MOA Chapter 18: Medical Billing Flashcards
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MOA Chapter 18: Medical Billing Flashcards

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Questions and Answers

What does 'adjudicate' mean?

  • To settle or determine judicially (correct)
  • To assist in medical procedures
  • To delay a decision
  • To ignore a problem
  • What is an audit?

    A process completed before claims submission in which claims are examined for accuracy and completeness.

    What is capitation?

    A payment arrangement for healthcare providers where the provider is paid a set amount for each enrolled person per period of time, regardless of services received.

    What does eligibility refer to in healthcare?

    <p>Meeting the stipulated requirements to participate in the healthcare plan.</p> Signup and view all the answers

    What is medical necessity?

    <p>Services or supplies used to treat a patient's diagnosis that meet the accepted standard of medical practice.</p> Signup and view all the answers

    What is the National Provider Identifier (NPI)?

    <p>An identifier assigned by the Centers for Medicare and Medicaid Services (CMS) that classifies the healthcare provider by license and medical specialties.</p> Signup and view all the answers

    What is pre-certification?

    <p>The process of determining if a procedure or service is covered by the insurance plan and what the reimbursement is.</p> Signup and view all the answers

    What is an Explanation of Benefits (EOB)?

    <p>A statement that indicates the patient's deductible and/or coinsurance.</p> Signup and view all the answers

    The steps for medical billing include _____ information when the patient calls.

    <p>collecting patient</p> Signup and view all the answers

    What should the MA always follow regarding claims, review, and signature?

    <p>Office policies related to claims processing.</p> Signup and view all the answers

    What is preauthorization?

    <p>Gives the provider approval to render the medical service.</p> Signup and view all the answers

    What are the steps in a precertification procedure?

    <p>Call the provider services number, provide procedures and diagnosis, document the outcome.</p> Signup and view all the answers

    Patients with HMO plans can obtain a referral to a specialist without visiting their assigned PCP.

    <p>False</p> Signup and view all the answers

    What are electronic claims?

    <p>Insurance claims transmitted over the internet from provider to health insurance company.</p> Signup and view all the answers

    What is electronic data interchange?

    <p>The electronic transfer of data between two or more entities.</p> Signup and view all the answers

    What is direct billing?

    <p>The process by which an insurance company allows a provider to electronically submit claims directly.</p> Signup and view all the answers

    What does a claims clearinghouse do?

    <p>Acts as a go-between for the healthcare facility and insurance company.</p> Signup and view all the answers

    What is an example of what a clearinghouse does?

    <p>Audits the claims for completeness.</p> Signup and view all the answers

    How is primary and secondary insurance determination made for a child?

    <p>By the birthday rule where the parent's birth date that occurs first in the year is considered primary.</p> Signup and view all the answers

    How many diagnostic codes can be in a CMS 1500 Form?

    <p>Up to 12</p> Signup and view all the answers

    What is a Patient-Centered Medical Home (PCMH)?

    <p>A holistic approach to medical care.</p> Signup and view all the answers

    What constitutes fraud in healthcare?

    <p>Knowingly executing a scheme to defraud a healthcare benefit program.</p> Signup and view all the answers

    What does abuse refer to in medical billing?

    <p>Actions contrary to ethical standards that result in overpayment to providers.</p> Signup and view all the answers

    What are clean claims?

    <p>Claims without errors of any type.</p> Signup and view all the answers

    What are dirty claims?

    <p>Claims with incorrect, missing, or insufficient data.</p> Signup and view all the answers

    To verify the claim status, you must provide the _____ and birth date.

    <p>insured subscriber's member number</p> Signup and view all the answers

    How do insurance companies determine medical necessity?

    <p>Based on diagnostic and procedural codes submitted on the claim.</p> Signup and view all the answers

    What is a deductible?

    <p>A set dollar amount that the policyholder is responsible for before insurance begins to reimburse.</p> Signup and view all the answers

    What is co-insurance?

    <p>The insured and the insurance company share the cost of covered medical services after the deductible has been met.</p> Signup and view all the answers

    Study Notes

    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.

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    Description

    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.

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