Quiz 1

Front 1

Primary Care Physician (PCP)

Back 1

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.

Front 2

Established Patient

Back 2

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.

Front 3

Encounter Form

Back 3

Is the financial record source document used by the health care provider to record the patient's diagnosis and services rendered during the encounter.

Front 4

Birthday Rule

Back 4

The primary policy is the one taken out by the policyholder with the earliest birthday occurring in the calendar year.

Front 5

New Patient

Back 5

Is a person who has not received any professional service from the health care provider within the last 36 months.

Front 6

Participating Provider

Back 6

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.

Front 7

New Patient Intake Interview

Back 7

Allows the office staff to gather preliminary data that ensures the patient's insurance eligibility and benefit status.

Front 8

Primary Care Referral Form

Back 8

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.

Front 9

Nonparticipating Provider

Back 9

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.

Front 10

Case Manager

Back 10

Is a medically trained person employed by a health insurance company to coordinate the health care of patients with long-term chronic conditions.

Front 11

Health Care Specialist

Back 11

Is a health care provider who is not a primary care physician.

Front 12

True or False: Patients may not be billed for uncovered or noncovered procedures.

Back 12

False - They may be billed.

Front 13

True or False: Patients may be billed for unauthorized services.

Back 13

False - All services must be approved before rendered.

Front 14

True or False: Any service that is considered not "medically necessary" for the submitted diagnosis code may be disallowed.

Back 14

True

Front 15

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.

Back 15

True

Front 16

True or False: Payment may sometimes be greater than the fee submitted by the provider if the allowed amount if greater than the charge.

Back 16

False - Payment is never greater than the charge.

Front 17

What is the name of the insurance claim form used to report professional and technical services?

Back 17

HCFA 1500

Front 18

What does HCFA stand for?

Back 18

Health Care Financing Administration

Front 19

What does HIPAA stand for?

Back 19

The Health Insurance Portability and Accountability Act of 1996

Front 20

Privacy

Back 20

is the right of individuals to keep their information from being disclosed to others

Front 21

Confidentiality

Back 21

is restricting patient information access to those with proper authorization

Front 22

Security

Back 22

is the safekeeping of patient information

Front 23

What is Breach of Confidentiality?

Back 23

is often unintentional and involves the unauthorized release of patient information to a third party

Front 24

First Party (in insurance terms)

Back 24

is the person designated in a contract to receive a contracted service

Front 25

Second Party (in insurance terms)

Back 25

is the person or organization who is providing the service

Front 26

Third Party (in insurance terms)

Back 26

is the one who has no binding interest in a specific contract

Front 27

Contract (in insurance terms)

Back 27

is an agreement between two or more parties to perform specific services or duties

Front 28

Guardian (in insurance terms)

Back 28

is the person who is legally designated to be in charge of a patient's affairs

Front 29

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.

Back 29

True

Front 30

True or False: Patients need to sign an authorization for the release of medical information statement before completing the claim form

Back 30

True

Front 31

According to HCFA, patient information and health insurance records are to be maintained for a period of ___ years.

Back 31

Five

Front 32

How many years does the State of Michigan require patient records and health insurance records be maintained?

Back 32

Seven

Front 33

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

Back 33

True

Front 34

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.

Back 34

True

Front 35

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

Back 35

False - They should be asked.

Front 36

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.

Back 36

True

Front 37

Fraud or Abuse: violations of participating provider agreements

Back 37

Abuse

Front 38

Fraud or Abuse: billing for services not furnished

Back 38

Fraud (upcoding)

Front 39

Fraud or Abuse: falsifying medical records to justify payment

Back 39

Fraud

Front 40

Fraud or Abuse: excessive charges for services

Back 40

Abuse

Front 41

Fraud or Abuse: unbundling codes

Back 41

Fraud

Front 42

Fraud or Abuse: submitting claims that include services not medically necessary to treat the patient's stated condition

Back 42

Abuse

Front 43

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

Back 43

Abuse

Front 44

Fraud or Abuse: receiving a kickback

Back 44

Fraud

Front 45

Fraud or Abuse: misrepresenting the diagnosis to justify payment

Back 45

Fraud

Front 46

True or False: The Health Care Financing Administration regulations permit government programs to accept only dated authorizations.

Back 46

False. HCFA regulations allow government programs to accept dated and undated authorizations.

Front 47

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.

Back 47

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.

Front 48

The process of sending data from one party to another via computer linkage is known as ______

Back 48

EDI: Electronic Data Interchange

Front 49

What is Upcoding?

Back 49

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.

Front 50

What is Fraud?

Back 50

HIPAA defines "fraud" as an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.

Front 51

What is Abuse?

Back 51

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.

Front 52

What is the difference between Fraud and Abuse?

Back 52

The difference is the individual's intent.