practice management & EHR chap. 8-10

third party payer
private or government organization that insures or pays for health care on behalf of beneficiaries and agrees to carry some of the risk of paying for services
patient, physician
__________(policyholder) is the first party, and the __________ is the second party
PPO
most popular type of health plan
HMO
they have the most stringent guidelines and the narrowest choice of providers.
PCP
HMO members are assigned _________ and must use the network except in emergencies or pay a penalty
HMO
organized around one of three business models: the staff model, the group or network model, and the independent practice associate model.
private insurance payers
_____________ include the federal employees health benefits program, self insured health plans, individual health plans
balance billing
whether participating provider can bill the patient for the difference between a higher physician fee and a lower allowed charge
address
____________ tab contains basic information such as the plan name, address, and contact information
insurance carrier dialog box
detailed information about an insurance carrier is stored in the ________________ for each carrier
edit
to view information on a carrier already in the database select the carrier in the insurance carrier list dialog box and click the __________ button
new
to enter a carrier not already in the database, click the ______ button
EDI/eligibility, electronic
the ______ tab contains information used for _________ claims and online eligibility verification
allowed tab
tab that list procedure codes in the database and the amounts allowed by the payer for procedures
values
_____ are entered in the allowed tab of the insurance carrier dialog box
charges, payments, adjustments
three types of transactions are recorded in the PM/EHR:
check out
during __________ you must provide a receipt for the patient, schedule follow up appointment, provide referral, and provide patient education materials
addenda
the national center for health statistics and the centers for medicare and medicaid services (CMS) release ICD-9CM updates called the ___________ twice a year
current, reporting
_______ codes must be used for _________ encounters as of the date they go into effect
proprietary code set, CPT codes
CPT is a ____________ meaning that it is not available for free to the public. rather, the information must be purchased from the american medical association (AMA) which issues revised __________ each year
october 1, january 1
annual changes are released by the AMA on ____________ & are in effect for procedures and services provided after ___________ of the following year
claim scrubber, medical codes
PM/EHRs typically include a software feature known as a __________ this software tool analyzes ___________ for patient encounters and reports those that appear to be outdated or otherwise problematic
before
the PM/EHR must be updated to reflect code changes based on the scrubbers report ___________ the claim is submitted
logically connected, medical necessity
medical services provided should be ____________ so that the ____________ of the charges is clear to the health plan
code linkage
____________ describes the connection between a procedure code and the related diagnosis code. procedures must be clinically appropriate, & not primarily for the convenience of the patient
physician
if medical necessity is not met, the __________ will not receive payment from the health plan
already
the procedure/payment/adjustment list dialog box lists codes ______ in the database
new, lists menu
the process of adding _______ procedure codes to the database begins with selecting procedure/payment/adjustment codes on the _________
general, amounts, allowed amounts
when the new button is clicked, the procedure/payment/adjustment dialog box is displayed which has three tabs:
amounts
the ____________ tab shows the amount charged for the procedure as listed in the practices fee schedule
allowed amounts
the __________ tab lists the amount each insurance carrier pays for a particular code
code, modifiers, amount
in the allowed amounts tab of the procedure/payment/adjustment (new) dialog box the following columns are listed INSURANCE NAME, __________, ___________, __________
global period
health plans set a __________- a certain length of time in which the expected services are to be provided- for each package.
CCI (correct coding initiative)
__________ controls improper coding that would lead to inappropriate payment for medicare claims
unbundling
CCI (correct coding initiative) edits also test for _____________
physicians
CCI (corrrect coding initiative) requires ____________ to report only the more extensive version of the procedure performed and disallows reporting of both extensive and limited procedures
MUEs (medically unlikely edits)
a __________ is related to a specific CPT or HCPCS code and applies to the services that a single provider (or supplier, for supplies such as durable medical equipment) provides for a single patient on the same date of service .
RTCA (real time claim adjudication)
ideal tool for collecting at the time of service is known as _______________
financial responsibility, eligibility of benefits
information transmitted by the health plan in RTCA allows the practice to know the patients __________ for the visit and collect it as well as verify that the services are covered under the policy known as ____________
real-time
note that the RTCA does not generate a ___________ payment
diagnosis, procedures, charges
claims communicate information about a patients _________, __________, & __________ to a payer
HIPAA X12 837 health care claim
the HIPAA standard transaction for electronic claims is the _________________
created, edited, submitted
insurance claims are __________, __________, & __________ for payment within the claim management area of MNP
navigator buttons
the upper right corner of the claim management dialog box contains five _______________ that simplify the task of moving from one entry to another
last claim
the ___________ button makes the last claim in the list active
claim, edit
the bottom of the ________ management dialog box contains a number of buttons that are used for various functions ________ opens a claim for editing
create claims , creation of claims
the create claims dialog box is accessed by clicking the _________ button in the claim management dialog box. this dialog box provides several filters to customize the ______________
filter
condition that data must meet to be selected
certain dollar amount
filters can be used to create claims for a specific patient & carrier, and for transactions that exceed a ______________
assigned provider
the __________ is the patients regular physician
diagnosis, procedure, amount
the transaction tab lists information about the transactions included in a claim such as the ___________, ___________, & ___________
electronically transmit, directly, mail
claims that have been created in medisoft network professional (MNP) are submitted using the revenue management to _________________ claims to clearinghouses as well as ___________ to payers via _________
claim management
insurance claims are created from within the ______________ area of medisoft network professional
X12 837
the HIPAA standard transaction for electronic claims is the HIPAA ____________ health care claim
crossover claims
claims are billed to medicare and then submitted ti medicaid are called _____________
claim edit
medisoft network professionals __________ feature allows claims to be reviewed and edited before they are submitted to insurance carriers for payment