Deck 13: Claim Processing, Payments, and Collections

Question 1

Health plan process of examining claims and determining benefits is called _____.

A) mediation
B) arbitration
C) adjudication
D) negotiation

Answer 1

adjudication

Question 2

Adjudication is made up of five steps designed to see how the benefits will be paid. Which of the following is not one of the steps?

A) initial processing
B) manual review
C) determination
D) resolve

Answer 2

resolve

Question 3

The process of gathering information to begin to adjudicate a claim is called ____.

A) assembly
B) initial processing
C) collecting
D) accumulating

Answer 3

initial processing

Question 4

The term used by payers to indicate that more information is needed for claim processing is called _____.

A) accruing
B) development
C) gathering
D) enhancement

Question 5

Payer's decision about the benefits due for a claim is called ____.

A) resolve
B) decide
C) regulate
D) determination

Question 6

Claims may be downcoded because_____.

A) the patient has not paid the copayment
B) service was performed out of state
C) the documentation fails to support the level of service claimed
D) insurance company has refused to pay the higher code

Question 7

______ is the use of a procedure code that provides a higher payment.

A) higher coding
B) upcoding
C) complex coding
D) advanced coding

Question 8

What is the name of a transaction that explains payment decisions to the provider?

A) electronic health record
B) electronic convention form
C) electronic consultation form
D) electronic remittance advice

Question 9

ERA is the abbreviation for _______.

A) electronic remittance advice
B) electronic release advice
C) electronic reference advice
D) electronic recommendation advice

Question 10

Monitoring claims during adjudication requires two types of information: the amount of time the payer is allowed to take to respond to the claim, and ______.

A) if the patient has paid the premium
B) where the health care service was performed
C) how long the claim has been in process
D) how long the patient has had the policy

Question 11

Classification of accounts receivable by length of time is called _____.

A) maturing
B) aging
C) progressing
D) succeeding

Question 12

________ is a report grouping unpaid claims transmitted to payers by the length of time they remain due.

A) insurance systematic report
B) insurance methodical report
C) insurance aging report
D) insurance organized report

Question 13

The practice management program is used to generate a report that lists the claims transmitted on each day and shows how long they have been in process with the payer. What is this report called?

A) insurance aging report
B) patient aging report
C) accounts receivable report
D) insurance systematic report

Question 14

_____ is the document sent to patients showing how the amount of a benefit was determined.

A) electronic advice for benefits
B) clarification of benefits
C) explanation of benefits
D) justification of benefits

Question 15

EOB is the abbreviation for ______.

A) enlightenment of benefits
B) explanation of benefits
C) elucidation of benefits
D) evidence of benefits

Question 16

A (n) ______ explains the adjustment on the insured's account.

A) alteration code
B) modification code
C) adjustment code
D) amendment code

Question 17

Electronic routing of funds between banks is called ______.

A) electronic reserves transmission
B) electronic resources allocation
C) electronic sources apportionment
D) electronic funds transfer

Question 18

Regulations mandated under the Affordable Care Act (ACA) as of January 1, 2014, require a _______ to appear on both the EFT and its ERA, so the documents are easy to match up electronically.

A) verification number
B) trace number
C) substantiation number
D) support number

Question 19

The feature in some software packages that automatically posts the payment data in the RA to the correct account is called ____.

A) autoposting
B) autocorrect
C) autoplacement
D) autoposition

Question 20

Software feature enabling automatic entry of payments on a remittance advice is called ___.

A) autoposition
B) autoplacement
C) autocorrect
D) autoposting

Question 21

The comparison of two numbers is called ____.

A) resolution
B) assessment
C) reconciliation
D) evaluation

Question 22

The process of _______ means making sure that the totals on the RA check out mathematically with the expected payments.

A) evaluation
B) reconciliation
C) appraisal
D) assessment

Question 23

Improper or excessive payment resulting from billing errors is called ____.

A) overpayment
B) imbursement
C) disbursement
D) compensation

Question 24

To improve the rate of paid claims over time, medical assistants_____.

A) track and analyze each payer's reasons for denying claims
B) call the insurance company
C) fax the claim
D) scrutinize the codes

Question 25

What is the request for reconsideration of a claim adjudication called?

A) petition
B) request
C) requisition
D) appeal

Question 26

If a claim has been denied or payment reduced, what is filed with the payer for reconsideration?

A) plea
B) appeal
C) application
D) petition

Question 27

A (n) ______ is a process that can be used to challenge a payer's decision to deny, reduce or otherwise downcode a claim.

A) appeal
B) demand
C) petition
D) supplication

Question 28

Most payers have an escalating structure of appeals: a complaint, an appeal, and a (n) ___.

A) dispute
B) grievance
C) objection
D) protest

Question 29

A claim that is denied because of untimely submission (submitted after the contractual deadline) is ______ to appeal.

A) subject
B) not subject
C) prolonged
D) automatically subject

Question 30

What is the report summarizing the business day's charges and payments called?

A) day sheet
B) day statement
C) day report
D) day account

Question 31

Record of a patient's financial transactions is called _____.

A) patient data sheet
B) patient report
C) patient explanation
D) patient ledger

Question 32

________ shows services provided to a patient, total payments made, total charges, adjustments, and balance due.

A) patient statement
B) patient explanation sheet
C) patient version sheet
D) patient interpretation sheet

Question 33

______ is a type of billing which divides patients with current balances into groups to even out monthly statement printing and mailing.

A) sequence billing
B) cycle billing
C) succession billing
D) series billing

Question 34

What is the first step in answering patients' inquiries about claims?

A) to talk with the office manager
B) to find out exactly what the problem is
C) to call the insurance company
D) to discuss it with the physician

Question 35

A (n) _________ is made when the practice has overcharged a patient for a service and the patient has a credit balance.

A) refund
B) rebate
C) reduction
D) discount

Question 36

A check drawn on an account that does not have adequate funds to cover the check is called ______.

A) refund check
B) discount check
C) NSF check
D) disregard check

Question 37

NSF is the abbreviation for _________.

A) nonsufficient funds
B) no such funds
C) non adequate funds
D) non satisfactory funds

Question 38

All activities related to patient accounts and follow-up are called ______.

A) gatherings
B) collections
C) assemblies
D) compendiums

Question 39

Collection activities should achieve a suitable balance between maintaining patient satisfaction and _______.

A) code compliance
B) insurance equilibrium
C) generating cash flow
D) physician satisfaction

Question 40

_____ are laws regulating collection practices.

A) Debt Practice Guidelines Act
B) Fair Debt Collection Practices Act
C) Debt Collection Guidelines Act
D) Fair Recording Collection Act

Question 41

_____ has laws regulating consumer collections to ensure fair and ethical treatment of debtors.

A) Telephone Consumer Protection Act
B) Fair Treatment of Debtors Act
C) Consumer Fairness Act
D) Telephone No Call Act

Question 42

_______ prohibits credit discrimination based on race, color, religion, national origin, sex, marital status, age, or because a person receives public assistance.

A) Good Samaritan Act
B) Equal Credit Opportunity Act
C) Equilibrium Recognition Act
D) Equal Expectation Act

Question 43

If the practice applies finance charges or late fees, or if payments are scheduled for more than four installments, the payment plan is governed by ______.

A) Notice of Office Policies Law
B) Notice of Privacy Law
C) Truth in Providing Act
D) Truth in Lending Act

Question 44

_______ is a report grouping unpaid patients' bills by the length of time they remain due.

A) patient aging report
B) patient mature report
C) patient established report
D) patient recognized report

Question 45

______ is money that cannot be collected and must be written off.

A) unaccumulated account
B) uncollectible account
C) default account
D) nonappearance account

Question 46

After the practice has exhausted all of its collection efforts and a patient's balance is still unpaid, the account may be labeled as a (n) ______.

A) absenteeism account
B) uncollectible account
C) malingering account
D) indolent account

Question 47

Account deemed uncollectible is called ______.

A) tax debt
B) bad debt
C) skiving debt
D) truanting debt

Question 48

The physician may decide to dismiss a patient who does not pay medical bills. If the patient is to be dismissed, this action should be _______.

A) documented in a letter to the patient
B) documented in a letter to the insurance company
C) documented in a letter to the government
D) documented in a letter to the IRS

Question 49

An amount entered in a patient's account balance because of a credit or debit is called a (n) _____.

A) write off
B) adjustment
C) transaction
D) correction

Question 50

After patient bills are sent, what process is used to follow up on late payments?

A) transaction
B) adjustment
C) aging
D) collection

Question 51

The process that payers follow to examine claims and determine payments is called ___.

A) adjudication
B) direct transmission
C) claim submission
D) mediation

Question 52

Which of the following is not included on a patient's statement?

A) insurance contact information
B) services and dates
C) charges and adjustments
D) payments and balance due

Question 53

An insurance aging report shows the ages of ______.

A) patients
B) unpaid claims
C) insurance memberships
D) provider

Question 54

When the level of service is reduced by the claims examiner, it is known as ____.

A) downcoding
B) adjusting
C) rejecting
D) denying

Question 55

Downcoding may occur when the procedure does not link correctly to the _____.

A) prognosis
B) physician
C) diagnosis
D) insurance

Question 56

To avoid late payments from payers, medical assistants regularly review the __________.

A) accounts receivable
B) insurance carrier policy
C) patient database
D) insurance aging report

Question 57

An electronic deposit is called a (n) _______.

A) walkout receipt
B) overpayment
C) explanation of benefits
D) electronic funds transfer

Question 58

What should a physician do if he/she considers the carrier's reimbursement for services to be inadequate or incorrect?

A) discontinue seeing the patient
B) file a claim appeal
C) file an electronic funds transfer
D) prepare an insurance aging report

Question 59

A claim appeal is a written request for a ______.

A) review of the determination
B) cancellation of services
C) professional investigation
D) increase in repayment

Question 60

To file a claim appeal, the physician should submit a (n) ____.

A) patient aging report
B) walkout receipt
C) patient statement
D) written document

Question 61

A patient ledger is a collection of what aspect of a patient's account?

A) financial activity
B) medications
C) diagnosis
D) appointment dates

Question 62

Typically, which patients should receive patient statements?

A) all patients who have been to appointments within the last month
B) patients with balances due on their accounts after insurance payments have been received
C) all patients who have been to appointments within the last week
D) patients with balances due on their accounts before insurance payments have been received

Question 63

The collection process really begins with _____.

A) collection phone calls
B) write-offs
C) patient statements
D) effective communications with patients about their responsibility to pay for services

Question 64

What document shows which patient's payments are due or overdue?

A) patient aging report
B) walkout receipt
C) electronic funds transfer
D) insurance aging report

Question 65

An account that is written off from the expected revenues is a (n) _____.

A) patient account
B) bad account
C) uncollectible account
D) past due account

Question 66

Appeals are sent by patients or providers to payers to _______.

A) request a review of a rejected or downcoded bill.
B) complain about a provider
C) negotiation payment
D) reach a compromise

Question 67

_______ ask insurance carriers to reconsider a claim determination.

A) appeals
B) requests
C) arbitration
D) mediation

Question 68

What may be sent when a carrier rejects a claim because preauthorization was not obtained?

A) statement
B) appeal
C) petition
D) plea

Question 69

______ is a payer's decision about paying a health care claim.

A) petition
B) request
C) submission
D) determination

Question 70

A determination by a payer comes _______ the claim review process.

A) at the end of
B) at the beginning of
C) whenever the patient complains
D) when there is an overpayment

Question 71

The insurance aging report is used to _______.

A) monitor deductibles paid by patients
B) monitor overdue claims from payers
C) monitor copayments paid by patients
D) monitor insurance premiums paid by patients

Question 72

The patient aging report is used to ________.

A) determine the age of the patient
B) manage the collection process
C) determine the compendium process
D) manage the insurance claims

Question 73

Uncollectible accounts are also called _______.

A) bad debt
B) negotiable funds
C) unprincipled account
D) debase debt