MAA 138 Medical Billing & Coding FINAL Review

MAA 138 Medical Billing & Coding FINAL Review What is coordination of benefits? - When the patient has two insurances; one is primary, one is secondary Are claim inquiries done by phone or in writing? - Both What is implied contract? - When a patient goes to the doctor's office seeking medical services and the physician accepts the patient and agrees to render treatment and both parties agree Can a photocopy of a claim form be scanned with optical character recognition? Why or why not? - No it must be the original claim with red print What could happen if a MAA completes a Medicare claim with information that is not true? - Possible fines & imprisonment Who pays the medical bill for an emancipated minor? - The emancipated minor What is a non-availability statement for TRICARE patients? - Allows patient to obtain services from a nonmilitary medical facility Give 4 reasons why a claim might be denied - Prior approval not received, incorrect code bundling, diagnosis and service don't match, specialty provider not eligible for services, location of procedure not eligible, service not covered, condition treated was preexisting, and missing information How many volumes are in ICD-9? - 3 When is a prospective internal audit performed? - Before the billing is submitted What is redetermination? - The first level of appeals for Medicare What is the timeframe claims are paid if sent electronically? By mail? - Less than two weeks (7-14 days), 4-6 weeks by mail What is A/R and what does it mean? How does the collection process affect it? - Accounts Receivable - money is owed to the doctor; slower the money is collected the higher the A/R What do you do when a claim has been rejected? - Investigate it first, it might not be a covered service; correct it if possible; and resubmit What is a clearinghouse? How do they charge fees to the provider? - Entity that receives EDI from the healthcare provider; they check the claims for errors, reject them and send them back to the provider and batch out the claims to third party payers that pass all the edits; It is a flat rate by claim or monthly fee What does encrypted data look like to unauthorized users? - Gibberish or scrambled data What is an EOB? Can it contain information for more than one patient? - It gives complete information about payment or nonpayment of the claim and is attached to the check; Yes When should we collect any payment due for services rendered? Why? - At the time of the appointment; Because it is too expensive to collect money later for copays What does "batch" claims processing mean? - A group of claims for different patients submitted at the same time What is assignment of benefits? - Signature authorizes payment to be sent to the provider What is the result of down coding? - Less reimbursement What does the term "pending claim" mean? - Claim held in suspense or review Are cash refunds given to a patient who has paid