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Business Practice
Chapter 16 - Insurance
| Term | Definition |
|---|---|
| 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
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