Healthcare Insurance & Claims Processing Flashcards

A provider writes off the difference between their billed charge and the payer-contracted rate. This write-off is called a:

Answer: Contractual adjustment

A contractual adjustment reflects the difference between the provider's billed charge and the negotiated contracted rate the provider has agreed to accept.

Which Medicare Part covers inpatient hospital stays, skilled nursing facility care, and hospice?

Answer: Medicare Part A

Medicare Part A is the hospital insurance component that covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services.

Under HIPAA, the standard code set for outpatient physician services and procedures is:

Answer: CPT/HCPCS Level I and II

HIPAA mandates the use of CPT (Current Procedural Terminology) and HCPCS Level II codes for reporting outpatient and physician services on professional claims.

What is the purpose of an Advance Beneficiary Notice (ABN) in Medicare billing?

Answer: To inform a Medicare patient that a service may not be covered and obtain their agreement to pay

An ABN is issued to a Medicare patient before a non-covered or potentially denied service, allowing the provider to collect payment from the patient if Medicare denies the claim.

A claim submitted more than 365 days after the date of service is denied by a commercial payer. This denial is categorized as:

Answer: Timely filing denial

Timely filing denials occur when claims are submitted after the payer's deadline, which is typically defined in the provider's contract and can range from 90 days to 2 years.

In value-based care reimbursement, what does a 'shared savings' model incentivize providers to do?

Answer: Reduce the total cost of care for a defined population while meeting quality benchmarks

Shared savings models reward providers who keep total care costs below a benchmark while meeting quality metrics, allowing them to share in the resulting savings.

Which of the following is an example of a 'clean claim' in healthcare billing?

Answer: A claim submitted with all required data elements, no errors, and within the timely filing period

A clean claim contains all required data elements, is free of errors or omissions, has valid codes, and is submitted within the payer's timely filing window.