Workbook for Fordney's Medical Insurance - Assignments Chapter 16
docx
School
UEI College, Gardena *
*We aren’t endorsed by this school
Course
MEDICAL BI
Subject
Health Science
Date
Jan 9, 2024
Type
docx
Pages
4
Uploaded by ConstablePigeonPerson975
Key Abbreviations
ALJ – Administrative Law Judge
CMS – Centers for Medicare and Medicaid Services
HIPAA – Health Insurance Portability and Accountability Act
NPI – National Provider Identifier
QIC – Qualified Independent Contractor
RA – Remittance Advice
RCM – Revenue Cycle Management
16.1 Review Questions
1. The process in the health care organization uses to track services provided from registration and appointment scheduling to the final payment for services is referred to as Revenue Cycle Management
.
2. Once a claim has been successfully submitted to the insurance carrier, the next step in the revenue cycle is for the insurance billing specialist to track
the claim until a response is received from the responsible party and the service has been paid in full.
3. Who dictates the guidelines for claims submission, such as which services are covered, the reimbursement rates, and time limits for claim submission and payment? The insurance company.
4. Time limits for filing claims promptly can be found in the Insurance contract
or the payer’s manual
.
5. What is the purpose of prompt payment laws? To set standards for the prompt, fair, and equitable settlements of patient claims and provider services.
6. After an insurance claim is processed by the insurance carrier (paid, suspended, rejected, or denied), a
document known as a/an Explanation of Benefits (EOB)
is sent to the patient and to the provider of professional medical services.
7. A claim that is processed by a third-party payer but is held in an indeterminate state is referred to as a
suspended
claim.
8. Claims paid with no errors are designated as closed
.
9. Claims that are not paid within 30–45 days of the service date are referred to as delinquent
claims.
10. A rejected
claim is a submitted claim that does not follow specific third-party payer instructions or contains technical errors.
11. A service is considered medically necessary
if it is provided in accordance with the generally accepted standards of medical practice and is clinically appropriate.
12. State the solution if a claim for routine foot care has been denied as a noncovered service. Send the patient a statement with a notation of the response from the insurance company.
13. State the solution if a claim has been denied because the professional service rendered was for an injury that is being considered as compensable under workers’ compensation. Locate the insurance
carrier for the industrial injury and send it a report of the case with a bill. Notify the patient’s health insurance carrier monthly of the status of the case
.
14. When an insurance carrier changes the code submitted to one of lesser value and it reduces the reimbursement amount, it is referred to as downcoding
.
15. When an insurance carrier reimburses a service at an amount over and above the amount due, it is referred to as an overpayment
.
16. Patient accounts with a balance should be billed on a monthly
basis.
17. A/an appeal
is a request for a review and reconsideration of a claim that has been underpaid, incorrectly paid, or denied by an insurance company.
18. A/an peer review
is an evaluation of a denied claim performed by a group of unbiased practicing physicians or other health care professionals to judge the effectiveness and efficiency of professional care rendered and to determine if payment can be made.
19. Name the five levels for appealing a Medicare claim.
a. Level 1: Redetermination – Medicare Administrative Contractor (MAC) that processed the original claim.
b. Leven 2: Reconsideration by a Qualified Independent Contractor.
c. Level 3: Administrative law judge hearing.
d. Level 4: Medicare Appeals Council review.
e. Level 5: Judicial review by a federal district court.
20. A/an Qualified Independent Contractor (QIC)
is an independent contractor who conducts reconsiderations for Medicare claims going through the appeals process.
21. To pursue judicial review of a Medicare claim in federal district court, the amount of the case must meet the minimum dollar amount of $1670
in 2020.
22. A TRICARE expedited appeal must be filed within 3 days
of the receipt of the initial denial.
23. A TRICARE nonexpedited appeal must be filed within 90 days
of the receipt of the initial denial.
24. State Insurance Commissioners
are public officials who regulate the Insurance Industry in their state.
25. Effective claim denial management starts with identifying
the reason for denials.
26. c. 30-45 days old
27. c. Review the rejection code, correct the field, and resubmit the electronic claim.
28. b. Appeal
29. d. Service providers return the overpayment promptly when the insurance poster identifies it.
30. a. Identify, Appeal, Categorize, Measure, Strategize
_T
_ 31. An insurance billing specialist’s primary goal is to assist in management of the revenue cycle.
_F
_ 32.A patient’s insurance card specifies the detailed benefits and coverages.
_T
_ 33. All health insurance companies are obligated to reimburse health care organizations promptly for services rendered.
_F
_ 34. The elements within a remittance advice (RA) document and an explanation of benefits (EOB) document are different.
_F
_ 35. There is a standard format for EOB forms that all carriers are expected to follow.
_T
_ 36. Due to issues concerning timely filing, it is wise to be aggressive on claims that are outstanding for more than 30-45 days.
_F
_ 37. Information collected at the front desk does not impact denials.
_T
_ 38. One of the criteria for a service to be considered medically necessary is that the service must be in accordance with the generally accepted standards of medical practice.
_F
_ 39. If any insurance carrier has downloaded a claim, thereby reducing reimbursement, there is no other recourse than to write off the balance.
_F
_ 40. If a claim has not been paid within a reasonable amount of time, the most effective follow-up method is to simply rebill the claim.
16.2 Using an Aging Report for Follow-Up
1.
Who were the three patients who were most recently billed?
a.
Eleanor Bassett
b.
Maxine Holt
c.
Lydia McDonald
2.
Do phone calls to Aetna need to be made for patients that are in the 0-30 days categories? Why or why not?
a.
Immediate calls need to be made for Aetna patients in the 0-30 days category are not necessary at this time. However, if Aetna processes claims quickly, it may be an internal policy to ideally process claims within 30 days, but initial inquiries are often best reserved for claims exceeding that timeframe.
3.
Which two patients have balances that are different from typical office visit charges submitted to Aetna?
a.
John Herron
b.
Frank Lincoln
4.
What would account for the difference in the balance from the original total charges submitted to Aetna?
a.
Payments received, adjustments, billing errors, aging report timeframes, additional charges
5.
Would it be appropriate to send the patients in categories beyond 60 days to a collection agency? Why or why not?
a.
The decision is complex, and it should be made on a case-by-case basis, considering these factors:
i.
Significant delinquency – 60+ days is a substantial delay, and exhausting internal
efforts at collection might be warranted.
ii.
Financial impact – Uncollected accounts impact the practice’s financial stability and ability to provide services.
iii.
Exhausted internal efforts – After attempting direct communication, payment plans, and other internal means, collections can be a final resort
b.
Some reasons to hesitate to send to collections:
i.
Patient hardship – Consider financial difficulties, unexpected events, or lack of understanding about their bill before resorting to collections
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
ii.
Damage to patient relationships – Collections can negatively impact patient satisfaction and damage trust
iii.
Potential for ineffectiveness - Collections are not always successful, and costs associated with agencies need to be considered
c.
Some alternatives to collections:
i.
Continued communications – Keep reaching out to patients through calls, emails, and letters, emphasizing payment options and offering assistance
ii.
Flexible payment plans – Provide customized plans tailored to patients’ situations to encourage gradual payments
iii.
Financial assistance programs – If available, offer programs to help eligible patients with their bills
d.
But in making the decision:
i.
Review each account – Analyze individual circumstances, attempt internal resolutions, and weigh the potential benefits and drawbacks of collections before proceeding.
ii.
Communication is key – Regardless of the chosen approach, maintain open communication with patients to explain the situation and explore potential solutions.
iii.
Consider regulations – Comply with ethical and legal practices surrounding debt collection and patient communication