Medical Insurance: An Integrated Claims Approach Process Chapter 1
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| What Are third Party Payers? | They are a insurance policy or plan that carry some of the risk of paying for medical coverage.
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| Who generally files claims for Patients? | The Practice usually handles the process of billing the insurance companies.
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| What does participation mean? | It means the provider has contracted with a health plan to provide services to the plans beneficiaries (patients).
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| What Benefits does participation bring? | More Patients, contractual duties and, reduced fees.
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| What is Medicare? | A 100% Federally funded health plan that covers people 65 y/o and over, are disabled, or have permanent kidney failure (ESRD)
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| What is Medicaid? | A jointly funded State and federal health plan for low-income people?
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| What is TRICARE? | Medical expenses are covered by The Department of Defense for active duty members, and their spouses, children and other dependents. Also covered are retired military personal and their dependents.
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| What is Champva? | The Civilian Health and Medical Program of the Department of Veteran Affairs. It covers veterans with permanent service-related disablities and their dependent. Also covers dependents and spouses.
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| What is a Practice Management system? | Are computer programs that streamline medical office processes; including, scheduling, billing, and record keeping.
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| What is a Typical Practice Size? | Fewer than a third of doctors work in a solo practice or a partnership. The trend is toward larger single-specialty practices of 6 to 50 doctors.
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| How do you keep up to date? | The internet offers many official websites that help keep Medical Billers and Coders up-to-date with the latest updates, instructions, and rules for their specialty. Ignorance on these items is not an excuse for incorrect billing.
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| Medical Insurance Specialist Skills | 1. Knowledge of medical terminology, anatomy, physiology and medical coding
2. Communication Skills
3. Attention to detail
4. Flexibility
5. Information technology (IT) skills
6. Honesty and Integrity
7. Ability to work as a ream member.
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| Health Maintenance Organization (HMO) | An organization that contracts with a network of providers for the delivery of health care for a prepaid premium
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| Capitation | A prospective payment to a provider made for each plan member.
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| Schedule of benefits | A list of medical services by an insurance policy
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| Fee-For-Service | A retroactive reimbursement method based on providers' charges.
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| Coinsurance | The percentage of each claim that an insured person must pay
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| Deductible | The amount of money that an insured person must pay before reimbursement for medical expenses begins
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| Co-Payment (Co-pay) | An amount that an insured person pays at the time of a visit to a provider
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| Premium | The amount of money paid to a health plan to buy an insurance policy
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| Preferred Provider Organization | A managed care network of providers under contract to provide services at discounted fees
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| Indemnity | A health plan that that reimburses policyholders based on the fees charged.
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| In an HMO with a gatekeeper system,a ___________ coordinates that patient's care and provides referrals. | PCP
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| What system permits members to see out-of-network providers? | POS (Point-of-service)
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| Health plans pay for __________ services. | covered
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| In an HMO, securing _________ may be required before services are provided. | preauthorization
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| A self-insured health plan may use its own.... | funds
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| Unlike an HMO, a PPO permits its member to use ___________, but at a high cost. | out-of network
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| The major government-sponsored health programs are.... | TRICARE, CHAMPVA, MEDICARE, and MEDICAID
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| Coinsurance is calculated based on.... | a percentage of a charge
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| When a patient has insurance coverage for which the practice will create a claim, the patient bill is usually done... | before the encounter
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| If a patient's payment is later than permitted under the financial policy of the practice, the ________ may be started. | collection process
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| List at least four important skill of medical insurance specialists. | Communication Skills,
Attention to detail,
Flexibility,
Information technology (IT)
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| List the ten steps in the medical billing process... | 1. Pre-register patients 2. Establish financial responsibility 3/4. Check in/out Patients 5/6. Review coding/billing 7. Prepare/transmit claims 8. Monitor payer adjudication 9. Generate patient statements 10. Follow-up on payements and collections
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| T/F; Employment opportunities for medical insurance specialists are increasing because providers need trained, knowledgeable staff members to maximize revenue and ensure patient satisfaction. | True
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| T/F; The Third party to a medical insurance contract is the policyholder. | False
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| T/F; A discounted fee-for-service schedule provides for prospective payment. | True
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