Healthcare Insurance & Claims Processing Flashcards

Which federal law requires employers with 20 or more employees to offer continuation of group health coverage to qualified beneficiaries after a qualifying event such as job loss?

Answer: COBRA

COBRA (Consolidated Omnibus Budget Reconciliation Act) requires applicable employers to offer continued health coverage for up to 18-36 months after qualifying events, at the beneficiary's expense.

A payer uses a 'capitation' payment model. How does this differ from a fee-for-service model?

Answer: Providers receive a fixed monthly payment per enrolled member regardless of services used

Capitation pays providers a fixed per-member-per-month (PMPM) amount to cover all contracted services for enrolled patients, shifting financial risk to the provider.

In the context of claim auditing, what does 'upcoding' refer to?

Answer: Billing for a higher-complexity or higher-cost service than was actually provided

Upcoding is a fraudulent practice of billing a code that represents a more expensive service than what was actually documented and performed.

When a claim is subject to a global surgical period, which services are typically included in the global fee and should NOT be billed separately?

Answer: Pre-operative visits one day before surgery and post-operative care during the global period

The global surgical package includes the pre-operative visit the day before surgery (for major procedures) and all routine post-operative care during the 10- or 90-day global period.

A patient's plan has a $2,000 out-of-pocket maximum. They have already paid $1,800 in cost-sharing. For a subsequent covered service with a $500 coinsurance, how much does the patient owe?

Answer: $200

The patient only owes the remaining $200 needed to reach the $2,000 out-of-pocket maximum; the payer covers the remaining $300 of the coinsurance.

Which of the following best describes the role of a clearinghouse in the claims process?

Answer: It translates and validates claims from provider format to payer-specific EDI format, checking for errors before transmission

A clearinghouse acts as an intermediary that receives claims from providers, validates them for format and data errors, and transmits them electronically to the appropriate payers.

What is the significance of the National Provider Identifier (NPI) on a healthcare claim?

Answer: It is a unique, standardized 10-digit number that identifies covered healthcare providers for electronic transactions

The NPI is a HIPAA-mandated, unique 10-digit identifier assigned to each covered healthcare provider, replacing legacy provider identifiers in all standard electronic transactions.