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Chapter 9
Medical Assisting
| Question | Answer |
|---|---|
| helps cover the cost of healthcare services | Health insurance |
| Not all _________cover the same services, and costs vary widely. | Policies |
| Most _________ companies provide online portals or websites that explain their claim procedures and the benefits of each plan | Health Insurance |
| A ________must be verified to be eligible, or able to receive benefits before she sees a provider. | Patient |
| may also require a deductible to be met before the insurer will pay any health care costs. Deductibles vary from $100 to $1000 | Insurance policies |
| require coinsurance payments for office visits, diagnostic procedures, and other expenses. These payments are based on the percentage of healthcare costs | Some plans |
| requires that insurance plans have an out-of-pocket maximum. After the maximum is reached, the insurance company will pay 100% of the healthcare costs (not including the premium) | The ACA (affordable care act) |
| Each insurer provides a summary of coverage to the subscriber after the insurance claim is made. The subscriber form is called the...... | Remittance Advice Statement (RA) |
| Most insurers set a standard fee for each healthcare service. That is called | allowable amount |
| are organized into four tiers, or levels: bronze, silver, gold, and platinum | ACA plans |
| An _____________ rider limits coverage. ______________riders exclude people with certain diagnoses and preexisting conditions from receiving healthcare benefits | Exclusionary |
| are the most affordable of the managed care plans | HMOs |
| gives workers and their families who lose group insurance coverage the ability to purchase that same health insurance coverage privately. This coverage may be purchased whether a person left a job voluntarily or involuntarily | COBRA (Consolidated Omnibus Budget Reconciliation |
| Although these plans do not provide ____________ coverage, a provider may need to certify that person is unable to work | Healthcare |
| Medicare Part D covers medications. Pg. 119 Medicare Part C is optional. These are called | Medicare Advantage Plans |
| provides low-cost health insurance for children in families that have lower incomes but earn too much to qualify for Medicaid | CHIP (Children’s Health Insurance Program) |
| is the health insurance program of the US military | TRICARE |
| For children in a family, the “__________” is often used to determine which parent’s insurance is the primary. The _________ rule makes the parent with the earliest birthday in the year the primary insurer | Birthday |
| An _________________ form must be signed by the patient. This form allows the insurance company to make payments directly to the medical office | assignment of benefits |
| The _________ is the standard form used for paper billing. | CMS-1500 |
| may also be denied when the service provided is not appropriate for the patient’s diagnosis. | Claims |
| When___________ is granted, the insurer provides a ______________ number. This number must be placed on the insurance claim form when billing for the procedure. | Preauthorization |
| Medicare has a notification form called the ______________________ to let patients know that a service will not be covered | Advance Beneficiary Notice |
| provide a uniform way to communicate information about a patient’s diagnosis and treatment. | Coding systems |
| is maintained by the CDC’s National Center for Health Statistics | The International Classification of Diseases-10 Clinical Modification (ICD-10-CM) |
| was developed by CMS. It is used for coding most inpatient procedures (procedures performed while the patient is in a hospital) | The ICD-10-Procedural Coding System (ICD-10-PCS) |
| codes are used for most patient visits. The following factors determine the correct E/M codes for a visit: The type of patient (new or established) Where the services are provided The procedure that was done The level of service | Evaluation and Management (E/M) |
| A ________ code is one that describes two or more procedures that often occur together. For example, the code for a surgical procedure may include many smaller procedures. | Bundled |
| is coding for supplies used in a procedure. ICD-10 codes should be used for the patient’s diagnosis, a CPT code for the procedure, and HCPCS codes would be used for the supplies. The HCPCS, ICD-10, and CPT would all be used for billing | HCPCS Level II |
| means paying for a lower level of procedure. It may occur when the insurance company decides that the diagnosis does not justify the level of procedure that was performed. It may result in the provider not being paid fully for services rendered. | Downcoding |
| in this situation means intentionally misusing codes to bill for services. As mentioned in the chapter, unbundling (separating codes to charge for more services) is considered a coding error, or “upcoding” | Abuse |
| are used to review diagnosis and procedure codes to make sure they are correct. | Audits |
Created by:
moreno25