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Medical Office 2

Insurance and Billing

Define the basic insurance terms used by the insurance industry. premium, benefit, lifetime maximum, deductible, coinsurance, copayment, exclusions, formulary, elective procedure, precertification, and preauthorization.
fee-for-service plans plans are traditional plans where, after a yearly deductible is met, the insurance plan pays for a percentage of the charges and the patient is responsible for the other percentage (often 80% insurance plan and 20% patient).
HMOs prepaid plans that pay the providers either by capitation or by contracted fee-for-service with patients choosing a PCP, seeing preferred providers, and paying a fixed per-visit copay.
PPOs managed care plan that establishes a network of providers to perform services for plan members. Members may seek out-of-network care, but their costs will be higher.
patient centered medical home model new approach to preventive care that puts the patient and family at the center of the decision-making process using a coordinated team approach to patient care.
Medicare coverage requirements health insurance for citizens aged 65 and older as well as for certain disabled workers, disabled widows of workers, and patients with long-term disability related to chronic kidney disease on dialysis and end-stage renal disease requiring transplant.
Medicaid coverage requirements benefit plan for low-income, blind, or disabled patients; needy families; foster children; and children born with birth defects. Every state has a program to assist with medical expenses for citizens who meet its qualifications
TRICARE coverage requirements families of uniformed personnel and retirees from the uniformed services
CHAMPVA expenses of the families of veterans with total, permanent, service-connected disabilities as well as expenses for surviving spouses and dependent children of veterans who died in the line of duty or as a result of service-connected disabilities.
allowed charge maximum dollar amount an insurance carrier will base its reimbursement on—it is also the maximum amount a participating provider is allowed to collect
contracted fee a negotiated fee between the MCO and the provider.
capitation fixed prepayment paid to the PCP in most plans
formula for RBRVS resource-based relative value scale. Its formula is RVU × GAF × CF.
claims process includes patient information, delivering services to the patient and determining the diagnosis and fee, recording charges and codes, documenting payment from the patient,
three methods used to submit a claim electronically. directly to the payer’s website > use of a clearinghouse > direct data entry, or DDE
All EOBs contain insured name & id number; patient name; claim number, date of service, place of service, and code for the service provided; amount billed; amount allowed; amount of subscriber liability; amount paid; and a notation of any services not covered and why
two major types of health plans traditional fee-for-service plans and managed care plans
Managed care organizations (MCOs) control both the financing and delivery of healthcare to policyholders. they also enroll licensed practitioners and other care providers to provide services for their members at reduced rates. This allows them to control all aspects of the care
How are providers paid using MCO one of two ways—by either contracted fees or a fixed prepayment called capitation. PCP, is reimbursed using the capitation method monthly.
Blue Cross and Blue Shield Each state’s organization operates under its own state laws, and covered services and benefits. plans can vary greatly from state to state and plan to plan.
liability insurance personal injury insurance, covers injuries that were caused by the insured or on the insured’s property, individual (or company)
disability insurance covers people who are injured or disabled for nonwork reasons. It may be offered by an employer to employees at employee expense, or provided free of charge by an employer for its employees.
Agency for Healthcare Research and Quality (AHRQ), 5 functions and attributes of the Primary Care Medical Home (PCMH) Comprehensive care •Patient centered •Coordinated care •Accessible service Prime, a health maintenance organizationQuality and safety
Medicare Part A hospital benefit, automatically enrolled, does not have to pay a premium
Medicare Part B voluntary program; covers a portion (usually 80%) of the allowed charges for a wide range of outpatient procedures and supplies
Medicare suffixes “A” is attached to the patient’s own Social Security number • “B” is attached to the Social Security number of the spouse •“D” is attached to the Social Security number of a spouse who is deceased (widows’ benefits)
Medicare Part D prescription drug plan
Medicare Part C also called Medicare Advantage plans
Original Medicare Plan also called Fee-for-Service, generally pays 80% part of this fee and part is due from the beneficiary
Medigap plan include coverage of the patient’s Part B deductible and the 20% balance of all charges that are allowed by Medicare. if Medicare does not pay a claim, Medigap is not required to pay
Medicare Administrative Contractor (MAC) jurisdictions for claims processing
Recovery Audit Contractor Program designed to guard and prevent waste, fraud, and abuse in Medicare
Dual Coverage, or Medi/Medi Elderly or disabled patients who have both Medicare and Medicaid
TRICARE offer three choices of healthcare benefits Prime, a health maintenance organization •Standard, a fee-for-service plan • Extra, a managed care network of healthcare providers families can use on a case-by-case basis without a required enrollment
TRICARE for Life Medicare-eligible military retirees and Medicare-eligible family members, and pays secondary payer to Medicare
State Children’s Health Insurance Plan known simply as CHIP, health coverage to uninsured children in families whose incomes are too high to qualify for Medicaid but too low to afford private insurance
Workers’ Compensation covers employment-related accidents and diseases, compensation laws vary from state to state, but, in most states
Workers’ Compensation Benefits Basic medical treatment •A weekly amount paid to the patient for a temporary disability or monthly sum paid to the patient for a permanent disability •Rehabilitation costs •Death benefits for survivors
Records management of workers’ compensation medical and financial records of the private care separate from the records of the care related to the case
Filing Limits some insurers will not pay a claim unless it is filed within 60 or 90 days from the date of service, while others, allow up to a year
Created by: baybro9933