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GuntermanINS Ch 1

Intro to the Medical Billing Cycle

Question	Answer
a prospective payment to a provider made for each plan member	capitation
the percentage of each claim that an insured person must pay	coinsurance
an amount that an insured person pays at the time of a visit to a provider	copayment
the amount that an insured person must pay before reimbursement for medical expenses begins	deductible
a health plan that reimburses policy holders based on the fees charged	fee-for-service
an organization that contracts with a network of providers for deliver of health care for aprepaid premium	HMO-health maintenance organization
a retroactive reimbursement method based on providers charges	indemnity
a managed care network of providers under contract to provide services at discounted fees	PPO-Preferred provider organization
the amount of money paid to a health plan to buy an insurance policy	premium
a list of medical services covered by an insurance policy	schedule of benefits
Spending on health care in the United States is rising due to what 2 factors	the cost of new technology and the aging population
Employment for well-trained medical insurance and coding specialists are	increasing due to rising demands.
What kind of medical services are annual physical examinations and routine screening procedures	preventive
Under an insurance contract the patient is the 1st party, the physician is the 2nd party, who is the 3rd party?	Insurance plan
Under a written insurance contract, teh policyholder pays a premium and the insurance company provides what	payments for covered medical services
Out-of-pocket expenses must be paid by who	the patient
What conditions must be met before payment is made under an indemnity plan?	payment of premium, deductible, and coinsurance
A capitated rate is	prospective payment
Correctly relating a patient's condition and treatment refers to	medical necessity
Which of the following is required with a HMO patient is admitted to the hospital for nonemergency treatment?	preauthorization
HMO's are regulated by	both federal and state law
Under a capitated rate for each plan member, who shares the risk?	Provider and the 3rd party payer
A capitated rate per member per month coveres what	services listed on the schedule of benefits
For a patient covered by an HMO, out-of-network means the provider is	not under contract with the payer
With a POS option under a HMO organization the patient may choose	to see a provider who is not int he HMO network
With a point-of-service type HMO the patient may use the services of	HMO network or out-of-network providers
To be covered patients who enroll in an HMO may use the services of	only HMO network providers
Under an indemnity plan a patient my use the services of	any provider
In a PPO plan referrals to specialists are	not required
Consumer-driven health plans combine a health plan with a special savings account that is used to pay the medical bills before what	the deductible is met
Employers that offer health plans to employees without using an insurance carrier is called	self-funded health plan
What is an example of a private-sector payer	insurance company
What government program covers patients who are over age 65?	Medicare
What government program covers people who cannot otherwise afford medical care	Medicaid
Step 1 of the medical billing cycle	Preregister patient
Step 2 of the medical billing cycle	Establish financial responsibility for visits
Step 3 of the medical billing cycle	Check in patient
Step 4 of the medical billing cycle	Check out patient
Step 5 of the medical billing cycle	Review coding compliance
Step 6 of the medical billing cycle	Check billing compliance
Step 7 of the medical billing cycle	Prepare and transmit claims
Step 8 of the medical billing cycle	Monitor payer adjudication
Step 9 of the medical billing cycle	Generate patient statements
Step 10 of the medical billing cycle	Follow up patient payments and handle collections
A patient ledger records what	The patient's financial transactions
What characterisitcs is most important when medical insurance specialists work with patients' records and handle finances?	honesty and integrity
standards of conduct based on moral principles	professional ethics
standards of professional behavior	professional etiquette
Registered Medical Assistant (RMA) is awarded by	(AMT) American Medical Technologists
Certified Medical Assistant (CMA) is awarded by	(AAMA) American Association of Medical Assistants
Certified Coding Specialist, (CCS) and Certified coding Specialist-Physician based (CCS-P) is awarded by	(AHIMA) American Health Information Management Association

Created by: monicagunterman

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