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Week 1 Flashcards

0
Q

Mission statement

A

Create value for organizations in healthcare industry thru innovative business solutions built on superior technology enhanced with excellent service

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1
Q

3 adjectives to describe quadax

A

Medical billing, technology, service

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2
Q

4 values

A

Dependability, integrity, respect, teamwork

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3
Q

6 business units

A

Managed a/r, administration, reimbursement support, itis, network services, edi

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4
Q

Founding year

A

1973

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5
Q

First quadax client

A

Ohio medicaid

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6
Q

First quadax function

A

Data entry with ibm punch cards

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7
Q

3 benefits of being privately held

A

Flexibility, agility, quick response to change

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8
Q

7 office locations

A

Strongsville, middleburg, columbus, norwalk, beachwood, youngstown, GA

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9
Q

Harp stands for?

A

Healthcare a/r processor

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10
Q

2 harp models

A

Partner (share work), manager (quadax does it all)

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11
Q

Pas stands for?

A

Patient advocacy software

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12
Q

3 functions of pas

A

Pre-billing, medical records and appeals

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13
Q

Edi stands for?

A

Electronic data interchange

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14
Q

Who is xpeditors biggest client?

A

Harp

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15
Q

Define clearinghouse

A

Facilitator of transactions between provider and payer, used for faster reimbursement and accuracy

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16
Q

Csc

A

Client support center; xpeditor

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17
Q

Quick

A

Quadax internal check; formatting claims

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18
Q

ecm

A

Enterprise content management; onbase

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19
Q

Who developed onbase?

A

Hyland

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20
Q

How long does harp implementation take?

A

90 days

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21
Q

3 levels of harp database

A

Software (shared by all), virtual (shared by some), client (individual)

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22
Q

Purpose of medical billing

A

Get claim to insurance as quickly and accurately as possible for max reimbursement

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23
Q

12 Steps in the journey

A

Encounter, superbill, coding, pre-billing, ticket, claim generation, xpeditor, payer edits, adjudication, remittance, insurance followup, statement

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24
2 parts of demographic information
Patient info, insurance
25
ELEL and RERE
Electronic eligibility and review response; used in pas to make sure insurance will accept procedure
26
What makes up a ticket?
Demographics from drs and charge info from crs, united by common account number
27
Cms1500
Outpatient form
28
Ub04
Inpatient form
29
837
Electronic form created by xpeditor to send to insurance
30
Emdeon
Post office in the sky; clearinghouse for small payers
31
Payer edits
Insurance company checks patient id, codes, and eligibility
32
Adjudication
Decide what to pay - all, none, line item, or deductible required
33
835
Electronic remittance sending money back thru clearinghouse for payment
34
Eft
Electronic funds transfer
35
Era
Electronic remittance advice
36
Lockbox
Where money and other correspondences from insurance company goes before being posted in system
37
Insurance follow up
Investigation & resubmit of denied claims
38
Expected growth in healthcare industry in next 10 years
10.8%
39
Leading cause of death in 1900s
Gastrointestinal infection
40
8 Causes of improved care/prolonged life
Infection control, less invasive surgery, gene therapy, preventive testing, specialized equipment, robotics, telemedicine, electronic charting
41
A/r
Accounts receivable, money due to provider
42
Accounts payable
Money due from provider
43
8 Modern medical challenges
Controlling expenses, occupancy rates, coordinating with insurance, decreased income, hipaa, jcaho, avoiding duplication, staffing
44
Quadaxs largest client base
Labs and hospitals
45
2 types of insurance
Individual and group
46
Traditional insurance plan
Most flexible, choose any doctor, deductible & co-insurance
47
Ppo
Preferred provider organization, any provider but pay more out of network, no pcp
48
Hmo
Health maintenance organization, pcp required, in network only, authorizations required, no deductiblr
49
Pos
Point of service, combo of ppo and hmo, pcp oversees most care
50
Capitation
Provider paid a set amount per billing cycle to see x number of patients
51
Dmg
Delegated medical group, aka ipa, california plan based on capitation and preventive medicine
52
Ipa
Independent practice organization, aka dmg
53
Hra
Health reimbursement account, employer pays
54
Hsa
Health savings account, employee pays
55
Medicare
Federal plan for elderly, disabled & end stage renal
56
Part a
Inpatient
57
Part b
Outpatient
58
Part c
Advantage replacement; commercial with no secondary allowed
59
Part d
Prescriptions
60
Medigap
Supplementary insurance for medicare, commercial
61
Rrmc
Railroad medicare
62
Umw
United mine workers
63
Tricare
Active and retired military
64
Champva
Relatives of permanently disabled veterans
65
Medicaid
Eligibility determined monthly based on income, can supplement medicare, state funded, patient not responsible for balance
66
Workers comp
Occupational illness and accidents, pre-auth required, patient not responsible for balance
67
Self funded
Employer pays third party admin, keeps premiums to pay claims, use stop loss insurance
68
Assignment of benefits
Patient agrees to let insurance pay provider directly
69
Coordination of benefits
Order of insurance (1st, 2nd, etc)
70
Co-insurance
Percentage required from patient
71
Guarantor
Person responsible for bill, can be dependent if they are over 18
72
Pre-authorization
Is service covered and medically necessary?
73
Pre-certification
Is treatment covered?
74
Pre-determination
Maximum allowable amt
75
Ucr
Usual customary rate, guideline for payment
76
Blue card local vs home plan
Local is where lab is located, home is listed on patient insurance card
77
Where is blue card claim sent?
State where specimen was collected
78
Who maintains cpt and icd?
World health organization
79
5 uses of icd and cpt coding
Analysis of diseases and therapies, reimbursement, decision support, outbreaks, fraud
80
Icd
International classification of diease
81
2 volumes of icd
Tabular by body system, alphabetical
82
Steps in icd coding
Determine reason for visit, use alphabetical index, use tabular index
83
V code
Visits without a procedure, primary or standalone
84
E code
External cause of injury or poisoning, cannot be primary or stanalone
85
Cpt
Current procedural technology, 5 digits with 2 possible modifiers
86
6 sections of cpt manual
Eval and mgmt, anesthesia, surgery, radiology, path/lab, medicine
87
3steps in cpt coding
Determine procedures, id codes, determine need for modifiers
88
Cpt tiers
Tier 1 is frequently used, tier 2 is infrequent
89
Modifier 22
Greater than listed
90
Modifier 25
Spearately identifiable procedures
91
Modifier 26
Professional component
92
Modifier tc
Technical component
93
Modifier 50
Bilateral
94
Modifier 52
Reduced service
95
Modifier 59
Multiple times in a day
96
Modifier 90
Outside lab
97
Modifier 91
Repeat procedure
98
Modifier ga
Abn signed
99
Abn
Advanced beneficiary notice, patient notified they'll be responsible for balance
100
Pqrameter
Determines rules for how data is handled in harp
101
Roster
Group of individuals from same facility with same charge grouped for easier billing

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