MOA Chapter 18: Medical Billing Flashcards

Medical Billing and Reimbursement Terminology

• Ajudicate: Refers to settling or determining matters judicially.
• Audit: A review process for verifying the accuracy and completeness of claims before submission.
• Capitation: A fixed payment model where healthcare providers receive a set fee for each enrolled patient, regardless of service usage.
• Eligibility: The criteria that must be met for participation in a healthcare plan.
• Medical Necessity: Services must align with the patient's diagnosis and adhere to accepted medical standards using CPT and HCPCS codes linked to ICD-10 Codes.

Provider Identification and Certification Processes

• National Provider Identifier (NPI): A unique identifier assigned by CMS to classify healthcare providers by their licenses and specialties.
• Pre certification: Evaluates the insurance coverage for specific procedures and services before they are rendered.
• Preauthorization: Provider approval process confirming eligibility to perform the requested medical services.

Claims Management and Submission

• Explanation of Benefits (EOB): A document detailing the patient's deductible and coinsurance status.
• Steps for Medical Billing: Involves collecting patient information, including demographic and insurance details upon appointment scheduling.
• Clean Claims: These claims are free of errors and eligible for processing by insurers.
• Dirty Claims: Claims that contain errors, omissions, or insufficient information, which can delay processing.

Health Insurance Plans and Referral Systems

• Patients with HMO Plans: Must obtain a referral from their assigned primary care physician (PCP) to see specialists.
• Primary and Secondary Insurance Determination: Governed by the birthday rule, where the earliest parent's birthday qualifies as the primary insurance.

Electronic Claims and Data Interchange

• Electronic Claims: Insurance claims submitted online via electronic data interchange directly from providers to insurers.
• Claims Clearinghouse: Acts as an intermediary that facilitates communication between healthcare providers and insurance companies.
• Direct Billing: Enables providers to electronically submit claims directly to insurance companies.

Financial Terms in Medical Billing

• Deductible: The specific annual amount the policyholder must pay before insurance starts covering medical costs.
• Co-Insurance: A shared cost system post-deductible, commonly structured as an 80/20 split between the insured and insurer.

Ethical Considerations in Medical Billing

• Fraud: Engaging in deceptive practices to wrongfully gain financial benefits from healthcare programs.
• Abuse: Actions that may breach ethical standards in healthcare billing, which may lead to overpayments, even if unintended.

Additional Concepts

• Patient-Centered Medical Home (PCMH): A comprehensive approach focusing on holistic patient care.
• Maximum Diagnostic Codes: Up to twelve diagnostic codes can be placed on a CMS 1500 Form for claims.

Test your knowledge on key terms related to medical billing and reimbursement essentials from MOA Chapter 18. This quiz covers important concepts such as adjudication, audits, and capitation. Perfect for anyone looking to enhance their understanding of medical reimbursement processes.