Healthcare Accounting Billing & Reimbursement Flashcards

A healthcare organization's accounts receivable (A/R) days is 65. What does this metric indicate?

Answer: It takes an average of 65 days to collect payment after services are rendered

Days in A/R measures the average number of days it takes a healthcare organization to collect payments after services are provided; lower is generally better.

What is the significance of the 'global surgery period' in physician billing?

Answer: It is the period following a surgery during which related follow-up care is bundled into the surgical payment and cannot be billed separately

The global surgery package bundles pre-operative, intra-operative, and post-operative care into a single payment, meaning providers cannot separately bill for routine follow-up within the global period (typically 0, 10, or 90 days).

Which modifier would a physician append to a CPT code to indicate a service was performed bilaterally?

Answer: Modifier -50

Modifier -50 indicates that a procedure was performed on both sides of the body during the same operative session.

Under the Resource-Based Relative Value Scale (RBRVS), which three components make up the Relative Value Unit (RVU) for a physician service?

Answer: Physician work, practice expense, and malpractice expense

Each CPT code's RVU is composed of physician work RVU, practice expense RVU, and malpractice (professional liability) expense RVU, all adjusted by a geographic practice cost index (GPCI).

A provider receives an Explanation of Benefits (EOB) showing that payment was applied to the patient's deductible. How should this be reflected in the patient's account?

Answer: Transfer the deductible amount to patient responsibility and bill the patient

When the EOB indicates payment was applied to the deductible, the provider should transfer that amount from the insurance balance to the patient's responsibility and issue a patient statement.

What is 'upcoding' in the context of healthcare billing compliance?

Answer: Intentionally assigning a higher-level diagnosis or procedure code than is supported by the documentation to increase reimbursement

Upcoding is a fraudulent billing practice where providers knowingly bill for a more expensive service than was actually performed or documented.

Which of the following best describes a 'capitation' payment model?

Answer: A provider receives a fixed per-member-per-month (PMPM) payment to cover a defined set of services regardless of how many are used

In capitation, payers pay providers a fixed monthly fee per enrolled member, and providers accept the financial risk of delivering all covered services within that amount.