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Module 5
Business Practices -- Chapters 16 Test Review
| 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 |
Created by:
monkmaroni
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