Intro to the Medical Billing Cycle

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Question

Answer

a prospective payment to a provider made for each plan member

capitation

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the percentage of each claim that an insured person must pay

coinsurance

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an amount that an insured person pays at the time of a visit to a provider

copayment

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the amount that an insured person must pay before reimbursement for medical expenses begins

deductible

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a health plan that reimburses policy holders based on the fees charged

fee-for-service

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an organization that contracts with a network of providers for deliver of health care for aprepaid premium

HMO-health maintenance organization

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a retroactive reimbursement method based on providers charges

indemnity

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a managed care network of providers under contract to provide services at discounted fees

PPO-Preferred provider organization

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the amount of money paid to a health plan to buy an insurance policy

premium

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a list of medical services covered by an insurance policy

schedule of benefits

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Spending on health care in the United States is rising due to what 2 factors

the cost of new technology and the aging population

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Employment for well-trained medical insurance and coding specialists are

increasing due to rising demands.

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What kind of medical services are annual physical examinations and routine screening procedures

preventive

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Under an insurance contract the patient is the 1st party, the physician is the 2nd party, who is the 3rd party?

Insurance plan

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Under a written insurance contract, teh policyholder pays a premium and the insurance company provides what

payments for covered medical services

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Out-of-pocket expenses must be paid by who

the patient

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What conditions must be met before payment is made under an indemnity plan?

payment of premium, deductible, and coinsurance

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A capitated rate is

prospective payment

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Correctly relating a patient's condition and treatment refers to

medical necessity

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Which of the following is required with a HMO patient is admitted to the hospital for nonemergency treatment?

preauthorization

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HMO's are regulated by

both federal and state law

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Under a capitated rate for each plan member, who shares the risk?

Provider and the 3rd party payer

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A capitated rate per member per month coveres what

services listed on the schedule of benefits

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For a patient covered by an HMO, out-of-network means the provider is

not under contract with the payer

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With a POS option under a HMO organization the patient may choose

to see a provider who is not int he HMO network

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With a point-of-service type HMO the patient may use the services of

HMO network or out-of-network providers

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To be covered patients who enroll in an HMO may use the services of

only HMO network providers

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Under an indemnity plan a patient my use the services of

any provider

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In a PPO plan referrals to specialists are

not required

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Consumer-driven health plans combine a health plan with a special savings account that is used to pay the medical bills before what

the deductible is met

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Employers that offer health plans to employees without using an insurance carrier is called

self-funded health plan

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What is an example of a private-sector payer

insurance company

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What government program covers patients who are over age 65?

Medicare

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What government program covers people who cannot otherwise afford medical care

Medicaid

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Step 1 of the medical billing cycle

Preregister patient

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Step 2 of the medical billing cycle

Establish financial responsibility for visits

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Step 3 of the medical billing cycle

Check in patient

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Step 4 of the medical billing cycle

Check out patient

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Step 5 of the medical billing cycle

Review coding compliance

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Step 6 of the medical billing cycle

Check billing compliance

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Step 7 of the medical billing cycle

Prepare and transmit claims

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Step 8 of the medical billing cycle

Monitor payer adjudication

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Step 9 of the medical billing cycle

Generate patient statements

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Step 10 of the medical billing cycle

Follow up patient payments and handle collections

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A patient ledger records what

The patient's financial transactions

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What characterisitcs is most important when medical insurance specialists work with patients' records and handle finances?

honesty and integrity

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standards of conduct based on moral principles

professional ethics

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standards of professional behavior

professional etiquette

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Registered Medical Assistant (RMA) is awarded by

(AMT) American Medical Technologists

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Certified Medical Assistant (CMA) is awarded by

(AAMA) American Association of Medical Assistants

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Certified Coding Specialist, (CCS) and Certified coding Specialist-Physician based (CCS-P) is awarded by

(AHIMA) American Health Information Management Association

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Created by: monicagunterman