Term | Definition |
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 |