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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
|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
|porcesses and temporarily holds information
|Permanently holds programs and other info used
|A collection of related files that serve as a foundation for retreiving data
|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?
|used to code diagnoses
|used to code procedures
|The process of converting verbal and written descriptions of medical conditions and procedure into numeric and/ or alphanumeric codes.
|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
|Submitting Claims for items or services that are not medically necessary to treat the patient's condition
|Private or Commercial Policies (non-government sponsored) such as Blue Cross Blue Shield operate on a fee-for-service basis
|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.
|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
|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.
|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
|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
|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.
|3 seperate provisions that govern phsician self-referral patients.
|clarification and modification of both services and items.