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

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

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

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.

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

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

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

The receipt of payment is dependent upon ________.

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

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

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

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

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..

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

____________________ is not just for Medicare and Medicaid compliance.

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

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

The reimbursement amount for Medicare is determined by _________.

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

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

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