALLY NECESSARY AND HOW LONG THE HOSPITAL STAY SHOUL BE.
DEDUCTIBLES
-AMOUNT PATIENT PAYS OUT OF POCKET BEFORE INSURANE PAYS FOR BENEFITS
-VARY BY PLAN
-MUST MEET EACH YEAR
-UNCOVERED EXPENSES APPLY
COPAYMENTS
FLAT FEE THAT A PATIENTPAYS FOR VISITING A PROVIDER OR PURCHASING PRESCRIPTION DRUGS. VARIES FROM PROVIDER TO PROVIDER AND PLAN TO PLAN
TIER ONE
-IN PPO NETWORK
-LEAST EXPENSIVE
-LOWEST PATIENT PREMIUM, COPAY
-PCP COORDINATES, AUTHORIZES ALL SERVICES
TIER TWO
-BROADER, CONTRACTED NETWORK
-PREFERRED PROVIDERS
-NO INDIVIDUAL’S COORDINATION PHYSICIAN
-MID-RANGE PREMIUM
-DEDUCTIBLE, COINSURANCE
TIER THREE
-OUT OF NETWORK
-MOST EXPENSIVE
-FREEDOM OF ANY HEALTH PROFESSIONAL
-HIGHEST DEDUCTIBLE
-COINSURANCE, COPAYMENTS
COINSURANCE
IS A PERCENTAGE OF THE COVERED BENEFITS PAID BY BOTH THE INSURANCE COMPANY AND DTHE PATIENT.
-RATE OF PAYMENT(PE-ESTABLISHED)
-PERCENTAGE PAID BY INSURANCE AFTER DEDUCTIBLE OFTEN 80/20
INSURANCE MAXIMUM
-INSURANCE PAYS 100% AFTER PREDETERMINED AMOUNT
3 KINDS OF INSURANE INFORMATION THAT NEEDS TO BE COLLECTED FROM THE PATIENT
-CORRECT POLLICY NUMBER
-GROUP NUMBER
-POLICY EFFECTIVE DATES AND TYPE OFF POLICY
ADVANTAGE OF EMPLOYER-BASED SELF-INSURANCE HEALTH PLANS
DUE TO ECONOMIES OF SCALE, EMPLOYER -BASED SELF-INSURED HEALTH PLANS AE MORE REASONABLY PRICED THAN PRIVATE INSURANCE
IMPLIED CONSENT
PATIENT VOLUNTARILY UNDERGOES TREATMENT
WRITTEN CONSENT
-ANESTHESIA, EXPERIMENTAL DRUGS
-SURGICAL MANIPULATION
-SIGNIFICANT RISK OF COMPLLICATIONS
-AT LEAST ONE WITNESS
-COPIES IN RECORD
PHYSICIANS RESPONSIBILITY
-RISKS, COMPLICATIONS, BENEFITS
AUTHORIZATION
-PERMISSION TO RELEASE INFORMATION NOT FOR TREATMENT, PAYMENT, HEALTH CARE OPERATIONS
-REQUIRED FOR PSYCHOTHERAPY NOTES
-ALLOWS FAILITY TO DISCLOSE TO OTHER ORGANIZATIONS
-PATIENT OR REPRESENTATIVE MUST SIGN
CONSENT
-PERMISSION TO RELEASE INFORMATION FOR TREATMENT, PAYMENT, HEALTH CARE OPERATIONS
AUTHORIZATION ELEMENTS
-DESCRIPTION OF INFORMATION
-IDENTIFICATION OF PERSON AUTHORIZED
-EXPIRATION DATE
-STATEMENT OF RIGHT TO REVOKE AUTHORIZATION
-STATEMENT OF INFORMATION SUBJECT TO REDISCLOSURE
-SIGNATURE, DATE
-DESCCRIPTION OF AUTHORITY
DOCUMENTATION
-RECORD OF SYMPTOMS, CONDITION, EXAM RESULTS, LAB TESTS
-NARRATIVE FORMAT
-USED BY PROVIDERS, BILLING
-TRANSLATED INTO CODES
CLAIMS
-RECORD OF SERVICE
-SUBMITTED TO THIRD-PARTY PAYER
-PROVIDERS, FACILITIES REIMBURSED
AUDITING
-REVIEW OF CLAIMS
-ACCURACY
-COMPLETENESS
-NONSPECIFIC, INACUCCURATE USE OF CODES
CODE SETS (5)
1.) HCPCS (HEALTHCARE COMMON PROCEDURE CODING SYSTEM)
USED TO CODE FOR MEDICAL PROCEDURES, SUPPLIES,
PRODUCTS, AND SERVICES.
2.) CPT-4 (CURRENT PROCEDURAL TERMINOLOGY) UNIFORM CODING
SYSTEM, IDENTIFY MEDIAL SERVICES AND PROCEDURES.
3.) CDT (CURRENT DENTAL TREATMENT) DENTAL CLAIMS
4.) ICD-10 (INTERNATIONAL CLASSIFICATION OF DISEASES)
EPIDEMIOLOGY, HEALTH MANAGEMENT, CLINICALPURPOSE
5.) NDC (NATIONAL DRUG CODE)
HIPAA
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
-APPROPRIATE CARE FOR DIAGNOSIS : UPCODING, UNBUNDLING
-BILLING FOR SERVICES NOT PROVIDED
-HHS REQUIRES REPORTING OF :
- REDERAL, STATE LICENSING AND CERTIFICAITON ACTIONS
- REVOCATION
- REPRIMANDS
- CENSURES
- PROBATIONS
- SUSPENSION
- LOSS OF LICENSE
- EXLUSION FROM PARTICIPATION IN HEALTH CARE PROGRAMS
STARK LAW
-PROHIBITS REFERRAL TO PRACTITIONER WITH PREVIOUS FINANCIAL RELATIONSHIP
-PROHIBITS PREFERRED PRACTITIONER FROM PRESENTING CLAIMS TO MEDICARE
SERVICES THAT CANNOT HAVE REFERRALS UNDER STARK LAW
- CLINICAL LABORATORY SERVICES
- PHYSICAL, OCCUPATIONAL, SPEECH/LANGUAGE THERAPY
- RADIATION AND IMAGING
- RADIATION THERAPY SERVICES, SUPPLIES
- DURABLE MEDICAL EQUIPMENT
- PARENTERAL, ENTERAL NUTRIENTS, EQUIPMENT, SUPPLILES
- PROSTHETICS, ORTHOTICS
- HOME HEALTH SERVICES
- OUTPATIENT PRESCRIPTION DRUGS
- INPATIENT, OUTPATIENT HOSPITAL SERVICES
FAIR DEBT COLLECTION PRACTICES ACT
-PROHIBITS UNFAIR ABUSIVE PRACTICES TO COLLECT PAYMENTS
-MEDICAL BILLS PROTECTED BY FTC
FALSE CLAIMS ACT PENALTIES
-FINES
-DAMAGE UP TO THREE TIMES SUSTAINED
FALSE CLAIMS ACT
PROTECTS GOVERNMENT FROM OVERCHARGES
MAIN JOB OF THE OFFICE OF INSPECTOR GENERAL
PROTECTS MEDICARE AND OTHER HHS PROGRAMS FROM FRAUD AND ABUSE BY CONDUCTING AUDITS, INVESTIGATIONS, AND INSPECTIONS.
ELECTRONICC DATA INTERCHANGE ADVANTAGES
-TRANSFER OF ELECTRONIC INFORMATION IN STANDARD FORMAT
-EFFECTIVE, COST-EFFICIENT
-TRANSMIT AMONG MULTIPLE ENTITES
-REDUCES HANDLING, PROCESSING TIME
-MINIMIZES RISK OF LOST PAPER DOCUMENTS
-CAN REDUCE BURDEN ON STAFF
-CAN REDUCE OPERATING COSTS
-CAN IMPROVE DATA QUALITY
PRIMARY VS SECONDARY POLICY
THE PRIMARY INSURANCE PAYS FIRST UP TO THE LIMIT OF ITS COVERAGE.
IF THE PRIMARY INSURANCE DID NOT COVER ALL THE CHARGES, THE BILL THAT IS STILL OUTSTANDING IS SENT TO THE SECONDARY INSURANCE.
THE SECONDARY INSURANCE MIGHT NOT PAY ALL THE COSTS
COMMON ERRORS
-DIFFERENCE IN PATIENTS NAME, SPELLING
-MISSING, INVALID:
- PATIENT ID NUMBER
- PATIENT INFORMATION
- SUBSCRIBER, MEMBER NAME
- CERTIFICATE, GROUP NUMBER
- MODIFIERS
- PROVIDER INFORMATION
-LACK OF AUTHORIZATION, REFERRAL NUMBER
-FAILURE TO CHECK BOX FOR ASSIGNMENT OF BENEFITS
-INVALID DATES OF SERVICE
-INCORRECT PLACE OF SERVICE
CLEAN VS DIRTY CLAIMS
CLEAN CLAIMS:
-ACCUEATE
-COMPLETE
-HAVE ALL INFOR FOR PROCESSING
-TIMELY
DIRTY CLAIMS:
-INACCURATE
-INCOMPLETE
-HAVE DELAYS
-OFTEN SENT BACK TO PROVIDER
-CAN UNDERGO MANUAL PROCESSING
CAUSES OF CLAIM TRANSMISSION ERRORS
- MISSING OR INVALID PATIENT IDENTIFICATION NUMBER
- LACK OF AUTHORIZATION OR REFERRAL NUMBER
IN 2012, THE ADMINISTRATION SIMPLIFICATION COMPLIANCE ACT (ASCA), PART OF HIPAA, MANDATED……..
THAT HEALTH CARE CLAIMS BE SUBMITTED ELECTRONICALLY WITH SOME EXCEPTIONS
INFORMATION THAT NEED TO BE ON A CLAIM
-PATIENT NAME
-HEALTH RECORD NUMBER
-GROUP OR PLAN NUMBER
-PROVIDER’S NAME
WHAT IS NPI NUMBER AND WHERE ON THE CMS-1500 DOES IT GO?
NATION PROVIDER IDENTIFIER, GOES ON BLOCK 17B
COMMON PROCESSING ERROR
MISSPELLING PATIENT NAME
MEDICARE IS SECONDARY INSURANCE FOR A PATIENT WHEN….
HE OR SHE HAS A GROUP HEALTH INSURANCE PLAN, IS COVERED BY WORKERS COMPENSATION, OR IS ON DISABILITY.
SIGNING BLOCK 12 ON THE CMS-1500….
AUTHORIZING THE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS A CLAIM
AGING REPORT
-CLAIMS THAT ARE OUTSTANDING
IDENTIFIES THE OUTSTANDING BALANCES IN EACH ACCOUNT USUALLY ORGANIZED IN 30 DAY INCREMENTS
REMITTANCE ADVICE (RA)
REPORT FROM THIRD -PARTY PAYER TO PROVIDER
OFTEN INCLUDES MORE INFO THAN THE EOB INCLUDING A BREADKOWN OF THE ALLOWABLE CHARGES VS ACTUAL CHARGES, WRITE-OFF’S, ANDD INFO FROM MULTIPLE PATIENTS.
EXPLANATION OF BENEFITS (EOB)
SENT TO POLICYHOLDER
*APPLIED FOR ONE POLICYHOLDER
MEDICARE SUMMARY NOTICE (MSN)
SENT TO MEDICARE PATIENTS
-DEDUCTIBLES
-COPAYMENTS
RAS FOR MEDICARE PARTICIPANTS
-ACCEPT ASSIGNMENT
-ACCEPTED AS PAYMENT IN FULL
-MEDICARE’S ALLOWABLE CHARGE
*PRIMARILY SENT TO PROVIDERS
BILL FOR SERVICES NOT COVERED BY MEDICARE
-MUST NOTIFY PATIENT
-NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS
-ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE
RECONCILIATION
REFERS TO THE PROCESS THE BILLING OFFICE GOES THROUGH TO DETERRMINE WHAT PAYMENTS HAVE COME IN FROM THE THIRD-PARTY PAYER AND WHAT THE PATIENT OWES THE PROVIDER.
BILLING OFFIE USES THE RA, EOB, AND MSN TO MAKE THESE DETERMINATIONS.
ROLE OF ACCOUNTS RECEIVABLE DEPARTMENT
MANAGES FOLLOW-UP TO THE BILLING PROCESS FOR A PROVIDER’S OFFICE
TWO KINDS OF INFO CDM STORES
CPT/HCPCS CODE
REVENUE CODE
CHARGE AMOUNT
CHARGE OF SERVICE CODE
GENERAL LEDGER KEY
ACTIVITY/STATUS DATE
ALLOWABLE CHARGE
AMOUNT THE HEALTH INSURANCE COMPANY WILL PAY THE PROVIDERS
