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Sunday 19 August 2012

Medical Billing-Interview Questions

Medical Billing

Federal Insurance

  1. Medicare
  2. Medicaid
  3. Tricare
  4. RR Medicare (RR-Rail Road)


Medicare Eligible

  1. People 65 Years above
  2. People Under 65 with certain Disabilities
  3. People of any aged with End-Stage Renal Disease ( ESRD) (Permanent Kidney Failure requiring or a Kidney transplant)
  4. FICA ( Federal Insurance Contribution Act) ( Continue 40 Quarters paid to Tax)
  5. Black hole Workers.

The Different parts of Medicare

  1. Part A
  2. Part B
  3. Part C
  4. Part D

Part A (Hospital Insurance)

Only Covered with Hospital Services. ( Ex. Bed Charges & Equipment charges)
Its Cover Inpatient care in Hospital.
Its cover Skilled Nursing facility, hospice and home health care.
Claims billing to UB92 & UB04 forms.

Part B (Medical Insurance)

Its Covered with Doctors’ Services, hospital outpatient care and home health care.
Its cover some Preventive services to help maintain your health and to keep certain illness from getting worse
Claims Billing to HCFA & CMS1500 forms.

Part C (PartA+PartB+PartD)

Medicare Advantage plans (like an HMO or PPO) are health plans run by Medicare-approved private insurance companies. Medicare Advantage plans (also called Part C) include Part A, Part B and usually other coverage like Medicare prescription drug coverage (Part D), sometimes for an extra cost


Part D ( Medicare prescription Drug Coverage)

Only Covered with Drug Programme ( supply for Medicine) Ex: Sugar Patient.


Medicaid:

It’s Covered with below Paverty people (or) Low income people. It’s monthly month basic.
It’s Called Spend down Charges for Copay
California States Called Medicall

Tricare:

It’s Coved with Army people.

Tricare Two Types:

  1. CHAMPVA ( Civilian Health and Medical programme for Veteran affairs)
  2. CHAMPUS ( Civilian Health and Medical programme for Uniformed services)

RR Medicare:

It’s Covered with Railway Department, Transport Department & Highway’s Department.


Worker’s Compensation:

It’s Covered with Work related injury and work relavent accident.


Auto Accident:

It’s Covered with Vehicle Accident.

Two types of Auto Accident:
  1. No fault Auto Accident
  2. Non-No fault Auto Accident
Managed Care Plans:
To provide High quality service at low Cast.

1.HMO (Health Maintanence Organization)

Patient must goes to in-network Provider. PCP Must. (Low premiums, low deductible, copay & coins). PCP means Primary care Physician.

2.PPO ( Preferred Provider Organization)

Patient get treatment any provider. (Premium, deductible, copay & coins High cost)

3.POS (Point of Services)

It’s companied with HMO+PPO
Patient goes to any network provider (In or Out). PCP Must.



PAR Provider: (Participating Provider)

Who agrees and accept Insurance fees schedule and willing to contract with Insurance company.

Non-PAR Provider ( Non-Participating Provider)
Who does not contract with any Insurance company. (no write off). Payment fully paid to Patient.


Notes:
PAR and NON-PAR provider only Contract with Insurance Company

Medical Terminology

Allowed Amount:
Insurance Company fixed Maximum amount allowed each and every procedure code is called Allowed amount.

Coins:
Portion of the Allowed amount (or) Part of the Allowed amount

Copay:
It’s fixed small doller amount pay’s to provider for every treatment


Deductible:
It annum fee patient should to pay to insurance company before get benefits starts.
Medicare & Commercial insurance starts in January of each year
Tricare insurance starts in October of each year

2009 PART-B annum Deductible amount - $135.00
2010 PART-B annum Deductible amount - $150.00
2011 PART-B annum Deductible Amount -$162.00
2012 PART-B annum Deductible Amount -$140.00
2013 PART-B annum Deductible Amount -$147.00
2014 PART-B annum Deductible Amount -$147.00

Authorization:

Two types of Authorization
  1. Prior Authorization
  2. Retro Authorization

Prior Authorization:
Provider get approvel from the insurance before rendered the service. It’s Called Prepaid service.

Retro Authorization:
After entered the service provider get approval from the insurance company. It’s applicable for Emergency Care.

ABN: (Advance Beneficiary Notice)
Expecelly Medicare Policy Holders. Ex: Cosmetic Surgery.

It Medicare denial “Medically not necessary then the medicare beneficiary based amount to the provider.

Waiver Liability:
Commercial Policy Holders.

AOB:
Patient assigned benefits to the provider behalf of the treatment.

COB:
Cordination of Benefits
It’s detail’s of Primary and secondary insurance.

Capitation:

  1. Fixed Capitation
  2. Rolling Capitation

  1. Fixed Capitation:
Provider will be get fixed amount for every month

2. Rolling Capitation:
Provider will be get the amount for every patient.

SSN: (Social Security Number)
This Number all US Citizen Must. This Number Given by Social Security Administrator. SSN 3-2-4 format. First 3digit-Area Code 2digit-Group no. 4digit-Serial no.

Refund or Take Back
Claim wrongly Process and pay to the provider after the insurance company find the amount and ask refund request from the provider.

Offset or Recoupment amount
It the provider not refund the amount in the insurance company bill be adjusted on the next Claim.

Modifier:

  1. Information Modifier
  2. Reimpursment Modifier

1.Information Modifier:
Does not Varie the payment just indimate the insurance company which part of the organ service was rendered (EX) LT, RT, Upper, Lower

2.Reimpursment Modifier:
Varie the payment who render the service patient (EX) PC, TC, 26

CMS :
Centers of Medicare and Medicaid Service

POS: (Place of Service)
It’s Indicate when the service was rendered. (EX) Hospital or Clinic

ROI: (Release of Information)
Patient accept agree to release their Medical Information

DX-Codes: (Diagnosis Code) (ICD9 or ICD10 codes)
DX-Codes means Diagnosis Code.
3-5 digit number. Ex: 123.45, Fever, Headage


Cpt Codes: Current Procedure Terminology
HCPCS level-1 codes
Cpt Code means Procedure code. 5 digit number
Procedure code include 6 types of Treatment.
  1. E/M (Evaluation Management) Visit. Starting with 99201-99499.
  2. Anesthesiology – Starting with 00100-01999, 99100-99140
  3. Surgery – Starting with 10021-69990
  4. Radiology (Including Nuclear Medicine and Diagnostic Ultrasound )(Ex: Exray, CT, MRI) – Starting with 70010-79999
  5. Pathalogy (Blood test, Urine test) – Starting with 80048-89356
  6. Medicine (except Anethesiology) (EKG (ECG), EMG) – Starting with 90281-99199, 99500-99602

HCPCS Code:
Health Care Financing Administration Common Procedure Coding System. (pronounced "hick-picks"). Three level system of codes.

Level I - American Medical Associations Current Procedural Terminology (CPT) codes.

Level II - The alphanumeric codes which include mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, etc. These are items and services not covered by CPT (Level I) procedures.

Level III - Local codes used by state Medicaid organizations, Medicare
contractors, and private insurers for specific areas or programs.


COBRA :

The term COBRA is an acronym for the Consolidated Omnibus Budget Reconciliation Act of 1986—federal legislation that governs the operation of group-sponsored health plans of businesses with twenty or more employees. The COBRA Plan will offer continuing healthcare coverage to you and your dependents if you leave your job.
You will have to pay the entire COBRA premium on your own, however.
It’s possible to extend COBRA’s Coverage for up to 18 months and a surviving dependent can receive further extensions

Pre-Existing Condition:

Patient alredy suffered from Some diesease before enter the policy, Insurance will not cover some duration for that disease, thats patient responsible.... thats period called "Waiting Period". Once the patient will complete their waiting period, insurance starts to pay their services.
Ex: Heart Disease, High blood pressure, Cancer and Asthma.

FECA- Federal Employee's Contribution Act.
The Federal Employees' Compensation Act (FECA) provides federal employees injured in the performance of duty with workers' compensation benefits, which include wage-loss benefits for total or partial disability, monetary benefits for permanent loss of use of a schedule member, medical benefits, and vocational rehabilitation. This Act also provides survivor benefits to eligible dependents if the injury causes the employee's death. The FECA is administered by the Office of Workers' Compensation Programs (OWCP).

ABBRIVATION

ABN - Advance Beneficiary Notice.
ATD - Applied to Deductible
AWP - Any willing Provider.
AOB - Assignment of Provider
COB - Coordination of Benefits
CMS -Centers for Medicare and Medicaid services.- Designed by National Uniform Claim Commission.
COBRA - Consolidated Omnibus Budget Reconcilation Act.
CHAMPVA- Civilian Health and Medical program for Uniformed service
CHAMUS – Civilian Health and Medical Program for Veteran affairs.
CPT - Current Procedural Terminology.
DEERS - Defense Enrollment Eligibility Reporting System.
DHHS - Department of Health and Human Services.
DOS - Date of Service.
DME - Durable Medical Equipment.
EBSA - Employee Bendfits Security Administration.
EDI - Electronic Data Interchange.
EGHP - Employer Group Health Plan.
EIN - Employer Identification Number.
ERISA - Employee Retirement income security Act.
ESRD - End stage Renal Disease.
EOB - Explanation of Benefits.
EPO - Exclusive Provider Organization
EMC - Electronic Media Claims
ERA - Electronic Remittance advice
FFS - Fee for Service.
GHP - Group Health Plan.
HBMA - Healthcare Billing Management Association.
HCFA - Health Care Financial Administration.
HIC - Health insurance Claim.
HCPCS - Healthcare common procedure coding system.
HMO - Health Maintanance Organization.
HIPAA - Healthinsurance Portability and Accountability Act.
ICD9CM-International Classification of Disease 9 the revision of clinical modifier
IPA - Individual Practice Association.
IVR - Interactive Voice response
LOP - Letters of Protection.
MSA -Medical Savings Account.
MSP -Medicare Secondary Payer.
NonPar- Non participating Provider.
NPI - National Provider Identifier.
OIG - Office of Inspector General.
OON - Out of Network.
OOP - Out of Pocket.
OWCP - Office of Worker's Compensation Program.
PCIP - Primary Care Incentive Program
POS - Point of Service.
POS - Place of Service
PEC - Pre-Existing Condition.
PHI - Protected Health Information
PPO - Preferred Provider Organization.
PIP - Personal Injury Protection.
PIN - Provider Identification number.
PCP - Primary Care Provider.
RA - Remittance Advice.
RAN - Referral Authorization Number.
RBRVS - Resource Based Relative Value Scale.
RRB - Railroad Retirement Board.
SSA - Social Security Administration.
SNF - Skilled Nursing Facility.
TPA - Third Party Administrator.
UPIN - Unique Physician Identification Number.
WC - Worker's Compensation
ZIP - Zonal Improvement Plan.

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