Seminar Test #3 (Ch 11-13)

Front 1

Health Insurance

Back 1

Protection Against Financial Loss of Unplanned Events

Front 2

Process of recording, classifying, summarizing, reporting, analyzing, and interpreting financial data:

Back 2

accounting

(provides financial info about the business operation)

Front 3

Types Of Health Insurance Programs

Back 3

1. Commercial
2. Managed Care
3. Government Plans

Front 4

property owned or controlled by a business (ie: land, buildings, office/medical equipment, accounts receivable, stocks, bonds, etc.)

Back 4

asset

Front 5

Commercial Health Plans

Back 5

Policies created and sold by private companies
a) Fee-for service
b) usually have a deductable
c) Commonly pay for percentage of allowed charges (commonly 80%)
d) patient can make appointment with any doctor in any specialty; insurance will pay designated amount for services.

Front 6

debt obligation of the business (ie: accounts payable, bank debts)

Back 6

liability

Front 7

Managed Care Plans

Back 7

Movement to control healthcare costs while improving preventative care
a) each patient chooses one provider as primary care provider
b) Care may be restricted to providers, labs, and hospitals unless they accepy payment
c) Patient may not have access to providers or services outside of plan
d) Plan may require referrals from primary care provider (Gatekeeper) for consults, therapy, and testing.
e) plan usually requires pre-authorization for surgery or other procedures

Front 8

amount by which assets exceed liabilities

Back 8

owner's equity

(aka: net worth)

Front 9

Types of Manged Care Plans

Back 9

1) Health Maintenance Organization (HMO)
2) Preferred Provider Organization
(PPO)
3) Exclusive Provider Organization
(EPO)
4) Point-of-service Plans

Front 10

The following are all examples of ______________:

Revenue (assets in)
Expense (assets out)
Drawing (personal use of assets)

Back 10

owner's equity

Front 11

HMO

Back 11

Health Maintenance Organization - Organization that provides a comprehensive range of services for a prepaid fee.

- Type of Managed Care Plan

Front 12

assets = _________ + owner's equity

Back 12

liabilities

Front 13

PPO

Back 13

Preferred Provider Organization - Agreement between employers and physician to provide services to employee subscribers at a discount

- Type of managed care plan

Front 14

liabilities = __________ -- owner's equity

Back 14

assets

Front 15

EPO

Back 15

Exclusive Provider Organization - Members must receive services within the network only

- Type of managed care plan

Front 16

owner's equity = ____??_____

Back 16

assets -- liabilties

Front 17

Point-of-Service Plan

Back 17

- In-network combined with out-of-network

- Type of managed care plan

Front 18

oldest and simplest method of bookkeeping that involves a Journal, Cash payment journal, and Accounts receivable ledger

Back 18

Singe-entry system

Front 19

Fee-for-service

Back 19

Commercial Plan

Front 20

Another term for daily log, daybook, day sheet...

Back 20

Journal

Front 21

Gatekeeper

Back 21

Primary Care Provider (PCP) in a managed care plan. Pt goes through "gatekeeper" for permission to see a specialist, get a procedure done, etc.

Front 22

amounts that patients owe the office

Back 22

accounts receivable

Front 23

Government Plans

Back 23

A) Medicare
B) Medicaid
C) State Children's Health Insurance Plan
D) Workers' Compensation
E) Armed Services and Veteran Insurance Plans (TRICARE and CHAMPVA)

Front 24

name the disadvantage of single-entry system bookkeeping:

Back 24

lacks methods for cross-checking to prevent errors

Front 25

Medicare

Back 25

1) Federal program administered by Health Care Financing Administration
(HCFA)
2) Established 1965 as Title 18 of the Social Security Act

Front 26

another name for "pegboard" system of bookkeeping:

Back 26

write-it-once

(most common manual method used in physician's offices)

Front 27

What makes you eligible for Medicare?

Back 27

1) Age 65 or older
2) Disabled under Medicare Rules

Front 28

in the write-it-once (pegboard) system, all transactions are recorded _____________

Back 28

at one time.

Front 29

Medicare Part A

Back 29

A) Covers inpatient care after applicable deductible is supplied

Front 30

Pegboard, day sheet, ledger card, charge slip (or charge receipt) are all supplies for...

Back 30

write-it-once system

Front 31

Is you Brain melting yet?

Back 31

Correct Answers:

1) Yes - keep studying
2) Not Yet - keep studying
3) Ahhhhhhhhh!! - Open a beer and keep studying (or Rum and Coke)

(I chose choice 3 at noon today.)

Front 32

Keeps track of all daily charges and payments for each patient

Back 32

ledger card

Front 33

Medicare Part B

Back 33

1) Voluntary Program (means you have to pay????)

2) Covers CERTAIN outpatient procedures.

Front 34

keeps track of all daily charges and receipts

Back 34

day sheet

Front 35

Medicare Part C

Back 35

Medicare + Choice, Medicare Advantage; Expanded benefits for a fee through private health insurance programs

Front 36

form used to record a charge; serves as a bill or receipt if pt makes payment

Back 36

charge slip, or charge receipt

Front 37

Medicare Part D

(Damn - I didn't even know it went up to D)

Back 37

Drug and Prescription Benefits

* Think "D" for "drugs" *

Front 38

Forms of charge slips:

Back 38

superbill; encounter form

Front 39

Medigap

Back 39

Commercial insurance policies available to cover the Medicare deductible, the co-insurance, and some specific treatments not covered by Medicare.

Front 40

bookkeeping entries are made and recorded simultaneously on all forms at the same time when using this system:

Back 40

Pegboard/ write-it-once

Front 41

Medicaid

Back 41

-Federal program administered by each state
-Established 1965 as Title 19 of the Social Security Act

Front 42

Form of bookkeeping that is inexpensive, can be manually or computer recorded, keeps a continued balance of accounting equation, and affects 2 accounts per transaction (one is debited, other is credited)

Back 42

double-entry system

Front 43

Which insurance always gets billed last?

Back 43

Medicaid

Front 44

Most receipts for accounts receivable come from _____________.

Back 44

third-party payers

*ie: insurance carrier
*may take 30-90 days after service for pymt

Front 45

Medicaid Eligibility Requirements

Back 45

- Determined by each state
- Available to persons with income levels below the federal poverty level
- Eligible patients receive an official identification card for their periods of eligibility
- Person may have both Medicaid and Medicare (Medi/Medi). Medicare is primary carrier and is always billed first.

Front 46

Accounts receivable accounts are classified according to the amt of _______ that the balance remains unpaid

Back 46

days

*ie: current, 30, 60, 90, & past due

Front 47

State Children's Health Insurance Plan

Back 47

- Federal government funding for states to further assist children whose parents cannot afford insurance for them.
- Administered by the state.

Front 48

Money owed to vendors for purchases and services

Back 48

accounts payable

*typically accompanied by an invoice

Front 49

Workers' Compensation

Back 49

-State-administered program to help pay the cost of medical care and lost wages associated with work-related injuries or illnesses.
- Patients are compensated in full for their related medical expenses and for a portion of their lost wages.

Front 50

cash kept within the office (typically about $50) to cover minor purchases

Back 50

petty cash

Front 51

Workers' Compensation Eligibility

Back 51

Patients must sustain an illness or injury while carrying out their job duties

Front 52

One person is designated to make disbursements from the petty cash fund, aka the ____________

Back 52

?????

Front 53

Classification of Workers' Comp. cases

Back 53

1) Claim with no disability : minor injuries or illnesses. Pt returns to work in a few days.
2) Temporary disability : injuries and illnesses requiring more than a few days of recuperation before returning to work
3) Permanent disability : injuries and illness resulting in diminished capacity of the pt; ranges from 10% to 100% disability
4) Vocational rehabilitation : filed for permanently or temporarily disabled persons who require training or education to return to work.

Front 54

only _____ person is designated to make disbursements from the petty cash fund

Back 54

one

Front 55

Claim with no disability

Back 55

Workers' Comp case for minor injuries or illnesses. Pt returns to work in a few days.

Front 56

True or False?

The petty cash fund does not get replenished.

Back 56

False.

Petty cash fund is always replenished.

Front 57

Temporary disability

Back 57

Workers' Comp case for injuries and illnesses requiring more than a few days of recuperation before returning to work.

Front 58

What are set up by a schedule that includes code numbers, detailed description, and cost of each particular service rendered within the practice.

Back 58

Fees

Front 59

Permanent disability

Back 59

Workers' Comp case for injuries and illness resulting in diminished capacity of the pt; ranges from 10% to 100% disability

Front 60

Fee schedules must be available to all __________.

Back 60

patients

Front 61

Vocational Rehabilitation

Back 61

Workers' comp case filed for permanently or temporarily disabled persons who require training or education to return to work.

Front 62

fee most frequently charged for a particular service

Back 62

usual fee

Front 63

Armed Services and Veterans Insurance Plans

Back 63

1) TRICARE - Active military and their dependents (formerly CHAMPUS)
2) CHAMPVA - dependents of injured or killed military veterans

I think the Vets themselves are under TRICARE. I can't figure it out.

Front 64

range of usual fees charged for the particular service by practitioners of similar training and experience

Back 64

customary fee

Front 65

TRICARE Standard

Back 65

fee-for-service plan for military personnel and their dependents

Front 66

fee assigned to an unusual service or a service that has complex features; meets the criteria of usual and customary fees

Back 66

reasonable fee

Front 67

TRICARE Extra

Back 67

PPO plan for military personnel and their dependents.

Front 68

what form is used to collect and maintain general information about the pt for billing purposes

Back 68

patient information forms

Front 69

TRICARE Prime

Back 69

HMO plan with a point-of-service option for military personnel and their dependents.

Front 70

form used to request information gathered by other medical providers; authorizes a 3rd party to be given info about the pt's treatment.

Back 70

release of information

Front 71

CHAMPVA

Back 71

Provides inpatient and outpatient benefits for dependent spouses and children of veterans who have suffered total, permanent service-connected disabilities.

Front 72

what is necessary to legalize the release of a pt's PHI?

Back 72

patient's signature

Front 73

Beneficiary

Back 73

person receiving the benefits of insurance program

Front 74

form signed the the pt to request that the insurance company sends insurance proceeds directly to the provider

Back 74

assignment of benefits

Front 75

Birthday Rule

Back 75

When individual is covered under 2 insurance policies, the insurance plan of the policy holder whose birthday falls first in the year (month and day) becomes the primary insurance.

Front 76

billing method involving the fee collection when the service is provided

Back 76

time-of-service

*reduces collection costs
*increases cashflow

Front 77

Carrier

Back 77

Insurance Company;
insurer

Front 78

billing method involving the bill being sent to each pt on a monthly basis

Back 78

monthly billing

Front 79

Co-insurance

Back 79

Percentage of the allowed amount that is the patient's responsibility; Policyholder and insurance company share the cost of covered losses in a specified ratio

Front 80

billing method involving a bill being sent to certain segments of the pt population at a consistent time each months, which each segment being sent at a different time during the month

Back 80

cycle billing

Front 81

Copayment

Back 81

Portion of the cost of service to be paid by the insured.

Set amount per visit. (example: $20)

Front 82

billing method involving the office contracting with an outside agency to prepare and send the bills to the patients

Back 82

billing service

Front 83

Deductible

Back 83

Annual amount to be paid by the insured toward the cost of service before insurance policy benefits are paid.
(example: $2000)

Front 84

harassing debtors is illegal, so any pt past allowed amount of time and overdue on their account is sent to ___________

Back 84

collections

Front 85

Exclusion

Back 85

treatment or conditions not covered by the insurance policy

Front 86

collection calls should only be placed btwn _____ and _____.

Back 86

8:00am and 8:00pm

Front 87

Explanation of Benefits

Back 87

Document prepared by the carrier that identifies the services covered by the policy, the amount billed by the provider and the amount paid by the carrier.

Front 88

collection calls should only be made to the pt's ___________ telephone

Back 88

home

*be positive and assertive

Front 89

EOB

Back 89

Explanation of Benefits

Front 90

FUN FACT!

Back 90

before the end of the debt collection call, attempt to obtain a commitment by the debtor

*follow up with a confirmation call

Front 91

fee-for-service

Back 91

provider bills for each service rendered

Front 92

Never use __________ for debt collection mailings

Back 92

postcards

Front 93

Group Policy

Back 93

policy purchased by an organization for the benefits of its members

Front 94

debt collection letters should be signed by the _____________.

Back 94

office manager

Front 95

Insured

Back 95

Policy holder; subscriber

Front 96

inform the pt by ________ Mail or Return ________ _________ of possible collection agency action or legal action to collect debt.

Back 96

Certified Mail; Return Receipt Requested

Front 97

managed care

Back 97

health care program that designates a primary care physician

Front 98

Progressive collection progress: first use friendly tones when identifying the collection process, then progress to more ________ tones as debt collection lags.

Back 98

assertive

Front 99

Preauthorization

Back 99

Process required by some insurance carriers where the provider obtains permission to perform certain procedures/ services or refer a pt to a specialist

Front 100

Preexisting condition

Back 100

Medical conditions present or being treated at the time a health insurance application is made

Front 101

Premium

Back 101

the fees paid for the health insurance coverage

Front 102

Provider

Back 102

health professional who provides services

Front 103

Rider

Back 103

Clauses to the health insurance policy designating coverage items in addition to those included within the standard contract

Front 104

Basic plan benefits

Back 104

diagnostic studies,
hospitalization,
surgical treatments,
obstetrical care,
intensive care,
chemotherapy

Front 105

List major medical services not usually covered by a basic plan

Back 105

outpatient visits,
minor surgery,
physical and occupational therapies,
cost of medical equipment,
mental health care,
dental care,
prescriptions

Front 106

Companion plans

Back 106

Policy that pays in addition to health insurance policies carried;
Pays the fees not covered by conventional plans.

Front 107

Physician fee profile

Back 107

usual, customary, and reasonable charges

Front 108

Assignment of Benefits

Back 108

A) gives carrier instructions to send insurance payments directly to the provider
B) most commercial carriers will reimburse the patient unless instructed not to do so
C) accomplished by the pt (insured) signing the appropriate box on insurance claim form or completing a separate assignment of benefits form
D) pt is responsible for paying the difference between the provider's charge and the insurance paid
E) if provider accepts the assignment,m the carrier then makes payment to the provider (in accordance with the policy language)
If provider claim is a government plan claim, the provider must then indicate on the claim form whether the assignment is accepted or rejected.
F) If the provider rejects the assignment of benefits, then the provider may bill the pt the difference between the fee charged and the fee reimbursed.

Front 109

AOB

Back 109

Assignment of Benefits

I think.

Front 110

Medicaid and Workers' Comp payment

Back 110

Provider must accept government reimbursement as payment in full if the provider agrees to treat Medicaid and/or Workers' Comp pts.

Front 111

Deductibles and Copayment payment

Back 111

pts are responsible to pay any deductible or copayment according to the terms of the insurance policy.

Front 112

Coordination of Benefits

Back 112

Term for the rules insurance companies use to coordinate payments so no provider is paid more than 100%

Front 113

If pt has more than one insurance policy, claim is sent first to ________________.

Back 113

Primary Insurance

Front 114

Order of Insurances billed

Back 114

1. Private insurance
2. Government Insurance
3. Medicaid is always last

Front 115

if both members of a couple have insurance:

Back 115

1. Pt's insurance is Primary and spouse's is secondary
2. If a child is the pt "birthday rule" applies
(Parent whose b-day comes first in the year is primary)

Front 116

Pt has Private insurance and Medicare. Which insurance is primary?

Back 116

Private Insurance is Primary.

*Always bill Private Insurance before Government Insurance.

Front 117

CMS-1500 Form

Back 117

Universal health claim form developed by HCFA that standardizes data required by most carriers so that claims can be processed

Front 118

CMS-1500 Form rules

Back 118

1. Before submitting make sure that pt information release forms are current
2. Use uppercase letters
3. no periods, hyphens, commas, dollar signs, or slashes
4. For whole dollar amount: Use "00" in cents column. (no blanks cents)
5. 8 digit dates: (mmddyyyy)
6. Fill necessary boxes in with "X"
7. Use correction fluid for corrections (white out)
8. Completed forms should be maintained in provider files for 6 years

Front 119

How long should a provider hold onto completed CMS-1500?

Back 119

6 years

Front 120

True or False?

Once a pt account is given to a collection agency, the clinic may continue collection efforts on the debt.

Back 120

False.

*The clinic may no longer continue collection efforts

Front 121

What does FICA stand for?

Back 121

Federal Insurance Contributions Act

Front 122

What does FUTA stand for?

Back 122

Federal Unemployment Tax Act

Front 123

When Income tax, FICA, and FUTA are withheld from employee checks, who does that money go to at regular intervals?

Back 123

Internal Revenue Service (IRS) and to the state tax commissioner

Front 124

Which law sets minimum wage laws and requires employers to pay 1.5 times employee's regular wage for time worked over 40 regular hours?

Back 124

Fair Labor Standards Act

Front 125

Which 1964 law prohibits discrimination based on employee's race, color, religion, or gender in hiring, firing, or promoting employees?

Back 125

Civil Rights Act of 1964
(Title VII)

Front 126

Which law prohibits unfair practices in employment decisions regarding people over 40 yrs of age?

Back 126

Age Discrimination in Employment Act

Front 127

Which law prohibits unfair practices in employment decisions (& in many other areas) regarding people with physical, mental, or medical disabilities?

Back 127

Americans with Disabilities Act

Front 128

In the case of birth, adoption, or sick or injured family member, an employee is entitled through WHICH LAW to receive unpaid leave to care for the child, spouse, parent, or for him or herself?

Back 128

Family Medical Leave Act of 1993

*employee is entitled to benefits and job protection while on leave

Front 129

True or False?

Employers are not required by law to withhold employee income tax.

Back 129

False

*Employers ARE required by law

Front 130

FICA involves ________ and _______ tax

Back 130

Social Security and Medicare

Front 131

FICA Taxes are deducted from the employee's earnings each _____ _____.

Back 131

pay period

Front 132

SIDE NOTE:

Back 132

REVIEW SECTION D "Forms and Reports" under PAYROLL (p.143)
*Too much to type all out!

Front 133

most common payroll system for smaller organizations, payroll is computed and processed by hand

Back 133

Manual

Front 134

payroll system in which data are entered into accounting management computer program; automatic calculations done by software; automatic detailed records & reports done by software.

Back 134

Computerized

Front 135

payroll system in which payroll data are sent to an outside service that prepares the payroll and delivers detailed records, reports, and payroll checks to the office.

Back 135

Payroll services

Front 136

The majority of money transactions out of the office are conducted via which method of payment?

Back 136

Check

Front 137

a commercial paper drawn on funds deposited in a bank account:

Back 137

check

*there are 2 definitions for this term amongst these flashcards!

Front 138

a written order for he bank to pay a person a specific amount of money:

Back 138

check

*there are 2 definitions for this term amongst these flashcards!

Front 139

True or False?

A check is negotiable

Back 139

TRUE

*anyone who properly endorses the check is entitles to receive the money

Front 140

List & identify the 3 parties involved in a check:

Back 140

1. drawer - person writing check
2. drawee - the bank
3. Payee - person receiving the money from the check

Front 141

List the 3 main requirements for opening a checking acct:

Back 141

1. Approval from bank official
2. initial deposit
3. signature card (contains names & sigs of all persons authorized to access the acct)

Front 142

FUN FACT!

Back 142

Deposits can be made by using:
Paper money, Coins (wrapped), Checks (endorsed via sig or stamp), & a Deposit slip

Front 143

"NSF" :

Back 143

Not sufficient funds

*(insufficient funds in acct)

Front 144

True or False?

Knowingly issuing an NSF check is illegal.

Back 144

TRUE

Front 145

What is a postdated check?

Back 145

One that is issued to the payee for a date in the FUTURE.

*may not be honored by bank until date on check

Front 146

statement of account sent to each depositor once a month by the bank

Back 146

bank statement

Front 147

What is a reconciled bank statement?

Back 147

A statement with the bank's balance in agreement with the office's balance.

Front 148

The translation of descriptions of diseases, illnesses, injuries, and procedures into numeric codes:

Back 148

coding system

Front 149

5 reasons "coding" system was developed:

Back 149

1. tracking disease process
2. Classification fo medical procedures
3. Medical research
4. Evaluation of hospital utilization
5. Reimbursement

Front 150

What is the name of the coding system used to code disease conditions or diagnosis?

Back 150

ICD-9-CM

*International Classification of Diseases, ninth edition, Clinical Modification

Front 151

What is the name of the coding system used to code procedures and medical services provided by practitioner

Back 151

CPT-4

*Current Procedural Terminology, fourth edition

Front 152

What is the name of the coding system used to report services performed to MEDICARE program?

Back 152

HCPCS

*Health Care Financing Administration (HCFA) Common Procedural Coding System

Front 153

RVS :

Back 153

relative value scale

Front 154

the assigned unit value given to commonly performed medical procedures

Back 154

relative value scale (RVS)

*based on time, knowledge, & skill required by practitioner
*point value multiplied by a dollar factor to find a final fee amount

Front 155

RBRVS

Back 155

resource-based relative value scale

Front 156

fee schedule for MEDICARE for services based on level of resources needed to provide the service

Back 156

RBRVS

Front 157

DRG

Back 157

diagnosis-related groups

Front 158

Medicare-fixed fee structure for hospital billing of inpatient services; based on principal diagnosis

Back 158

DRG

Front 159

Which volume of the ICD-9 arranges conditions numerically?

Back 159

Volume I

*(Tabular List of Diseases)

Front 160

Which volume of the ICD-9 lists conditions alphabetically?

Back 160

Volume II

*(Disease: Alphabetical List)

Front 161

codes that refer to factors that influence health status

Back 161

V-codes

*ie: well-baby checks, annual physicals

Front 162

codes referring to morphology of neoplasms

Back 162

M-codes

Front 163

codes of external causes

Back 163

E-codes

Front 164

ICD-9 fourth & fifth digits of codes are added for _____________________.

Back 164

specificity to cause

Front 165

SIDE NOTE:

Back 165

"Conventions" (Section D) on page 147, Ch. 12

I don't know how vital these are to know, so I suggest just skimming these..

Front 166

NEC :

Back 166

Not elsewhere classified

Front 167

NOS :

Back 167

not otherwise specified

Front 168

specific factors that influence a diagnostic code are know as:

Back 168

Modifiers

Front 169

Coding steps:

(more for the sake of review than memorizing)

Back 169

1. Locate term in alphabetical index of volume II
2. Read & act on the notes printed after the term
3. Consider modifiers of the term
4.Follow cross-references
5. Verify the code number in Volume I and make modifications as instructed
6. Record the code assignment

Front 170

Name the 2 coding tables in volume II of the ICD-9

Back 170

1. HYPERTENSION TABLE
a.malignant
b.benign
c. unspecified
2. NEOPLASM TABLE (arranged by site- 6 classifications)

Front 171

neoplasm table:
define "primary malignancy"

Back 171

original tumor site

Front 172

neoplasm table:
define "secondary malignancy"

Back 172

tumor metastasized

Front 173

neoplasm table:
define "carcinoma in situ: localized"

Back 173

noninvasive malignant tumor

Front 174

neoplasm table:
define "benign"

Back 174

nonspreading, noninvasive tumor

Front 175

neoplasm table:
define "uncertain behavior"

Back 175

impossible to predict behavior or morphology

Front 176

neoplasm table:
define "unspecified"

Back 176

tumor with no indication of histology