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Okay, now we have our medical insurance midterm.

I know some of your very favorite subject to talk

about, uh when health insurance plans.

Prior approval requirements are not met by the providers.

What happens?

Um, is there an administrative costs are reduced.

Payment of the claim is denied.

Providers pay a fine to the plan.

Patients coverage is canceled.

Essentially, the payment would be denied.

What would be I found on a Remittance advice detected

errors and omissions from claims payment information about the claim

provider. Qualification responsibilities are documentation of medical necessity.

Again. Remember, the Remittance is actual payment through the electronic

systems that the government uses for insurance.

So payment information about the claim um clinical Laboratory Improvement

act, clear legislation established what for all laboratory testing Quality

of standards is what the clear established the health exchanges.

A health information exchange network for, um, what is it

used for?

Reducing costs and time for review of contractors, securely sharing

clinical information over the Internet, mailing or faxing medical documentation

promoting research and development.

Um so the main focus of the exchanges securing share

clinical um, information over the Internet Nationwide.

The primary purpose of the patient record is to provide

what, what blank of care.

So is it continuity, reimbursement, quality or provisions?

Um, and the purpose of it is continuity of care.

Total practical practice management software is used to generate the

electronic medical record automating which of the following medical practice

functions um, third party payment payer reimbursement, patient check, writing,

appointment, scheduling are collecting bad debts.

Remember that the total practice management one of the main

focuses of that, is to help with appointment scheduling.

Which type of health insurance coverage includes federal and state

government health programs that are available to eligible individuals.

That's public health care, so that includes Medicare, Medicaid chips

and Tricare.

So public health Care, which uses data from electronic health

records and health information technology systems to measure health care

quality. E calms.

I'm sorry.

E cute.

E C.

Q. M s e commerce health maintenance organizations.

HMOs is an alternate alternative traditional group health insurance coverage

and provides comprehensive health care services to voluntary voluntarily enrolled

members On a what basis?

Prepaid. Mhm, integrated Interrogated, uh, delivery System Ideas is an

organization of what that offer Joint health care services to

subscribers affiliated provider sets managed health care was developed as

a way to provide affordable, comprehensive prepaid healthcare services.

To WHO?

The provider, the payers, enrollees or patients?

Um, the correct term is enrollees.

Medicare established the quality improvement system for managed care to

assure the accountability of managed care plans in terms of

objective, measurable, uh, what is it?

Mandates, regulations, laws or standards?

These standards healthcare, effectiveness, data and information, or otherwise known

as the hottest was developed by the who and created

standards to assess managed care.

So who developed the hardest?

H e d.

I. S.

And that is the National Committee for Quality Assurance.

The primary care provider or the PCP is responsible for

what? Which is a method of controlling health care costs

and quality of care as that quality management, health information

management, risk management, utilization management, the correct answers.

Utilization management.

Just remember that utilization management is the one that helps

utilize the money that we receive and to use it

responsibly. A charge master team jointly shares the responsibility of

updating and revising the charge master to ensure what, um,

they're making sure that there is accuracy in it nonparticipating

by providers in an out of network provider who does

not contract with insurance plan.

Patients who are elected to receive care from non pars

or nonparticipating providers will incur higher out of pocket expenses.

The patient blank expected to pay the difference between the

insurance payment and the providers fee is usually expected or

is not, and the answer is usually expected.

A pre existing condition is any medical condition that was

diagnosed or treated within a specific period before or after

the enrollees.

Effective. So just like pre existing condition says that is

before denied and rejected claims are unpaid claims that have

been returned to the provider by third party prayers.

Um, which is an example of a reason why there

might be a denial procedure was medically necessary.

Absence of pre existing condition, covered, benefit fit or coding

error. So which one of those would cause a denial

revenue cycle focuses on what revenue cost charges patient satisfaction.

So exactly like the name says revenue cycle management.

We're focusing on revenue.

Um, there will be a question here that has you

calculate, um, based on how much of a down payment

or co pay that the patient gives how much the

physician is reimbursed.

You're gonna have to figure out, um, what will the

physician receive as a check?

And then what will the patient have to pay?

Which are the amounts owed to business for service or

goods provided?

So when that when you're looking at your budget, um

what what area of the budget shows what money is

coming into you?

That's accounts receivable, which established the rights, liabilities and responsibilities

of participants in electronic fund transfer systems.

So is that Fair Credit Billing Act, Equal Credit Opportunity

Act, Electronic Fund Transfer Act, Fair credit and charge Our

disclosure. So Electronic funds transfer, which is a review for

medical necessity of tests and procedures ordering ordered during an

inpatient hospitalization.

The concurrent review basically the review and on both at

one time, which prohibits discrimination on the basis of race,

color, religion, national origin, sex, marital status, age, receipt of

public assistance or good faith exercise of any rights under

the Consumer Credit Protection Act.

That's the equal credit opportunity.

Remember, anybody has the right to get in debt.

A code listed next to a main term in the

I C 10 index is referred to as a what

code default Cold code, All codes and I see 10

tabular are listed in what boldface?

An outpatient, uh, is treated in which of the following

settings. So if their outpatient, are they in a dummy

celery care facility nursing home, acute inpatient admission or hospital

observation unit?

So when we put them into hospital observation, that is

not an actual admission into the hospital.

That's just a time where the patients left there to

be able to kind of observe all that would be

an example of an outpatient setting.

Yeah. Um, I see 10 codes require up to how

many characters?

657 or eight seven is the answer on that?

I see 10 table of NEA plasm.

Um, which column classifies the original cancerous tumor site.

So which one is original Primary carcinoma Institute Secondary or

unspecified? Remember the term primary means first.

That's the first site that they found the cancer so

it would be primary malignant, which is a condition that

occurs, um, as a result of another condition, um, for

which codes are always reported.

Symptoms, syndrome manifestation or sun manifestation codes are present because

of other conditions that are going on a history is

an interview.

The patient that includes Which of the following elements Chief

Complaint. History of present illness, Past family, social history and

review of systems Home services are provided individuals in where

where is the patient when they're getting home health.

They're in their place of residence, which is an assessment

of the patient's body area in organ systems.

Physical examination, which services included as part of a surgical

package or global surgery.

Surgical procedure performed which supply patients with durable medical equipment.

Dems in stage renal or E S.

R D um, composite payment rates system is blank adjusted

to provide a mechanism to account for differences in patients.

Utilization of healthcare costs.

So discharge status.

Hey, so hopefully that helps you where you can focus

on your medical insurance again.

It will be an open book exam and we'll see

you tomorrow.

I'm at nine o'clock.

Hi,

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