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MIC Exam I


What are the skill requirements of an Insurance Specialist 1. Medical Terminology 2. Human Biology 3. Critical reading skills 4. excellent communication skills 5. good computer skills 6, math skills 7. application knowledge of medical insurance
Needed to help differentiate between technical descriptions of different but similar diagnoses or procedures Critical Reading Skills
The Language of the health care industry Medical Terminology
What are to 2 most important components of effective oral communication? - Listening - Speaking
What is considered appropriate nonverbal communication with a patient ? - Smiling - An open and relaxed posture - A light touch on the arm to comfort a patient in distress
What are some important humaln relation skills? - Being friendly to coworkers - Being calm and supportive of patients - Being attentive to your supervisors
What are some basic computer hardware knowledge? -monitor -hard disk -mouse -keyboard -modem
What are some basic computer terms? CPU- Central Processing Unit RAM- Random Access Memory ROM- Read Only Memory Database- A collection of related files that serves as a foundation for retrieving data
brain of the computer CPU
porcesses and temporarily holds information RAM
Permanently holds programs and other info used ROM
A collection of related files that serve as a foundation for retreiving data Database
Patient Records Database referred to as biomedical and clinical databases. meaning the ability to save, retrieve, and backup files as necessary.
Insurance specialist must possess a basic understanding of what 2 major codes? -ICD-10-CM -CPT
ICD-10-CM used to code diagnoses
CPT used to code procedures
The process of converting verbal and written descriptions of medical conditions and procedure into numeric and/ or alphanumeric codes. Coding
Why is managing insurance payments crucial? beacause the livelihood of the physician and staff depend on it
Responsibilities of an insurance specialist: -consult with a physician for clarification of data -code information from medical records -verify fee schedules or sheets
Professional or Medical Etiquette consideration for others, in conduct, courtesy, and manners
The unauthorized release of confidential patient informationto a third party. Breach of Confidentiality
Demonstrating the "Need to Know" Never give information over the phone or in persson until you have verified that the party making the request is entitled to the information.
from a legal standpoint what raises critical issues in patient confidentiality? faxing patient information
An intentional deception or misrepresentation that an individual makes, knowing it to be false which could result in some unauthorized benefit Fraud
Submitting Claims for items or services that are not medically necessary to treat the patient's condition Insurance Abuse
Private or Commercial Policies (non-government sponsored) such as Blue Cross Blue Shield operate on a fee-for-service basis Traditional Insurance
Federal insurance program for senior citizens age 65 or older and retired Medicare (Government Sponsored)
Jointly funded by the state and local governments to provide health care benefits to indigent persons on welfare (needy and low income people) Medicaid (Government Sponsored)
Provides civilian health benefits for military personnel, military retirees, and their dependents, including some members of the Reserve Component. TRICARE (Government Sponsored)
Reimbursement for lost income resulting from temporary or permanent illness or injury. Disability Insurance
Examples of Liability Insurance : -automobile -business -homeowner's -worker's compensation -malpractice
Which Parent's policy is primary in the case of divorced parents with a minor child (both parents have insurance on the child)? The policy is usually covered by the custodial parent primarilly (unless ordered otherwise by the court)
A specified amount of annual out-of-pocket expenses for covered health care services the insured must pay to a health care provider before the the insurer pays benefits Deductible
The percentage paid by the insurance carrier or that paid by the insured. After the spplication of the deductible to the submitted bills, the insurance policy pays a percentage of the remaining amount. Coinsurance
Participating Provider the in-network provider or preferred provider they are the physicians or medical facility that the insurance company is contracted with - the allowed amount as payment in full for service provided in exchange for direct payment
CMS-1500 Insurance claim form used by Medicare and accepted by nearly all insurance carriers. Formerly known as the HCFA-1500 form
Fair Debt Collection Practice Act 1977 federal law that outlines collection practices. Collection calls are only to be done between the hours of 8am and 9pm.
What information should be obtained when a New Patient arrives? 1. Patient's name, address, phone numbers, social security number, and date of birth. (If the patient is a minor- obtain the name of the parent or guardian. 2. the reason for the appointment 3. if the patient has insurance
Who should sign an Authorization for Release of Medical Information Form? All Patients (with insurance)
Encounter form or charge slip the financial record source document used by health care providers
An alphanumerical desination for a specific illness, injury, or disease Diagnosis Code
The insurance form used to report provider services is known as the? CMS-1500 form (formerly HCFA-1500) Developed by CMS-Centers for Meidcare and Medical services
The bottom of the CMS-1500 form is divided into 33 sections or blocks
some reasons for Claim rejections: -incorrect coding of diagnosis or procedures -missing policy numbers -diagnosis codes and procedure codes do not match -charges not itemized
The Explanation of Benefits Form (EOB) is a statement telling the patient and/or provider how the insurance company determined it's share of the reimbursement.
"Stark Law" 3 seperate provisions that govern phsician self-referral patients.
"Stark II" clarification and modification of both services and items.
Created by: chandymigues
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