Question

1. Discuss the effects of : a. a) up-coding b. b) down -coding ?

2. Define as they relate to medical insurance:

a. confidentiality

b. ethics

c. fraud

d. abuse

3. Define medical necessity as it applies to procedural and diagnostic coding?

4. Describe types of adjustment that may be made to a patient's accounts including:

a. non-sufficient funds(NSF) check

b. collection agency transaction

c. credit balance

d. third-party

Answer 1

1 a Effects of upcoding include higher medical costs for tax payers and the insured.it can have negative health ramifications for patients.it pouts false information on their medical records and can affect their future ability to get insurance.Both down coding and upcoding are illegal practices and medical assistants can be prosecuted for either practice.

b Insurance carriers always downcode.Codes are ambiguous and reimburse the provider for the lowest possible fee.If Workers Compensation claims examiner has to convert a CPT code to a relative value scale,the examiner will select the lowest paying code.When attached documentation does not match the written description of the procedure,the reimbursement will always be the lowest paying code.

2 a Confidentiality is defined as the right to privacy and it applies to both medical and personal information.

b Ethics is the standards or rules governing proper conduct,developed by ones understanding of right and wrong.

c Fraud is the deliberate deception for unfair or unlawful gain such as using another persons insurance card to obtain medical care.

d Abuse refers to excessively to other providers for unnecessary services such as perform a battery of diagnostic tests when only a few are required for services.

3 Medical necessity is a determination made by a third party that a certain service or procedure was necessary based on sound medical practice.

4 a Non sufficient funds is a demand for payment cannot be honnered because insufficient funds are available in the account on which the instrument was drawn and not having enough money in an account to make a payment .

d Third party is involved in some way in an interaction that is primarily between two other entities.

c Credit balance is balance in ones favor on an account ,promise to pay at a later date.

b Collection agency transaction is a business that collects payments on unpaid loans or on bills. the agency that collects past due bills or payments.