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Business Practice

Chapter 16 - Insurance

TermDefinition
premium monthly dues to keep insurance active
deductible yearly fee that must be met before insurance picks up incurred fees - amount the insured must pay in a fiscal year before an insurance company will begin the payment of benefits
co-pay partial payment of the visit - form of cost sharing
Dx co-pay partial payment of procedures
Obamacare aka Affordable Care Act - five main plans - need to know three only becomes affordable for those below poverty level
ACA Bronze 60% insurance pays, 40% pt responsibility - lower premium, higher out-of-pocket expense
ACA Silver 70% insurance, 30% pt responsibility
ACA Gold 80% insurance pays, 20% pt responsibility - higher premium, lower out -of-pocket expense
main government insurance programs Medicare, Medicaid, Tricare, CHAMPVA
third-party payers - three basic entities three basic entities involved in healthcare reimbursement - pt, provider (Dr.), public (insurance or 3rd party) or private (self-pay) payer
AHIP americas health insurance plans - represents health insurers on federal and state regulatory issues
commercial insurance owned and run by private companies - consist of traditional indemnity benefit plans (preventative), self-insured plans, managed care plans
the insured is also known as a member, policyholder, subscriber, recipient
in an insurance contract, the waiting period is also called the elimination period and a time frame after the beginning date of a policy before benefits for illness or injury becomes payable
unit values for each procedure code are used in which payment method RVS
medical necessity is insured when the insurance carrier mandates preauthorization
the oldest of all prepaid health plans HMOs
medicaid is sponsored by federal, state and local governments
which system does Medicare use to calculate fees Resource-Based Relative Value System
state disability is available in Puerto Rico and in the states of CA, HA, NJ, NY, RI
when working in a Dr's office which Medicare Part will billed Medicare Part B
In the TRICARE program, an enrollment fee is sometimes charged for TRICARE Prime
In a workers' compensation case, who does the MA communicate with adjuster
the CMS-1500 claim form has an assignment of benefits for government program which field Field 12
a standard unique health identifier for health care providers is called NPI
why is the CMS-1500 claim form is printed in red ink to comply with OCR machines
advantages of electronic transmission of claims fewer errors and omissions, quicker turnaround, increased cash flow, built-in code edit checks
claim scrubber built-in edits in electronic software that prompt the biller to change or enter information on claims
Advance Beneficiary Notice must be completed when it is suspected that Medicare may not deem a service or supply medically necessary
suspended claim claim held by the insurance company as pending because of an error or the need for additional information
liability under the False Claims Act can lead to civil monetary penalties for every fraudulent claim filed $5,500 to $10,000
third-party payer insurance carrier that intervenes to pay hospital or medical expenses on behalf of beneficiaries or recipients
indemnity benefits paid in a predetermined amount in the event of a covered loss
carrier organization that offers 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 of 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 rights to collect an amount payable under an insurance contract
partial disability illness or injury preventing the insured from performing one or more functions of their occupation
a document from the insurance company that arrives with a check for payment of an insurance claim is called an EOB = explanation of benefits
temporary disability injured cannot perform all functions of their job for a limited period of time
total disability insured unable to perform major duties of their specific occupation
RA (Medicare) remittance advice - EOB for Medicare
MSN Medicare Summary Notice - EOB for patients
HMO health management organizations
PPO preferred provider organization
IPA independent practice association
PPG physician provider groups
POS point-of-service-plan - combines qualities of PPO and HMO
predetermination maximum dollar amount insurance company will pay for professional services to be rendered to pt
preauthorization used for hospital admissions, inpatient or outpatient surgeries, elective procedures, medication or when pt needs to be seen by specialist aka prior-authorization or pre-approval
medical necessity mainly used for prior-authorizations
RBRVS system to calculate MEDICARE fees
How Dr's are paid by HMOs network, group, staff
HMO - Staff Drs paid by salary - drs must be contracted with insurance co.
HMO - Network Drs. contracted with HMO
HMO - Group Drs paid by salary - contracts are with hospital
Created by: gcjlentz