Business Practices -- Chapters 16 Test Review
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| Copayment | Form of cost sharing in which the insured pays a specific portion toward the amount of the professional services rendered
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| Third-Party Payer | Insurance that processes payments to providers on behalf of t\state or federal agencies or insurance companies
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| Indemnity | Benefits paid in a predetermined amount in the event of a covered loss
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| Deductible | Amount the insured must pay in a fiscal year before an insurance company will begin the payment of benefits; yearly dues
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| Premium | Monthly payment to maintain the policy and keep plan in effect
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| Carrier | Organization that offer protection against losses in exchange for a premium
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| Adjuster | Employee of an insurance carrier with whom a case is assigned and who follows the case until it is settled
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| Fiscal Intermediary | Contractor that processes payments to providers on behalf of state or federal agencies or insurance companies
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| Elimination Period | Period of time after the beginning of a disability for which no benefits are payable
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| Assignment | The transfer of one's right to collect an amount payable under an insurance contract
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| Insured is also known as the following: | Member; policy holder; subscriber; recipient
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| HSA | Health Savings Account (protects pt and their family; Tax sheltered trust account you pay into and withdraw for medical expenses)
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| HFSA | Healthcare Flexible Spending Account
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| HDHP | High Deductible Health Plan (Higher than normal deductibles i.e. $1,100 pp/$2,200 per family)
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| UCR | Usual, Customary and Reasonable
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| COB | Coordination of Benefits
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| An elimination period written in an insurance policy is also known as: | Waiting period or Excepted period
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| Attachment to a policy excluding certain illnesses or disabilities is called: | Waiver
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| Managed carte plans pay the physician via: | Capitation
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| Determining if managed care plans cover a particular surgical procedure is called: | Precertification
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| Preauthorization may also be known as: | Prior authorization or Prior approval
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| Prior to scheduling elective surgery you must find out what the max amount the insurance will pay. Fill out this form: | Predetermination
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| Five popular types of managed healthcare plans | HMO; PPO; IPA; PPG and POS
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| Medicare participating physicians receive what percent of the allowable fee? | 80 percent
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| 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
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| Document from the insurance company that arrives with check for payment of insurance claim: | Explanation of Benefits (EOB)
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| In the Medicare program the EOB is known as: | Medicare Remittance Advice (MRA)
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| An EOB sent to the patient in plain language is known as: | Medicare Summary Notice (MSN)
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| When submitting Medicare/Medicaid claims, the physician must always what? | Accept assignment otherwise insurance will send payment to the patient
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| A claim processed by Medicare and automatically processed by Medicaid is referred to as a: | Crossover Claim
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| Total Disability | Unable to perform all major tasks of his/her job due to illness or injury; unable to return to work
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| After worker's comp report, a pt should be seen and a progress report submitted how often? | Monthly basis
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| Paper insurance claim form accepted by most commercial (private) insurance companies, Medicare, Medicaid and Tricare are called | CMS-1500 forms
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| Where is insurance check sent if the patient sings an assignment of benefits statement? | Provider
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| The Birthday Rule | Birth month determines whose insurance is deemed primary, honored in most states, may not apply in divorce situations
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| Unique health identifier that all health care providers use when submitting claim forms: | National Provider Identification (NPI)
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| Service that receives claims, edits and sorts them, then electronically transmits them to insurance companies: | Clearing House
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| Can an original or copy of CMS-1500 claim form be optically scanned? | Original only
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| Should claim forms be typed in all caps or lower case if being optically scanned? | All caps only
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| When entering data to be optically scanned the date should be recorded as: | 2 digit month, two digit day and 4 digit year
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| The new version of the data element field that will be used for electronic billing is: | Standard Code Set -- 5010
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| If payment is not received after inquiries have been made | Appeal may be filed
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| Medical necessity is insured when the insurance carrier mandates: | Preauthorization
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| Medicaid is sponsored by: | Federal, state and local governments
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| As a medical assistant in an office we will bill for | Medicare Part B
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| Medicare Part A | Covers hospital
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| Medicare Part B | Covers office visit
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| Medicare Part C | Advantage which combines A and B
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| Medicare Part D | Voluntary prescription drug coverage offered by government insurance carriers (CMS)
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| Which system does Medicare use to calculate fees? | Resource-based Relative Value System (RBRVS)
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| Which Tricare program sometimes charges an enrollment fee? | Tricare Prime
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| State disability is available in the following states: | Puerto Rico; California; Hawaii; New Jersey; New York, Rhode Island
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| Who will the MA communicate with in worker's comp cases? | Adjuster
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| The CMS-1500 claim form has an assignment of benefits for government programs in which field? | Field 12
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| Why is the CMS-1500 claim form printed in red ink? | To comply with OCR machines
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| Some advantages of electronic transmission of claims are: | Fewer errors and omissions; quicker turnaround time; increased cash flow; built-in code edit checks
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| What is a claim scrubber? | Built-in edits in electronic software that prompt the biller to change or enter info on claims
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| When must an Advanced Beneficiary Notice be completed? | When it is suspected that Medicare may not deem a service or supply medically necessary
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| What is a suspended claim? | Claim held by the insurance company as pending g due to an error or the need for additional info
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| Liability under the False Claims Act can lead to civil monetary penalties for every fraudulent claim filed ranging from: | $5,500 to $10,000
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| 3 basic entities involved in healthcare: | Patient; Provider; Public or Private payer (insurance, gov't program, self insurers and managed care programs)
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| When was the Patient Protection and Affordable Act signed and then implemented? | Signed -- March 2012; Implemented -- 2014
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| Insurance Claim (form CMS-1500) | Tool used to request insurance payment under an insurance contract
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| Four main government insurance programs | Medicare; Medicaid; Tricare; CHAMPVA
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| America's Health Insurance Plans (AHIP) | National Association that represents health insurers on federal and state regulatory issues.
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| Commercial Insurance | Owned and run by private companies consisting of traditional indemnity benefit plans
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| 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
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| Group Insurance | Obtained through employer; PT may also obtain through association or club he/she belongs (AARP)
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| Conversion Privilege | Where insured may continue with same or lesser coverage under an individual policy
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| 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.
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| Major Medical | Extended benefits when an individual encounters large expenses caused by long illness or serious injury (ranging from $150k-$500k)
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| Insurance Agent | Person that represents the insurance company and helps candidate complete the application process
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| For inpatient services, payment may be determined in fee schedule for: | Diagnosis Related Group (DRG)
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| Fee For Service (FFS) | Method of payment in which patient pays the physician according to set schedule of fees
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| Examples of health care reform exclusion or limitations | Pregnancy or self inflicted injury may not be covered under certain policies
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| Usual Fees | Normally charged for a given professional service
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| Customary Fees | Fee that is in the range of usual fees charged by physicians of similar training and experience
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| Reasonable Fees | Fee that meets the two preceding criteria or is considered justifiable by responsible medical opinion considering any special circumstances
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| Physicians Profile/Fee Profile | Statistical summary of the fee pattern of each physician for a defined population of patients
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| 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
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| How often should you verify insurance coverage with a pt? | At every visit to ensure payment is still active and up to date
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| Precertification | Refers to finding out if service or procedure is covered under pt insurance policy
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| Predetermination | Finding out the max dollar amount the insurance will pay for a professional service to pt
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| Preauthorization | Determines medical necessity of certain services, hospital admissions, in/outpatient surgeries, elective proc., medication or specialist need
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| Formal Referral | An authorization request required to determine medical necessity that can be faxed, called in, mailed or emailed
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| Direct Referral | Handed right to pt at time of referral
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| Verbal Referral | Physician calls the specialist and indicates the pt is being referred for an appt (MA will usually make these calls)
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| Self-Referral | Pt refers him/herself and may be required to inform their PCP
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| Medical Review | Professional Review Organizations (PROs) are physicians who evaluate the quality of professional care/assessment of care given
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| Oldest Managed Care Organization | HMO (require copayment)
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| Group Practice Model | Physicians are paid a salary by their own independent group
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| Staff Model | Hires individual doctors and pays them salary rather than contracting with a medical group (think hospital)
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| Network Model | 2 or more group practices provide health services
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| 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
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| 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
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| Physician Provider Groups | Physician owned businesses that have flexibility built in. Capitation may change. Select list of referrals are within this group
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| Point of Service Plan (POS) | Combines elements of an HMO and PPO and offer some unique features
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| Medicaid | Is more of an assistance program than an insurance program. May be considered coinsurance. Arizona was last state to join Medicaid program
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| What does Medicaid set a limit on? | The number of office visits per year
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| Who might qualify for Medicaid? | Low income people; blind or disables; families receiving aid to dependent children
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| Medicare | Funded is funded by the federal gov't; administered by CMS and available to those 65yrs and older
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| 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
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| Additional Tricare plans offered: | Tricare Young Adult; Tricare for Life; Tricare Plus
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| Tricare Young Adult | Premium based plan for qualified dependents that have aged out
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| Tricare for Life | Supplemental Medicare plan
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| Tricare Plus | Primary care program available at selected military treatment facilities
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| CHAMPVA (aka Dept. of Veterans Affairs) | Civilian Health and Medical Program of Veterans Administration; no premiums; preauthorizations are typically not needed except select services
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| Worker's Compensation is | Mandatory in all states
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| Federal Employee's Compensation Act (FECA) | Provides benefits for on the job injuries to all federal workers
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| 3 types of worker's comp (w/c) claims | Non-disability; Temporary disability; Permanent disability
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| Non-disability (in w/c claims) | Pt seen by physician but may continue working
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| Temporary Disability (in w/c claims) | Injured cannot perform all duties of his/her job for limited period of time
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| 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
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