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Medical Insurance
| Question | Answer |
|---|---|
| Renewable Provision | A cancel-able policy grants the insurer the right to cancel the policy at any time and for any reason. |
| Optionally Renewable | The insurer has the right to refuse to renew the policy. |
| Conditionally Renewable | Policy grant the insurer a limited right to refuse to renew a health insurance policy at the end of the premium payment period. |
| Guaranteed Renewable | Classification is desirable because insurer is required to renew the policy as long as the premium payments are made. |
| Non-cancelable | The insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract. |
| Blue Cross- Blue Shield | Independent, non-profit that contract with the hospitals and physicians to give prepaid health care. |
| CHAMPUS | Civilian Health and Medical program of uniformed services, Government sponsored for active service members and those who die on duty. |
| CHAMPVA | Civilian and Medical health program for veterans and their family. |
| CMP | Federal legislature enrollment of medicare benefits into managed care. |
| EPO | Member eligible for benefits only when they use services of limited network of providers. |
| Foundation for Medical Care | Organization of physicians. Concerned with development and delivery and cost of health care. |
| All Medical records are confidential, except in what cases? | 1)PT signed an authorization form to release info. 2)Worker's compensation cases. 3) When PT is suing, such as employer, who must protect himself. 4)When PT record are subpoenaed or there is a search warrant. |
| Preauthorization | Form before they will approve certain hospital admissions. |
| Precertification | Refers to discovering whether a treatment is covered. |
| Predetermination | Discovering the max dollar amount the carrier will pay. |
| Adjuster | Assists in settlement of claims. |
| Assignment | Transfer of right to receive payment from PT to physician. |
| COB | Coordination of Benefits- insurer takes into account another companies benefits before remitting payment. |
| Carrier | Insurance company. |
| Deductible | Amount insured must pay before policy will. |
| Exclusions | Certain illnesses, injuries, benefits not included in policy. |
| Indemnity | Benefits paid to insured. |
| Premium | Periodic payment required to keep insurance effective |
| Subscriber | One who belongs to insurance plan-usually finically responsible party. |
| Waiting Period | Time that must elapse before indemnity paid. |
| Time Limit | Period of time within which claim must be filled. |
| Eponyms | Name for disease. "Parkinson's disease" |
| Dual Coverage | Patients with two insurers. |
| Statue of Limitations | 3 years for legal action. |
| Clean Claim | Claim that was submitted with all pertinent info supporting documents, was processed and paid in timely matter. (60 days) |
| Dingy Claims | Medicare contractor cannot process a claim for a service rendered. The claim is held until changes within the system allows. |
| Dirty Claims | Claims with errors or those that require manual processing. |
| Rejected Claims | Claims that require investigation. These claims may have coding errors, or clarification. |
| What action is done when PT misses an appointment? | Bill sent for about $25-$50 for doctors time. |
| What type of info should not be faxed? | STDS, drug or alcohol abuse/ treatment, HIV status. |
| How can instance claim be filled? | Manual, in office, outside service bureau, telecommunications network, HCFA-1500. |
| Describe the process for an abstract of a medical record. | 1) Agent must pay for the time and effort 2) signed release from PT 3)Only registered info. |
| What must be done prior to insurance companies creating medical record copies? | 1) Copy make an appointment. 2)signed release from PT 3) only registered info |
| Billing for services not rendered. | Fraud |
| Forging the medicare co-payment or deductible. | Fraud |
| Excessive charges for services or supplies. | Abuse |
| Billing Medicare beneficiaries at a higher rate. | Abuse |
| Up-coding | Fraud |
| Changing a date of service | Fraud |
| Claims for services not medically necessary. | Abuse |
| Requiring patients to pay for services not normally billed, such as telephone calls and/or prescription refills. | Abuse |
| What does MCO stand for? | Managed care organization |
| What does HMO stand for? | Health Maintenance Organization |
| What does PPO stand for? | Preferred Provider Organization |
| In what two ways does managed care pay for their participating physicians? | Contracted fees and fixed prepayment (capitation) |
| In exchange for _________________, the health care provides benefits. | Payment for medical services. |
| What is liability insurance? | Covers injuries cause by the insured or that occurred on the insurer's property. |
| What are the three participants in an insurance contract and what is the definition? | 1st party holders: policy holder. 2nd party: physician who provides medical services. 3rd party: who agrees to carry the risk of paying. |
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