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52 Cards in this Set

  • Front
  • Back
Primary Care Physician (PCP)
Is a family practitioner, internist, pedicatrician, and in some insurance plans, a gynecologist, responsible for providing all routine primary care for the patient. Also known as GATEKEEPER.
Established Patient
Is a person who has been seen within the last 36 months by the health care provider or another provider of the same speciality in the same group practice.
Encounter Form
Is the financial record source document used by the health care provider to record the patient's diagnosis and services rendered during the encounter.
Birthday Rule
The primary policy is the one taken out by the policyholder with the earliest birthday occurring in the calendar year.
New Patient
Is a person who has not received any professional service from the health care provider within the last 36 months.
Participating Provider
Is a provider who has a contract with the insurance company to provide medical services to subscribers and to accept the insurance company's allowed fee for the procedure and/or service performed.
New Patient Intake Interview
Allows the office staff to gather preliminary data that ensures the patient's insurance eligibility and benefit status.
Primary Care Referral Form
Is a form issued by the PCP that is either hand carried by the patient or faxed to the specialist/ancillary services provider. It is a preauthorization (referral form) from the PCP or case manager to schedule an appointment with a specialist.
Nonparticipating Provider
Is a provider who has no contractual relationship with the patient's insurance company, and has a legal right to expect the patient to pay the difference between the insurance allowed fee and the amount charged.
Case Manager
Is a medically trained person employed by a health insurance company to coordinate the health care of patients with long-term chronic conditions.
Health Care Specialist
Is a health care provider who is not a primary care physician.
True or False: Patients may not be billed for uncovered or noncovered procedures.
False - They may be billed.
True or False: Patients may be billed for unauthorized services.
False - All services must be approved before rendered.
True or False: Any service that is considered not "medically necessary" for the submitted diagnosis code may be disallowed.
True or False: The "allowed charge" is the maximum amount the insurance company will pay for each procedure or service, according to the patient's policy.
True or False: Payment may sometimes be greater than the fee submitted by the provider if the allowed amount if greater than the charge.
False - Payment is never greater than the charge.
What is the name of the insurance claim form used to report professional and technical services?
HCFA 1500
What does HCFA stand for?
Health Care Financing Administration
What does HIPAA stand for?
The Health Insurance Portability and Accountability Act of 1996
is the right of individuals to keep their information from being disclosed to others
is restricting patient information access to those with proper authorization
is the safekeeping of patient information
What is Breach of Confidentiality?
is often unintentional and involves the unauthorized release of patient information to a third party
First Party (in insurance terms)
is the person designated in a contract to receive a contracted service
Second Party (in insurance terms)
is the person or organization who is providing the service
Third Party (in insurance terms)
is the one who has no binding interest in a specific contract
Contract (in insurance terms)
is an agreement between two or more parties to perform specific services or duties
Guardian (in insurance terms)
is the person who is legally designated to be in charge of a patient's affairs
True or False: Breach of confidentiality cannot be charged against a health care provider if written permission to release necessary medical information to an insurance company or other third party has been obtained from the patient or guardian.
True or False: Patients need to sign an authorization for the release of medical information statement before completing the claim form
According to HCFA, patient information and health insurance records are to be maintained for a period of ___ years.
How many years does the State of Michigan require patient records and health insurance records be maintained?
True or False: A dated, signed release statement is generally considered to be in force for one year from the date stated on the form
True or False: The authorization for release of medical information form authorizes the processing of claim forms but the phrase "signature on file" or the patient's signature still needs to appear on each form.
True or False: Patients who undergo screening for the human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) infection should not be asked to sign an additional authorization statement releasing information regarding the patient's HIV/AIDS status
False - They should be asked.
When health care providers agree to treat either Medicaid or a worker's compensation case, they agree to accept the program's payment as payment in full for covered procedures rendered to these patients.
Fraud or Abuse: violations of participating provider agreements
Fraud or Abuse: billing for services not furnished
Fraud (upcoding)
Fraud or Abuse: falsifying medical records to justify payment
Fraud or Abuse: excessive charges for services
Fraud or Abuse: unbundling codes
Fraud or Abuse: submitting claims that include services not medically necessary to treat the patient's stated condition
Fraud or Abuse: improper billing practices that result in a payment by a government program when the claim is the legal responsibility of another third-party payer
Fraud or Abuse: receiving a kickback
Fraud or Abuse: misrepresenting the diagnosis to justify payment
True or False: The Health Care Financing Administration regulations permit government programs to accept only dated authorizations.
False. HCFA regulations allow government programs to accept dated and undated authorizations.
True or False: The federal government allows two exceptions to the required authorization for release of medical information to insurance companies: patients covered by Medicaid or Blue Cross Blue Shield.
False: Patients covered by Medicaid and Workman's Comp. There is also a third: patients seen at hospitals but who are not expected to receive follow-up care in the physician's office.
The process of sending data from one party to another via computer linkage is known as ______
EDI: Electronic Data Interchange
What is Upcoding?
It is the assignment of an ICD-9-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement. Some hospitals engaged in Upcoding and this became a serious fraud concern under DRGs.
What is Fraud?
HIPAA defines "fraud" as an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.
What is Abuse?
It involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments.
What is the difference between Fraud and Abuse?
The difference is the individual's intent.