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Module 5

Business Practices -- Chapters 16 Test Review

Copayment Form of cost sharing in which the insured pays a specific portion toward the amount of the professional services rendered
Third-Party Payer Insurance that processes payments to providers on behalf of t\state or federal agencies or insurance companies
Indemnity Benefits paid in a predetermined amount in the event of a covered loss
Deductible Amount the insured must pay in a fiscal year before an insurance company will begin the payment of benefits; yearly dues
Premium Monthly payment to maintain the policy and keep plan in effect
Carrier Organization that offer protection against losses in exchange for a premium
Adjuster Employee of an insurance carrier with whom a case is assigned and who follows the case until it is settled
Fiscal Intermediary Contractor that processes payments to providers on behalf of state or federal agencies or insurance companies
Elimination Period Period of time after the beginning of a disability for which no benefits are payable
Assignment The transfer of one's right to collect an amount payable under an insurance contract
Insured is also known as the following: Member; policy holder; subscriber; recipient
HSA Health Savings Account (protects pt and their family; Tax sheltered trust account you pay into and withdraw for medical expenses)
HFSA Healthcare Flexible Spending Account
HDHP High Deductible Health Plan (Higher than normal deductibles i.e. $1,100 pp/$2,200 per family)
UCR Usual, Customary and Reasonable
COB Coordination of Benefits
An elimination period written in an insurance policy is also known as: Waiting period or Excepted period
Attachment to a policy excluding certain illnesses or disabilities is called: Waiver
Managed carte plans pay the physician via: Capitation
Determining if managed care plans cover a particular surgical procedure is called: Precertification
Preauthorization may also be known as: Prior authorization or Prior approval
Prior to scheduling elective surgery you must find out what the max amount the insurance will pay. Fill out this form: Predetermination
Five popular types of managed healthcare plans HMO; PPO; IPA; PPG and POS
Medicare participating physicians receive what percent of the allowable fee? 80 percent
What is the time limit for submission of a Medicare claim form Up to one year but best to submit within one month to get paid sooner
Document from the insurance company that arrives with check for payment of insurance claim: Explanation of Benefits (EOB)
In the Medicare program the EOB is known as: Medicare Remittance Advice (MRA)
An EOB sent to the patient in plain language is known as: Medicare Summary Notice (MSN)
When submitting Medicare/Medicaid claims, the physician must always what? Accept assignment otherwise insurance will send payment to the patient
A claim processed by Medicare and automatically processed by Medicaid is referred to as a: Crossover Claim
Total Disability Unable to perform all major tasks of his/her job due to illness or injury; unable to return to work
After worker's comp report, a pt should be seen and a progress report submitted how often? Monthly basis
Paper insurance claim form accepted by most commercial (private) insurance companies, Medicare, Medicaid and Tricare are called CMS-1500 forms
Where is insurance check sent if the patient sings an assignment of benefits statement? Provider
The Birthday Rule Birth month determines whose insurance is deemed primary, honored in most states, may not apply in divorce situations
Unique health identifier that all health care providers use when submitting claim forms: National Provider Identification (NPI)
Service that receives claims, edits and sorts them, then electronically transmits them to insurance companies: Clearing House
Can an original or copy of CMS-1500 claim form be optically scanned? Original only
Should claim forms be typed in all caps or lower case if being optically scanned? All caps only
When entering data to be optically scanned the date should be recorded as: 2 digit month, two digit day and 4 digit year
The new version of the data element field that will be used for electronic billing is: Standard Code Set -- 5010
If payment is not received after inquiries have been made Appeal may be filed
Medical necessity is insured when the insurance carrier mandates: Preauthorization
Medicaid is sponsored by: Federal, state and local governments
As a medical assistant in an office we will bill for Medicare Part B
Medicare Part A Covers hospital
Medicare Part B Covers office visit
Medicare Part C Advantage which combines A and B
Medicare Part D Voluntary prescription drug coverage offered by government insurance carriers (CMS)
Which system does Medicare use to calculate fees? Resource-based Relative Value System (RBRVS)
Which Tricare program sometimes charges an enrollment fee? Tricare Prime
State disability is available in the following states: Puerto Rico; California; Hawaii; New Jersey; New York, Rhode Island
Who will the MA communicate with in worker's comp cases? Adjuster
The CMS-1500 claim form has an assignment of benefits for government programs in which field? Field 12
Why is the CMS-1500 claim form printed in red ink? To comply with OCR machines
Some advantages of electronic transmission of claims are: Fewer errors and omissions; quicker turnaround time; increased cash flow; built-in code edit checks
What is a claim scrubber? Built-in edits in electronic software that prompt the biller to change or enter info on claims
When must an Advanced Beneficiary Notice be completed? When it is suspected that Medicare may not deem a service or supply medically necessary
What is a suspended claim? Claim held by the insurance company as pending g due to an error or the need for additional info
Liability under the False Claims Act can lead to civil monetary penalties for every fraudulent claim filed ranging from: $5,500 to $10,000
3 basic entities involved in healthcare: Patient; Provider; Public or Private payer (insurance, gov't program, self insurers and managed care programs)
When was the Patient Protection and Affordable Act signed and then implemented? Signed -- March 2012; Implemented -- 2014
Insurance Claim (form CMS-1500) Tool used to request insurance payment under an insurance contract
Four main government insurance programs Medicare; Medicaid; Tricare; CHAMPVA
America's Health Insurance Plans (AHIP) National Association that represents health insurers on federal and state regulatory issues.
Commercial Insurance Owned and run by private companies consisting of traditional indemnity benefit plans
Indemnity Insurance Protection against injury or illness and covers a preset number of visits. May only cover hospital cost or pay when person is ill or injured
Group Insurance Obtained through employer; PT may also obtain through association or club he/she belongs (AARP)
Conversion Privilege Where insured may continue with same or lesser coverage under an individual policy
Consolidated Omnibus Budget Reconciliation Act (COBRA) Act of 1985; applies to employees who left their job and require an extension of their group health. Very costly to maintain.
Major Medical Extended benefits when an individual encounters large expenses caused by long illness or serious injury (ranging from $150k-$500k)
Insurance Agent Person that represents the insurance company and helps candidate complete the application process
For inpatient services, payment may be determined in fee schedule for: Diagnosis Related Group (DRG)
Fee For Service (FFS) Method of payment in which patient pays the physician according to set schedule of fees
Examples of health care reform exclusion or limitations Pregnancy or self inflicted injury may not be covered under certain policies
Usual Fees Normally charged for a given professional service
Customary Fees Fee that is in the range of usual fees charged by physicians of similar training and experience
Reasonable Fees Fee that meets the two preceding criteria or is considered justifiable by responsible medical opinion considering any special circumstances
Physicians Profile/Fee Profile Statistical summary of the fee pattern of each physician for a defined population of patients
Capitation Method of payment for health services by which a health group is paid per capita for each pt enrolled w/o considering the actual amount of service provided to each pt
How often should you verify insurance coverage with a pt? At every visit to ensure payment is still active and up to date
Precertification Refers to finding out if service or procedure is covered under pt insurance policy
Predetermination Finding out the max dollar amount the insurance will pay for a professional service to pt
Preauthorization Determines medical necessity of certain services, hospital admissions, in/outpatient surgeries, elective proc., medication or specialist need
Formal Referral An authorization request required to determine medical necessity that can be faxed, called in, mailed or emailed
Direct Referral Handed right to pt at time of referral
Verbal Referral Physician calls the specialist and indicates the pt is being referred for an appt (MA will usually make these calls)
Self-Referral Pt refers him/herself and may be required to inform their PCP
Medical Review Professional Review Organizations (PROs) are physicians who evaluate the quality of professional care/assessment of care given
Oldest Managed Care Organization HMO (require copayment)
Group Practice Model Physicians are paid a salary by their own independent group
Staff Model Hires individual doctors and pays them salary rather than contracting with a medical group (think hospital)
Network Model 2 or more group practices provide health services
Preferred Provider Organizations (PPO) Highest level of benefits, more freedom of choice than an HMO, precerts and preauths usually still required but pt is free to go where they wish
Independent Practice Association (IPA) Physicians are not employees and are not paid a salary but agree to treat in their own offices at a fixed capitation payment per month
Physician Provider Groups Physician owned businesses that have flexibility built in. Capitation may change. Select list of referrals are within this group
Point of Service Plan (POS) Combines elements of an HMO and PPO and offer some unique features
Medicaid Is more of an assistance program than an insurance program. May be considered coinsurance. Arizona was last state to join Medicaid program
What does Medicaid set a limit on? The number of office visits per year
Who might qualify for Medicaid? Low income people; blind or disables; families receiving aid to dependent children
Medicare Funded is funded by the federal gov't; administered by CMS and available to those 65yrs and older
Tricare (3 main types): Standard -- fee for service cost sharing plan; Extra -- Preferred provider organization plan; Prime -- HMO plan with POS option and is only one enrollment fee
Additional Tricare plans offered: Tricare Young Adult; Tricare for Life; Tricare Plus
Tricare Young Adult Premium based plan for qualified dependents that have aged out
Tricare for Life Supplemental Medicare plan
Tricare Plus Primary care program available at selected military treatment facilities
CHAMPVA (aka Dept. of Veterans Affairs) Civilian Health and Medical Program of Veterans Administration; no premiums; preauthorizations are typically not needed except select services
Worker's Compensation is Mandatory in all states
Federal Employee's Compensation Act (FECA) Provides benefits for on the job injuries to all federal workers
3 types of worker's comp (w/c) claims Non-disability; Temporary disability; Permanent disability
Non-disability (in w/c claims) Pt seen by physician but may continue working
Temporary Disability (in w/c claims) Injured cannot perform all duties of his/her job for limited period of time
Permanent Disability (in w/c claims) Injured worker is left with residual disability; condition becomes permanent and stationary (p&s) and no further improvement is expected
Created by: monkmaroni