Deck 16: Payment for Professional Health Care Services Auditing and Appeals

Question 1

Most patients understand that their health insurance plan will not cover all services.

Answer 1

False

Question 2

Patient's marital status is important in determining the financially responsible party.

Answer 2

True

Question 3

If your physician is a PAR with BC/BS and you need to obtain copies of their payment policies and procedures, you can request these from BC/BS either in writing or via phone and they will send them to the office..

Answer 3

True

Question 4

If the patient's insurance has not changed, there is no need to get a copy of the card at each visit.

Question 5

Retroactive payment for services provided is referred to as reimbursement.

Question 6

HIPAA requires insurance plans and clearinghouses to use standard rejection codes and descriptions.

Question 7

Encounter forms, rounding forms, or electronic devices help physicians keep track of time spent with patients and the corresponding coding for billing purposes.

Question 8

If someone purposefully attempts to deceive by inflating claims submitted, it can result in _____.

A) fines
B) prison
C) forfeiture of future claim payments
D) All of these answers are correct.

Question 9

The reimbursement amount for Medicare is determined by _________.

A) The aging council
B) AARP
C) CMS
D) HCFA

Question 10

The H prefix on an insurance card most likely means the patient only has hospital coverage.

Question 11

It is imperative to verify eligibility and benefit coverage for the patient prior to their being seen by the physician.

Question 12

Commonly, claim forms are sent back for time errors in the ADMISSION process.

Question 13

Medicare has which of the following steps in the claims process?

A) Redetermination
B) Reconciliation
C) Appeals
D) Magistrate

Question 14

Insurance eligibility is verified either by calling the insurance company or via the Internet.

Question 15

If a physician chooses not to participate in a contract with insurance programs, they are left to do their own _______.

A) advertising
B) insurance program
C) billing
D) payment collection

Question 16

The CMS-1500 claim form is only for use in billing Medicare and Medicaid.

Question 17

If a patient has no insurance, it is okay to send them a bill to pay at their convenience.

Question 18

If an insurance claim is denied, you can appeal through the insurance company's appeal process.

Question 19

A major challenge for the coder is correlating the CPT service code with the HCPCS codes.

Question 20

Even if you have an outside intermediary that checks for accuracy in your claims, you should still have an internal quality control process to ensure accuracy of the claim.

Question 21

The receipt of payment is dependent upon ________.

A) accuracy of data on the claim
B) which insurance company you are billing
C) the intermediary
D) the third-party administrator

Question 22

Outpatient services such as physical therapy, physician visits, etc. are covered by what type of Medicare?

A) A
B) B
C) C
D) D

Question 23

When physicians are paid a certain amount to treat a group of patients in their plan, it is called

A) capitation
B) net profit
C) HMO
D) per diem

Question 24

___________________________ are mandatory tools for success in billing.

Question 25

What types of audits are there? Describe the goal of each.

Question 26

____________________ is money the practice does not earn because all services were not coded appropriately.

Question 27

______________________________ has NOT signed an agreement with an insurance carrier to accept insurance as payment in full and therefore can charge the patient the balance.

Question 28

Performing a ____________________ involves review of the claim and the medical record for consistency.

Question 29

____________________ is not just for Medicare and Medicaid compliance.

Question 30

If a medical record is __________________________ it can be misinterpreted and a claim may not be approved.

Question 31

List and define three of the "risky behaviors" coders should avoid.

Question 32

A traditional indemnity plan is paid ____ by the insurance and ___ by the patient.

A) 70%, 30%
B) 80%, 20%
C) 90%, 10%
D) 100%, 0%

Question 33

The process of reviewing EOBs, posting payments, and determining if the payment amount is correct is called ____________________.