Insurance Basics
This type of insurance plan requires patients to choose a primary care provider and obtain referrals.
What is an HMO?
This standard claim form is used for outpatient and physician services.
What is the CMS-1500 form?
This reimbursement system is based on preset payments for diagnoses.
What is DRG (Diagnosis-Related Groups)?
This law prohibits offering incentives for patient referrals.
What is the Anti-Kickback Statute?
This coding system is used to report procedures and services.
What is CPT?
This organization administers Medicare.
What is CMS (Centers for Medicare & Medicaid Services)?
This term refers to the percentage a patient pays after the deductible is met.
What is coinsurance?
This is the process of checking a claim for errors before submission.
What is claim scrubbing?
This payment model pays providers a fixed amount per patient per period.
What is capitation?
Charging for services not provided is known as this.
What is fraud?
This modifier indicates a significant, separately identifiable E/M service.
What is modifier -25?
This is the time limit for submitting claims to an insurance payer.
What is timely filing limit?
A patient has a $500 deductible and has paid $300. A $200 service is performed. How much does the patient owe?
What is $200? (remaining deductible)
If a claim is rejected due to incorrect patient information, what should be done first?
What is correct and resubmit the claim?
This system determines Medicare payment based on physician services.
What is the Resource-Based Relative Value Scale (RBRVS)?
Unbundling services to increase reimbursement is considered this.
What is abuse (or fraudulent billing practice)?
Using a higher-level code than warranted is called this.
What is upcoding?
A claim is denied for lack of medical necessity. What is the best next step?
What is review documentation and submit an appeal?
A patient has 80/20 coinsurance. The allowed amount is $1,000. How much does insurance pay?
What is $800?
This number identifies a provider in electronic transactions.
What is NPI (National Provider Identifier)?
This prospective payment system applies to hospital outpatient services.
What is OPPS (Outpatient Prospective Payment System)?
This federal law protects patient health information privacy.
What is HIPAA?
Failing to include all documented diagnoses is known as this.
What is undercoding or incomplete coding?
A patient has primary and secondary insurance. What is the correct billing order?
What is bill primary first, then secondary?
A patient’s plan requires preauthorization. It was not obtained. The claim is denied. Who is responsible?
What is the provider (may not be reimbursed)?
A claim is denied due to “CO-50: Not medically necessary.” What should the MA check?
What is documentation supporting medical necessity?
Under capitation, a provider receives payment but the patient requires extensive care. Financial risk falls on whom?
What is the provider?
Knowingly billing for a more expensive service than performed violates this law.
What is the False Claims Act?
A procedure and E/M service are billed together improperly. What issue is this?
What is unbundling or incorrect modifier use?
A claim is denied, corrected, and resubmitted after the filing deadline. What is the likely outcome?
What is denial due to exceeding timely filing limits?