Revenue Cycle Fundamentals Flashcards

Which Medicare Advantage plan type allows enrollees to see out-of-network providers but at a higher cost-sharing?

Answer: PPO

Medicare Advantage PPO plans allow beneficiaries to use out-of-network providers at a higher out-of-pocket cost compared to in-network providers.

A patient presents with workers' compensation as their insurance. What is a key characteristic of workers' comp billing?

Answer: It covers work-related injuries or illnesses, and the employer's carrier is billed — not the patient

Workers' compensation covers job-related injuries or illnesses; the employer's insurance carrier is responsible, and the patient has no financial liability.

What is a 'superbill' in the context of physician office billing?

Answer: A document containing diagnosis and procedure codes completed by the provider after a visit

A superbill is a standardized form where providers document diagnoses (ICD codes) and services (CPT codes) rendered during a visit, serving as the source document for billing.

Under HIPAA, what is the 'minimum necessary' standard as it applies to patient information?

Answer: Only the information necessary to accomplish the intended purpose should be disclosed

The minimum necessary standard requires that covered entities limit the use and disclosure of protected health information to only what is needed for the specific purpose.

What is the purpose of an advance beneficiary notice (ABN) in Medicare billing?

Answer: To notify a Medicare patient before a service that Medicare may not cover it and they may be responsible for payment

An ABN informs Medicare beneficiaries before a potentially non-covered service is provided, giving them the choice to receive the service and accept financial responsibility.

Which metric is used to measure the percentage of claims denied by payers out of total claims submitted?

Answer: Denial rate

The denial rate is calculated by dividing the number of denied claims by the total claims submitted, expressed as a percentage; lower rates indicate better front-end accuracy.

In the context of healthcare billing, what does 'assignment of benefits' mean?

Answer: The patient authorizes the payer to send payment directly to the provider rather than to the patient

Assignment of benefits is an authorization signed by the patient allowing the insurer to pay the provider directly instead of reimbursing the patient.