Practice Management & Billing Ethics Flashcards
6 cards from real AAPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Practice Management & Billing Ethics flashcards as text
What is a 'payer mix' in practice management?
Answer: The proportion of patients covered by different insurance types (Medicare, Medicaid, commercial, self-pay)
Payer mix describes the breakdown of a practice's revenue sources by insurance type, directly affecting financial performance since different payers reimburse at different rates.
What is 'credentialing' in healthcare practice management?
Answer: The process of verifying a provider's qualifications, licenses, and experience to grant privileges or payer enrollment
Credentialing verifies that providers meet the required standards of education, training, and licensure before they can treat patients or be enrolled with payers.
What is the National Provider Identifier (NPI)?
Answer: A unique 10-digit identification number assigned to healthcare providers for use in standard transactions
The NPI is a HIPAA standard unique identifier for covered healthcare providers, required on all HIPAA-covered electronic transactions including claims.
What is a 'charge master' (chargemaster) in a hospital setting?
Answer: A comprehensive list of all billable services, supplies, and fees that a hospital uses to generate patient charges
The charge master is a hospital's internal price list containing all items and services that can be billed, including assigned CDM codes and standard prices.
What is a 'first-pass resolution rate' in billing operations?
Answer: The percentage of claims paid on the first submission without denials or rejections
First-pass resolution rate measures billing efficiency; a high rate indicates claims are submitted cleanly and accurately the first time, reducing rework costs.
What is the purpose of the OIG Work Plan in healthcare compliance?
Answer: To identify areas where OIG will focus audits and investigations of healthcare providers during the fiscal year
The OIG Work Plan lists ongoing and planned audit and investigative activities, helping providers proactively review their own practices in areas of heightened scrutiny.