What Is The Role Of Medical Malpractice Reform Flashcards

WHAT IS THE PROGRAM MANDATED BY FEDERAL AND STATE GOVERNMENT THAT REQUIRES EMPLOYERS TO COVER MEDICAL EXPENSES AND LOSS OF WAGES FOR WORKERS WHO ARE INJURED ON THE JOB? -WAGNER NATIONAL HEALTH ACT -WORKER COMPENSATION -HILL BURTON ACT -BLUE CROSS BLUE SHIELD WORKERS COMPENSATION ACCORDING TO THE US CENSUS BUREAU DATA FROM 2005 WHAT % OF PEOPLE IN THE UNITED STATES ARE COVERED BY GOVERNMENT PLANS(MEDICARE, MEDICAID) -9% -27% -60% -45% 27% WHICH ACT MANDATES REGULATIONS THAT GOVERN PRIVACY, SECURITY AND ELECTRONIC TRANSACTIONS STANDARDS FOR HEALTH CARE INFORMATION. -ADMINISTRATIVE COMPLIANCE ACT -HIPPA -BALANCED BUDGET ACT TEFRA HIPPA THE FIRST BLUE SHIELD PLAN WAS FOUNDED IN? -MICHIGAN -CALIFORNIA -CONNECTICUT -OHIO CALIFORNIA A SUCCESSFUL HEALTH INSURANCE SPECIALIST SHOULD HAVE WHICH OF THE FOLLOWING CHARACTERISTICS? -WORK INDEPENDANTLY -ATTENTION TO DETAILS -ETHICS -ALL OF THE ABOVE ALL OF THE ABOVE REIMBURSEMENT FOR INCOME LOST AS A RESULT OF TEMPORARY/PERMANENT ILLNESS OR INJURY IS: -LIABILITY INSURANCE -RELIABILITY INSURANCE -DISABILITY INSURANCE --NONE OF THE ABOVE DISABILITY INSURANCE WHAT DOES CPT STAND FOR? -CODES POSTED VIA TELEPHONE -CLINICAL PROCEDURE TESTS -CURRENT PROCEDURAL TERMINOLOGY -NONE OF THE ABOVE CURRENT PROCEDURAL TERMINOLOGY DISABILITY INSURANCE PROVIDES THE DISABLED PERSON WTIH FINANCIAL ASSISTANCE BUT DOESNT GENERALLY PAY FOR -MEDICAL SERVICES- -UNEMPLOYMENT INSURANCE BENEFITS - BOTH -NEITHER BOTH MEDICAL SERVICES AND UNEMPLOYMENT INSURANCE BENEFITS WHICH OF THE FOLLOWING IS NOT A PROFESSIONAL ASSOCIATION FOR HEALTH INSURANCE SPECIALIST -AMERICAN ACADEMY OF CODERS -AMERICAN MEDICAL ASSOCIATION -AMERICAN HEALTH MANAGEMENT AMERICAN MEDICAL ASSOCIATION ICD-9CM STANDS FOR INTERNATIONAL CLASSIFICATION OF DISEASES-9TH REVISION , CLINICAL MODIFICATION IF THE INSURANCE PLAN HAS A HOLD HARMLESS CLAUSE; IT MEANS PATIENT IS NOT RESPONSIBLE FOR PAYING WHAT THE INSURANCE PLAN DENIES HEALTH CARE COVERAGE AVAILABLE THROUGH EMPLOYERS AND OTHER ORGANIZTIONS IN WHICH EMPLOYERS USUALLY PAY PART OR ALL OF THE PREMIUM COST IS CALLED? GROUP HEALTH INSURANCE THIS TYPE OF INSURANCE PROVIDES COVERAGE FOR CATASTROPHIC OR PROLONGED ILLNESS AND INJURIES -MAJOR MEDICAL INSURANCE -LIFETIME INSURANCE -LIABILITY INSURANCE -NONE OF THE ABOVE MAJOR MEDICAL INSURANCE ANOTHER NAME FOR HEALTH INSURANCE SPECIALIST IS -MEDICAL RECORDS CLERK -BILLER -REIMBURSEMENT SPECIALIST -NONE OF THE ABOVE REIMBURSEMENT SPECIALIST WHO REQUIRES PHYSICIAN OFFICES TO SUBMIT ICD-9SM CODES ON CMS1500 CLAIM FORMS? -HEDIS -MEDICARE -NATIONAL HEALTH INSURANCE COMMITTEE -MEDICAID MEDICARE EACH NEW PROVIDER MANAGED CARE CONTRACT INCREASES THE -PRACTICE'S PATIENT DATA BASE - # OF CLAIMS REQUIRMENTS/REIMBURSMNTS -TIME THE OFFICE STAFF MUST DEVOTE TO FULFILLING CONTRACT REQUIRMENTS -ALL OF THE ABOVE ALL OF THE ABOVE THE CPT MANUAL IS PUBLISHED BY THE: -AMERICAN BOARD OF PHYSICIANS -AMERICAN MEDICAL ASSOCIATION -AMERICAN BILLING ASSOCIATION AMERICAN MEDICAL ASSOCIATION IF PREAUTHORIZATION FOR TREATMENT BY SPECIALISTS AND POST TREATMENT REPORTS WERE NOT FILED THE CLAIM WOULD BE: -DENIED -BILLED ONLY TO PATIENT -RESUBMITTED DENIED TRICARE INCLUDES 3 PLAN OPTIONS WHICH OF THE FOLLOWING IS NOT ONE OF THOSE OPTIONS? -TRICARE STANDARD -TRICARE PRIME -TRICARE SELECT -TRICARE EXTRA TRICARE SELECT LIABILITY INSURANCE CLAIMS ARE MADE TO: -COVER COST OF MEDICAL CARE FOR TRAUMATIC INJURY OR LOST WAGES -COVER THE COST OF PHYSICIANS OVERHEAD -COVER COST OF MEDICAL CARE TO NEEDY COVER THE COST OF MEDICAL CARE FOR TRAUMATIC INJURIES OR LOST WAGES WHAT INVOLVES LINKING EVERY PROCEDURE OR SERVICE CODE REPORTED ON THE CLAIM TO A CONDITION CODE THAT JUSTIFIES THE NECESSITY OF PERFORMING THAT PROCEDURE OR SERVICE? -DISGNOSIS CODING -PROCEDURE CODING -MEDICAL NECESSITY (2 ANSWERS) DIAGNOSIS CODING AND MEDICAL NECESSITY US CENSUS BUREAU DATA FROM 2005 ESTIMATES THAT WHAT % OF PEOPLE IN THE US ARE COVERED BY SOME FORM OF HEALTH INSURANCE -60% -95% -84% 84% PREVENTATIVE SERVICES: -MAY RESULT IN EARLY DETECTION OF HEALTH PROBLEMS -REQUIRED BY MOST INSURANCE COMPANIES -ALLOW TREATMENT OPTIONS THAT ARE LESS DRAMATIC AND LESS EXPENSIVE (CHOOSE 2) THE FRST AND 3RD CHOICE THE PROCESS OF REPORTING DIAGNOSES, PROCEDURES AND SERVICES AS NUMBERIC AND ALPHANUMERIC CHARACTERS ON THE INSURANCE CLAIM IS CALLED: -WORK -HEALTH INFORMATION -CODING -DATA ENTRY CODING t or f? to reduce coding & billing errors health insurance specialists need to ecplain complex insurance concepts and regulations to patients effectivly true t or f? insurance specialists who are employed by insurance companies review claims for completeness and accuract before authorizing the appropriate payment? true t or f? liability insurance is a policy that covers losses to a 3rd party caused by the insured? true t or f? OSHA was designed to protect all employers against injuries from occupational hazards in the workplace? false t or f? medical malpractice insurance is a type of liability insurance that covers physicians and other health care professionals for liability as to claims arising from patient treatment? true t or f? the mutual exchange of data between the provider and insurance company is called electronic claims processing? false t or f? the AAPC, AHMA and AMBA offer exams leading to professional credentials? true t or f? disablility insurance always pays for health care services and provides the disabled person with financial assistance? false t or f? health insurance specialists review health related claims to determine the medical necessity for procedures or services performed before reimbursment is made to the provider? true t or? medical care includes the identification of disease and te provision of care and treatment such as that provided my members of the health care team to persons who are sick injured status? true t or f? the patient receives a remittance advice which is a report that details the reults of processing a claim? false t or f? a health care facility that employs health insurance specialists is legally responsible for employees actions performed within the context of their employment is called respondeat superior? true t or f? group health insurance is coverage available through employers and other organizations where employers usually part part or all of premium costs? true t or f? title XVIII of the social security act provides health care services to americans over the age of 65 and is known as medicare? true t or f? third party administrators (TPAs) administer health care plans and process claims thus serving as a system of checks and balances for labor and managment? true t or f? in patient is person admitted to a hospital for treatment with expecation patient will remmain in hospital for period of 24hrs or more? true t or f? the first listed diagnoses and the primary disagnosis are the same thing? false t or f? codes that desribe signs and symptoms as opposed to definitive diagnoses are never acceptable for reporting purposes when the physician has not documented an established or confirmed diagnosis false t or f? v codes are located in the index and are assigned for patient encounters when a circumstance other than a disease or injury is present? false t or f? e codes are located in the tabular list of diseases and describe external causes of injury poisoning or other adverse reactions affecting a patients health? true t or f? nonessential modifiers are qualifying words that dont have to be inclded in the diagnostic statement fo the code # listed at the end of the parenthetical statements to apply true t or f? coding conventions are rules that apply to the assignment of icd9-cm codes and are always found in the guidelines false t or f? a lesion is a neoplasm defined as any discontinuity of tissue that is not malignant? false t or f? an adverse effect or reaction is the appearance of a pathologic condition cause by ingestion or exposre to a chemical substance properly administered or taken? true t or f? a late effect is a residual effect or sequelae of a previous acute illness injury or surgery? true t or f? the health insurance specialist employed in a physicians office assigns icd9-cm codes to procedures documented by the health care provider? false t or f? the icd9-cm is organized into 3 volumes? true the health insurance specialist employed in a physician's office assigns icd9-sm codes to: -diagnoses signs symptoms documneted by nurse -diagnoses signs symptoms documented by provider by provider what volume of the icd9sm contains the index to disease? -voolume 3 -volume 2 -volume 1 volume 2 the medicare catastrophic coverage act mandated the reporting of icd9 diagnosis codes on what type of claims? -outpatient -inpatient -medicare and medicaid claims -medicare claims all medicare claims an outpatient is a person treated in which of the following settings? -hospital observation unit -ambulatory surgery center -physician office -all the above all above codes that describe signs and symtoms as opposed to deginitive diagnosis are acceptable to report when -dr uses terminology rule out or probale -coder cnt find appropriate code for diagnosis -dr hsnt documented cnfrmd diagnosis -sign n symptoms are never coded the dr hasnt documented a confirmed diagnosis __codes are located in the tabular list of diseases and are assigned for patient encounters whn a circumstance other than a disese or injury is present -e code -v code -m code v code removal of a cast applied by another physician personal history of breast cancer and exposure to TB are all examples of what types of codes? -e code -v code -m code v code what type of code describes external causes of injury poisining or other adverse reactions affecting a persons health? -m code -v code -icd 9 cm code -e code e codes the classification of industrial accidents accoding to agency is found in what appendix of the icd9cm? Appendix: A B C or D? D the list of 3 digit categories is found in what appendix of the icd9cm? Appendix E D C or B? E ____identifies codes to be assigned when info needed to assign a more specific code cnt be located in the icd9cm coding manual? -codes in slanted brackets -nonessential modifiers -NEC -essential modifiers NEC A ___is a procedure performed for definitive treatment rather than diagnostic purposes -principal procedure -secondary procedure -primary procedure -first listed procedure principle procedure it is always necessary that these codes be coded directly from the pathology report -codes of AIDS -codes for hypertension -codes for neoplasm -codes for diabetes codes for neoplasms requiring diagnosis codes to be reported on submitted claims? -e codes -v codes -medical necessity -principal diagnosis medical necessity acknowledges patient responsbility for payment if medicare denies the claim? -complication -advanced benfit notice -sequelae advanced benfit notice automates the coding process using computerized or web based software? -encoder -codes -cpt encoder condition that develops after outpatient care? -volume 3 -complications -burns complications working diagnosis that isnt yet proven or established? -qualified diagnoses -primary diagnosis -secondary diagnosis qualified diagnosis tabular list of diseases? -volume 2 -volume 1 -volume 3 volume 1 index to disease? -volume 3 -volume 2 volume 1 volume 2 late effects of an injury or illness? -iatrogenic -burns -seqauelae seqauelae result of medical intervention? -iatrogenic -seqeuelae -complcation iatrogenic what constitutes as a qualified diagnoses? wokring diagnosis that hasnt been proven or established. errors and omissions insurance? -professional liability insurance -hold harmless clause -medical malpractice insurance professional liability insurance certified professional coder? -cpt -aapc -eob aapc national codes -hcpcs level 1 codes -" " level 2 codes -" "level 3 codes level 2 exchange of data between provider and insurance company -remittance advice -coding -electronic data interchange electronic data interchange diagnostic codes? -j codes -icd 9cm -cpt codes icd9cm patient not responsible for paying what the plan denies -eob -remittance adivce -hold harmless clause hold harmless clause results of processing a claim sent to patient -eob -mmp -cpt eob hcpcs level 1 codes -national -icd 9 -cpt cpt which of the following is not an example of a managed care plan? -integrated delivery system -concumer directed health plan -exclusive provider organization -tripled option plan consumer directed health plan method of utlilizing health costs and quality of care by reviewing the appropriatness and necessity of care provided to patients prior to the administration of care is: -surgical managment -utillization management -physician managemnt utilization managment managed care plan enrollees received most of their care from: -any nonparticipating provider -their primary care provider -the physician of their choice the primary care provider network of physicians and hospitals that have joined together to contract with insurance companies to provide health care to subscribers for a discounted fee -preferred provider organization -integrated provider organization -exclusive provider organization preferred provider organization what organization is owed by hospitals and phsyician groups that obatin managed care plan contracts? -intergarated delivery organziation -physician hospital organization -inetgrated hospital/physician organizations physician hospital organziation this is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees health status age sex and occupation -internet data base -risk pool -risk databse risk pool plan offered by single insurance plan or as joint venture by 2 or more insurance carriers and which provides subc=scribers or employees with a coice of HMO PPO or traditional health plan is a : -triple option plan -flexible beneft plan -cafteria plan triple option plan prior to scheduling elective surgery managed care plans often require -preauthorization -second surgical opinion -preadmission secon surgical opinion the health care plan that reimburses providers for individual health care services provided is: -managed care plan -quality assurance plan -fee for service plan fee for service plan what organization is responsible for the health of a group of enrollee and can be a health plan hospital physician group or health system? -managed care organization -quality assurance organization -external review organziation managed care organization which of the following would be considered an example of a managed care plan? -exclusive povider organization -triple option plan -point of service plan -all the above all the above nonprofit organzation that contracts with and acquires the clinical and business assets of physician practices -mso -medical foundation -network foundation medical foundation primary care provider -gatekeeper -enrolles -capitation gatekeeper heatlh care accreditation organization -joint comision -case managment -gate keeper joint comission physicians and hospitals joined together to contract with insurance companies for a discounted fee -hmo -ppo -mso ppo provides health care to enrolled members on a prepaid basis -hmo -ppo -mso hmo provides practice management services to individual physician practices -mso -hmo -ppo mso development of patient care plans -enrollees -case managment -joint comission case management patients may use hhmo providers or self refer to non hmo providers -network provider -point of service plan -gate keeper point pf service plan t or f? hmos dont provide preventative care services to promote wellness or good health false t or f? a health maitenance organization(hmo) is an alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a pay monthly basis false t or f? case managment involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost effective manner true t or f? the inspector general established the quality improvment system for managed care to ensure the accountability of managed care plans in terms of objective measurable standards false t or f? accredtation is a voluntary process that a health care facility or organization undergoes to demonstrate tht it has met stndrs beynd thse required by law true t or f? in managed health care plan enrollees receive care frm a primary care prvider who is a physician tht serves as a gatekeeper by providing essential health care services at the lowest possible cost. true t or f?a netwrk provider is a physician or health care facility under contract to the managed care plan.? true t or f?a risk pool is created when a number of people are grouped for insurance purposes true t or f? the national committee for quality assurance is a private for profit organization that asseses the quality of managed care plans in the united states false t or f? a preferred provider organization is a network of physicians and hospitals that have joined together to contract with insurance companies employers or other organizations to provide health care to subscribers for a substantial fee? false t or f? the intent of managed health care was to replace conventional fee for service plans with more affordable quality care to health care consumers true t or f? when a second physician is asked to evaluate the necessity of surgery and recommend the most economic appropriate facility it is considered coordination of care? false areas of the law that are not classified as criminal -civil law -criminal law -case law civil law information communicated by a patient to a health care provider -privacy -privelaged communication -fraud privealged communication intentional deception or misrepresentation -abuse -fraud -case law fraud the practice of reporting multiple codes for a service when a single code should be assigned unbundling actions inconsistent with accepted practices -fraud -abuse -miscommunication abuse document containing list of question that must be answered in writing interrogatory law based on court decisions that establish a precedent -civil law -criminal law -case law case law public law that defines crimes and their prosecution -criminal law -civil law -case law criminal law explain the difference between assignemtne of benefits and accept assignment assisngment of benefits: regarding benefits accept assignemnt: provider accepts the assignment t or f? protected health information is information that is identifiable to an individual sch as name address etc true t or f?the HIPPA security rule adopts standards and safe gaurds to protect health information that is collected maintained and trasmitted electronically true t or f?a dated signed special release form is generally considered valid for as long as the patient sees the physician false t or f? the patient account record is a permanent record of all financial transactions between the patient and the practice true t or f?workers compensation insurance is always considered to be the primary insurance plan true t or f? the encounter form is the financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter true t or f? a claims attachment is a set of supporting documentation or information that is associated with a health care claim or patient encounter true t or f? the privacy rule establishes standards for how PHI should be controlled by indicating authorized uses and disclosures and patients rights with respect to their health information true t or f?an appeal is documented as a letter signed by the provider explaining why a claim should be reconsidered for payment true t or f? an insurance company that is prohibited from reviewing patient records will probably refuse to reimburse the provider for a submitted claim true t or f? the national correct coding initiative was developed to reduce medicare program expenditures by detecting inappropriate codes submitted on claims and denying payment true t or f? record retention is the storage of documentation for an established period of time usually mandated by federal and or state law true t or f? the birthday rule state that the parent whose birth year is the the earliest holds the primary policy for dependent children false t or f? a clean claim is one that contains all required data elements needed to process and pay the claim true t or f? when submitting claims "signature on file" can be submitted for the patients signature as long as the patients signature is on file in the office true t or f? it is not necessary to submit a claims attachemnt when using an unlisted cpt code false t or f? hippa requires all health plans health care clearing houses and health care providers that conduct electronic financial or administrative transactions to comply with national patient privacy standards true t or f? a voluntary compliance program can help physicians avoid generating erroneous and fraudulent claims by ensuring that submitted claims are true and accurate. true t or f? third party payers use medical necessity measurements to make a decidion about whether to pay a claim true the___mandates the retention of patient records and health insurance claims for a minimum of 6 years -hippa -ama -patient safety and quality improvement act hippa the most common form of medicare fraud is: -soliciting offering or receiving kickbacks -misrepresenting the diagnosis to justify payment -billing for services not provided -all all participants maintain at their own expense and at the same rate health care plan coverage tat would have been lost due to a triggering event -health care financing administration -prinvacy act -consolidated omnibus budget reconciliation act consolidation omnibus budget reconciliation act medical necessity is the measure of whether a health care procedure or service is appropriate for -diagnosis and treatment of condition -3rd party allowed amont -tests tht were ordered diagnosis and treatment of condition the cms 1500 claim form is used to report -professional services -inpatient expenses -technical services (choose 2) professional services and technical services __is the storage of documentation for an established period of time usually mandated by federal and or state law -patient file review -record retention -physician storage act record retention which of the following is not an example of abuse -falsifyin certificates of medical necessity plans -violations of participating provider agreements -excessive charges for services equipment or supplies frst one before scheduling an appointment w/a specialist a manage care patent must obtain a: -referral from pcp -preauthorization -copy of medical records (choose 2) the frst 2 the patient ledger is also known as the -patient account record -superbill -encounter form patient account record the chick in process for a patient who is__is more extensive than for a____patient -established/new -new/returning -referred/new new/returning which of the following is NOT a criteria used to determin medical necessity? -reimbursement -value -scope -purpose reimbursment the cms1500 claim form requires responses to standard questions pertaining to whether the patients condition is related to: -auto accident -secondary insurance -employment -all all the__are the financial record source documents used by health care providers to record serices and diagnoses rendered duing the visit -check out form -superbill -encounter form (choose 2) super bill and encounter form in 1996 congress passed the ___because of concerns about fraud and abuse -health insurance portability and accountability act -center for medicare ad medicaid act -group health plan requirement act health insurance portability and accountability act a ___contracts with a 3rd party payer and accepts whatever the plan pays for procedures or services performed -nonparticipating provider -network provider -participating provider -(choose 2) network provider and participating provider the health care industry is heavily regulated by___and_____legislation -state/city -city/local -federal/state federal and state the___is the person responsible for paying the charges -gaurantor -patient -beneficiary garuantor the development of an_____begins when the patient contacts a health care providers office and schedules an appointment -superbill -insurance claim -patient claim insurance claim