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150 Cards in this Set
- Front
- Back
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Utilization review |
Start with pre-certification for elective admissions and continuous with concurrent review of care and treatment while patient is hospialized |
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Tricare (formerly Champus) |
Eligible after servicing the 7 uniformed services |
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Regions of Tricare |
North, South, and West |
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Tricare Program Options |
Tricare Prime, Private/ Commerical payer, Managed Care |
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Tricare Prime |
Similar to HMO; available in North, South, and West Regions
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Private/Commercial payer |
Group health plan or individual care plan |
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Managed Care |
system that manage delivery of Healthcare to control cast
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Managed care systems |
HMO, PPO, POS, EPO |
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Types of Reimbursement |
Medicare: Part A, B, D and Medicaid |
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Peer Review Origanization (PRO) |
medical review organization that contracts with medicare to review medical necessity, appropriateness, and quality of healthcare services |
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Two Parts of Medicare Program |
Medicare Part A- Hospital Insurance: taxes while working-covers input care in hospital critical access hospital SNF Hospice Care Some home healthcare blood and blood products ambulance services during input stay |
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Medicare part B coverage |
Coverage when deemed medical necessary: 1. DR services 2. Ouput hospital care 3. Ambulatory surgery center facility 4. Some medical services that Part A don't cover 5. Output physical and occupational therapy 6. Some home healthcare 7. Output mental healthcare 8. DME, DX tests and surgical options |
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Level IV appeals Council Review |
must be filed in writing written 60 days after the date of the date of the ALJ hearing decision notice. |
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Limits of filing Part A appeals |
Level 1- Redetermination-120 days of denial letter Level 2- Reconsideration- 180 days of the date of the notice of the MRN Level 3- Administrative Laws- Judge Hearing Request for ALJ hearing- 60days of date on the QIC Level 4- Appeals council review- filed in writing written 60days of date of the ALJ hearing decision notice |
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No fault INS (Personal in way Protection (PIP)) |
Med-Pay accident medical converage |
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Third Party Adminstrator (TPA) |
organizations that are hired by employer to process and administer benefit per employer policies and pay claims at rate deemed as reasonable |
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Workers Compensation |
reimbursement benefits for illness or inquiry that results from job related accident. Hospital benefits basic on DRG output charges reimbursed on fee schedule |
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DEERS |
Active duty and retired sponsors, eligible formerly member and beneficiaries must be entered into DEERS |
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How to secure a lien |
15 days prior to filing a lien a letter should be sent to patient and all responsible parties within 75 days of discharge. |
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Medicaid and State Children's Health Insurance Program (S-ChIP) Peachcare |
provide coverage to targeted low income children in family income below 200% (FPL) eligiblity same as medicaid. |
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Hard Denials |
one which an appeal will be required to rectify the technical, clinical, or substantive denial EX: improper coding, untimely claims submission, etc. |
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Soft denials |
requires additional work in party the provider to obtain payment EX: wrong birthdate of patient or waiting for additional information from the insured.
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Partial Denials |
Claims that are only partially payable; occurs when something is messing or additional information necessary or if are info not obtained thru a certain date and deemed by the insurer as not medically necessary |
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Coding |
process of converting a narrative description of decrease inquires and operative into a numerical classification |
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ICD9-CM |
International classification of decrease 9th edition clinical modification |
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Diagnosis Definition: Reason for Visit |
Compliant which is primary reason for output visit |
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State Health Benefit Plan |
administered by the Dept. of Community; provides health coverage to state employees, teachers, reitrees, and dependents; self insured exception of fully insured HMO; funded by employer and employee contributions |
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How to Verify individual coverage |
1. Name Insurance Company: confirm coverage 2. Verify correct address/ contact person for claim processing and F/U 3. Determine of company hones an assignment of benefits. |
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Concurrent Review |
process of reviewing coverage for the member's inpatient confinement based in the terms of the memberships agreement, condition of member, appropritateness of venue discharge treatment planes |
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CMS Authorization and Reimbursement |
1. Requires prior authorization for all services. 2. Is the payer of last resory all bills must be submitted to CMS in 180 day of last date of service. |
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The Five Healthcare Control Points |
1. Before admissions/ registration and before service is provided, except when EMTALA laws apply obtain info by phone, verify INS, estimate pts portionof bill and ins coverage, state policy and financial counseling process 2. At admission/registration- review info, obtain signatures, obtain ins. and dempgraphic info and pt. portion 3. IN house 4. At discharge 5. 30 days after discharge. |
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Medical necessity requirement upon registration |
an analyst of the medical treatment ordered to determine if it is reasonable and necessary and provided in the most appropriate setting to meet the needs of the patient illness or injury. |
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Split Billing for Federal Employees Program |
requires all inpatient stays exceeding 30 days be split billed by 30 days Initial claim must be billed within 45 days of admission if stay carries over one year, the next all chrop in the first year should be on the claim |
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Authorization |
consent, permit, approve, give the right to and or authorized a person medical care- written or oral
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Types of authorization |
1. prospective- issued before any service is rendered 2. concurrent- generated at time the service is rendered 3. retrospective- takes place after the fact 4. pended for review 5. denial- no authorization 6. sub authorization
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Certification or Authorization Number |
these number will time the service claim, and authorization together to facilitate timely reimbursement |
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Underwriting |
Analysis of a group that is done to determine rates or to determine wheter the group should be offered coverage.
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What are the 3 CMO's for medicaid and peachcare for kids? |
1. GA families 2. Amerigroup community care 3. Wellcare of GA and Peach state health care plan |
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Two types of Audits |
1. Insurance Company Audit 2. Hospital/ Defense Audit -payments for claim may also be delayed if a claim is audited |
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4 types of consent for Treatment |
1. Actual or expressed- written/oral 2. Implied- consent by silence 3. Implied consent by law- when patient is unconscious and taken to ER 4. Informed- hospital aim for patient understand what he is being treated for and what procedure is performed. |
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The following BCBS that requires service that span 2 years to be split into separate claims for each years of service. |
1. State Health benefit plan 2. federal employee program (FEP) 3. all-out-of-state BCBS plan
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Federal Employee claims |
must be submitted 180 days from date of service are rendered under federal employee health benefit program |
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Usual, customary, reasonable charges (UCR) |
the amount a health plan will recognize for payment for a paticular medical procedure |
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State health benefit , federal, all out of state BCBS plan |
requires service that span 2 years to be split for each year of service. |
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BC and FEP |
-well baby and mom claim file together -sick baby file separate from mother claim from date of birth
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state health benefit |
always file separate mother and baby claim |
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Children's Medical Service (CMS) |
to provide a community-based family focused care coordinated system of medical healthcare for eligible children birth to 21 months with chronic medical conditions. |
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Home Health care |
full range of medical or other health realted services such as physical therapy, nursing, counseling, and social services that are delievered in the home of a patient by a provider. |
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Gate Keeper |
a primary care physician , utilization review, case management, local agency, or manged care entitiy responsible for detereming when and what services a patient can access and recieve reimbursement for. |
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International Classification of Disease, Ninth Revision, Clinical modification (ICD-9-CM) |
the universal coding method used to document the incidence of disease, injury, mortality, and illness classification of disease by diagnoisi, codified into 6-digit numbers
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Purpose of ICD-coding |
to establish medical necessity to facilitate reimbursement.
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Withold |
portion of a claim deducted and held by a health plan before payment is made to a capitated physician |
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HMO |
Health Maintenance Organization offers prepaid, comprehensive health coverage for both hospital and physician services. |
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Centers of Medicare and Medicaid Services (CMS) |
a federal agency in the US dept. of Helath and human services responsible for medicade, medicare and state children's health insurance program |
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ICD9-CM codes |
establishes medical necessity - 1st step in reimbursement process |
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Medically Needy |
covers aged, blind, disabled children under 18 and pregnant women
Process allows a person to use incurred medical bills to spend down the difference between income.
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Unbilled Accounts |
another aspect of accounts receivable billing is measuring how many discharged not final bill is pending. |
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Consolidated Omnibus Budget Reconciliation Act (COBRA) |
an act that allows workers and their families to continue their employer sponosored health insurance for a certain amount of time after terminating employment 60days to elect COBRA |
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Medicare Secondary Payer (MSP) |
a system which requires provider to identify payers that is primary to medicare as part of the registration process |
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National provider Indentifier |
the number that will replace healthcare provider indentifiers in use today in HIPAA standared tranactions. |
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Sterilizations consent |
Mandatory waiting period between signed/consent and sterilization is 30 days expires; 180 days from date of signature |
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Pre-existing conditions |
a medical condition developed prior to issurance of a health policy that may result in limitation in the contract on coverage or benefits. |
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72 hour (3 day) rule |
a medicare regulation in which all outpatient diagnostic services or other services related to admission performed within the 3 days prior to a hospital admission must be bundled together on the same bill to medicare |
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bad debt |
an account which is uncollectible from a patient |
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Assignment of benefits |
method used when a claimant directs that payment to be made directly to the healthcare provider by the health plan |
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EMTALA ( Emergency Medical Treatment and Labor Act) |
an act pertaining to emergency medical situations requires hospitals to provide emergency treatment to individuals regardless of insurance status and ability to pay |
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Explanation of Benefits (EoB) |
A statement sent to covered individuals explaining services provided, amount to be billed and payments made
a summary of benefits provided subscribers by the carrier |
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Allowance |
the amount of money that is written off and not collected due to a contracted obligation with a payor |
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Workers Compensation |
A state program funded by the employers in that sate coverage provides funds to pay for illness or injury that resulted from a job related accident.
Out patient is reimbursed on fee schedules
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Co-payment |
a set fee that a patient has to pay the provider each time he/ she recieves care or medication |
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Urgent admission |
that patient requiring admission to the hospital for a clinical condition that would require admission for a diagnosis and treatment within 48 hours |
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ERISA (Employee Retirement Income Security Act) |
Federal act passed 1974 regulates majoruty of private pension and welfare group benefit plans in the US |
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Crime Victims Compensation |
assist eligible victims of violent crime with expenses that are incurred due to the victimization
a payer of last resort
total awards 25,000
innocent victims that's been physically injured in violent crimes
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Estates |
know which country patients resided
to locate an estate contact probate court |
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Durable medical equipment (DME) |
equipment that typically withstands repeated use, improves function or retards further deterration of a phyiscial condition and primarily provides a medical function |
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Health care financing adminstration (HCFA) |
federal government agency with dept of health and human services directs and overseas the medicare and medicaid programs
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Pre-Access |
a form designed to capture all delay necessary to assess the patients ability to pay or meet hospital financial requirement |
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Penal and appeals |
methodology used by provider to ask for preconsideration of payment on denied claims |
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What's the differ between CPT and HCPCS codes? |
CPT codes- identify medical procedures
HCPCS codes to identify various different medical supplies such as medications |
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Scheduling |
the process by which a patient is allocated a time for services ordered by their physicians |
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190 days lifetime limitation |
a patient covered under medicare hospital insurance is entitled to have payment made for inpatient psychiatric hosiptal services for this period. |
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Condition codes |
2 digits alphanumeric codes that indicate conditions or event for billing period
field locator: 18-28 |
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Occurence codes |
dates define a significant event realting to this bill that may effect processing
describes when event happen on date
field locator: 31-34 |
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Value code |
related dollar or unit amount identify data of a monteary nature that are necessary for processing of claim
field locator: 30-41 |
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Cancer State Aide (CSA) Payment |
the hospital is reimbursed at 100% of the drug cast plus an established handdling fee per drug per day
handling fee is established as of july 1st each year
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The 5 healthcare collection control points |
1. before admissions/registration and beofre servies except when emtala law apply 2. at admission/ registration 3. in house-monitor charge on change in benefit 4. at discharge- collect patients portion on make financial arrange 5. 30 days after discharge F/U overdue account f/U by phone on large account by may small balance |
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benefit period |
a way which medicare measures a beneficiary's use of hospital and SNF services.
period begins the bay the beneficary is admitted to a hospital or SNF and ends when patitent reveived hospital or SNF services for at lease 60 consecutive days. |
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Medicare and Medicaid |
the major sources of reimbursement for nursing homes or skilled facilitites |
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Accuracy |
utmost importance because the basic of sound billing and collections depends on the type of information collected |
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2 basic collection ratios every physican practices should review |
gross collection ration and net collection ration |
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third party administrators (TPA) |
Organizations that are hired by employers to process claims, administer benefits per the employer's policies and pay claims at rates the TPA determines as reasonable. |
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vital statistics |
statistics relating to births, deaths, marriages, health and disease.
can be obtained from CDC, state, helath depts, county health depts and other agencies
like blood pressure, temperature, and weight |
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consumers drivers healthcare |
developed as a buisness model for health ventures
designed to engage consumer more directly in their healthcare purchases
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medically needy |
covers aged, blind, disabled, children under 19 and pregnant women |
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coordination or benefit's (COB) |
the procedure set forth in a subscription agreement to determine which coverage is primary payor with members with duplicate coverage |
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deductible |
the amount of money or value of certain services a patient or family
must pay before costs are covered by the health plan of insurance company per year |
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birthday rule |
the benefits of the insurance plan of the parent whose birthday falls early in a year are deteremined before those of the insurance plan of a parent whose birthday fall later in that year |
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cancer state aid (CSA) |
a program established in 1937 by GA legislature to provide cancer treatment to uninsured and under uninsured low income cancer patients. |
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Advanced Directive for healthcare act |
referred to as a living will and a healthcare power of attonery |
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ICD9-CM coding system utilized to |
report the daignoses applicable to each service rendered |
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when usage of ICD9CM codes |
medicare required this usage after passage of the medicare catastrophic act of 1988 |
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Purpose of ICD system |
provide morbidity states for the world health organization to report info to support the need for patient care or treatment |
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HIPPA |
Health Insurance Portablility and Accountatblilty Act of 1996.
federal involvement in insurance regulation
a federal law that sets minimum standard for regulating the small group insurance market |
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certification |
required to be signed when obtained.
healthcare as soon as practiable after the sart of care and prior to submitting a claim to the intermediary
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What is managed care? |
-To healthcare providers- manage care is simpliy a healthcare company who contracts with provides to give discount on health services
-To Patient- it is a health benefit plan that cast lens when patient chose a providers that is in network
-to State- Health benefit plans which provides health benefits on prepaid basis |
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Medical Necessily Denials |
occurs at all states before, during and after provision of service |
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Financial Counselor |
responsible for interviewing patients and assisting them in making suitable arrangements to meet their finanancial obligations to the provider |
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gender rule |
used by payers the male's insurance is considered to be the primary payer |
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catastropic changes |
used by medicaid to describe a serious illness that is expected to consume the major share of recipients income and sources |
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revenue code |
code on the UB-04 used to identify a specific accommodation charge, ancillary service cahrge, or a type of billing calculation
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Skilled nursing facility (SNF) |
a licensed institution as defined by medicare enaged in the provision of skilled nursing care |
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admission |
the formal acceptance of inpatients into a hospital or other inpatient health facility |
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co-insurance |
a cost-sharing requirement under a health insurance policy |
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medicare advantage plan part C |
offered by torirate companies- covers all of Part A (hospital insurance) and part B ( medical insurance) coverage ; extra coverage, vision, dental, and health and wellness programs
most include medicare Rx drug coverage (part D) |
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Type of Bankrucpty |
Chapter 7: complete discharge of all debts chapter 11: business reorganization Chapter 12: bankrupticies for farmers Chapter 13: to reorganize debt and restructive a payment plan with bankruptcy, court, and 3-5 years to pay of bank. plan |
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Short Term account care |
medicaid reimbursement for psychiatric services is limited to 30 days |
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Long Term Acute care hospital (LTAC) |
hospital that have an average in patient length stay greater than 25 days |
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ICD- 9CM coding |
the process of converting a narrative description of diseases, injuries, and options into a numerical classification system |
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hospice |
providing care for the terminally ill
reqs. patient must have terminal DX prognosis- expected to live 6 months or less patient must be a resident of state where treatment is rendered |
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Diagnosis Related groups (DRGs) |
a system for classifying hospital stays according to the diagnosis of the medical problem being treated for the purposes of payment 3 digit code |
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Advance Benficary notice (ABN) |
A notification that the patient may be expected to pay for lab testing that medicare has determined as a non-covered services
by signing, patient understand they will be responsible for the test if medicare doesn't pay |
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Linking |
critical to associate the correct ICD-9 code to the correct CPT code |
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25,000/person and 50,000/person |
GA mandatory auto insurance law requires that drivers have at least they following liablilty coverage for bodily injury |
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pre-authorization |
a cost containment feature of many group medical policies whereby the insured must contact the insures prior to a hospitalization or surgery and receives authorization for the service. |
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the goals of utilization review to ensure healthcare services are: |
medically necessary
appropriate for the patient's condition and treament
each hospital day is necessary |
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Billing Forms |
CMS 1450 or UB04 claim form
used to bill hospital inpatient, outpatient, hospice, home health swing beel, and skilled in services
UB04 contains 81 forms locators |
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Skilled nursing facility |
a licensed instiution as defined by medicare engaged in the provision of skilled nursing care
DRG or PPS exempt |
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Utilization Management (UM) |
the process of evaluting the nessity, appropriateness and efficiency of healthcare services against established guidelines and criteria |
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Technical Denials |
denials occur when there is alleged coding or informational errors on claims, which prevent them from being considered clean and therefore payable by an insurer. |
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clinical denials |
denials that may occur when certain medical criteria is not met in accordance with standards |
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Tort |
a civil wrongdoing, other than a breach of contract done to another person |
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med pay (medical payment coverage) |
no longer mandate coverage for medical expenses or wage loss of occupants of the insured vehicle who are injured |
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HIPAA privacy |
notification sent to patient advising of their medical rights |
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HIPAA security |
protection of the electronic data |
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Precertification |
the process of determining medical necessity, required for certain procedures, determined by insurance/medicare and medicaid claims |
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Crime Victims eligible requirements |
crime has to be reported to proper government authorties within 72 hours
filed claim within 1 year of crime; applications received 2 years after the crime can't be considered for compensation |
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Pre-certification/Preauthorization |
notification must be made prior to visit on elective preplanned procedure/admission and within 24-48 hours of urgent. emergent procedures and hospital admissions
Denials and appeals submission: 90- 180 days from denial issued |
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Type of Bill Form |
provides specific information; a 3 digit code regards to the type of facility;
1st digit: type of provider 2nd digit: bill classification 3rd digit: frequency of bill |
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State Children's Health Insurance Program |
a program for uninsured children in the United States that is administered by CMS in conjunction with the Health Resources and Services Administration |
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Medical Necessity |
an analysis of the medical treatment ordered to determine if it is reasonable and necessary, and provided in the most appropriate setting to meet the needs of the patient's illness or injury |
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Modifiers |
used to further describe after or enhance the description of the services
3 levels of HCPCS |
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Healthcare common procedure coding system (HCPCS) |
a medical code set using CPT4 alphanumeric and local codes to identify healthcare procedures, equipment and supplies for claims submission |
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What are the 3 levels of Healthcare common procedure coding system? |
Level 1: CPT (current procedural terminology) 5 digits with descriptive terms
Level 2: National codes, alpha and 4 digits
Level 3: alpha and 4 digits; reports service not yet part of level 1 or 2 assigned by carriers
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Special Billing Situation (Inpatient maternity claims) |
F/C both mother and baby charges on some claim of baby
if sick baby- file 2 claims one for mother charges and separation for baby from date of birth
State health benefits- always file 2 separate claim for mother and baby |
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Cancer State Aid Does NOT pay for the following: |
1. treatment for conditions other than cancer 2. treatment provided by non participating CSA facilities 3. Treatment rendered by special /other vendors without prior approval of CSA administration 4. Prostheses 5. Routine dental services/entreatment |
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Home heatlh Agency (HHA) |
a public agency or private organization that is primarily engaged in providing SN services, theraputic services, physical speech or occupational therapy
requires you to obtain a signed certification as soon as practicable after the start of care and prior to submitting a claim to the intermedary
does not requrie prior approval by medicaid |
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What's covered by home health services: |
nursing services, home health aid service, therapy services
filed on 1500 claim form |
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Fair credit billing Act |
for the protection of consumers applies to all creditors
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What does the Fair credit billing Act covers? |
1. the patient must notify hospital in 60 days after statement is mailed of any error 2. hospital must response within 30 days of receiving 3. the error must be corrects with 2 billing cycles or 90 days
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Truth in Lending Act (AKA Consumer Credit Protection Act) Federal Regulation Z covers: |
1. Someone who regularly extends credit that: a. subject to a finance charge b. payable in more than 4 installments 2. And to who the obligation is initially payable by agreement or on the face of the note. b. consumer credit must be great by virtue of written agreement to pay more than 4 installments
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