Chapter 16 - Insurance
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| premium | monthly dues to keep insurance active
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| deductible | yearly fee that must be met before insurance picks up incurred fees - amount the insured must pay in a fiscal year before an insurance company will begin the payment of benefits
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| co-pay | partial payment of the visit - form of cost sharing
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| Dx co-pay | partial payment of procedures
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| Obamacare | aka Affordable Care Act - five main plans - need to know three
only becomes affordable for those below poverty level
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| ACA Bronze | 60% insurance pays, 40% pt responsibility - lower premium, higher out-of-pocket expense
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| ACA Silver | 70% insurance, 30% pt responsibility
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| ACA Gold | 80% insurance pays, 20% pt responsibility - higher premium, lower out -of-pocket expense
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| main government insurance programs | Medicare, Medicaid, Tricare, CHAMPVA
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| third-party payers - three basic entities | three basic entities involved in healthcare reimbursement - pt, provider (Dr.), public (insurance or 3rd party) or private (self-pay) payer
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| AHIP | americas health insurance plans - represents health insurers on federal and state regulatory issues
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| commercial insurance | owned and run by private companies - consist of traditional indemnity benefit plans (preventative), self-insured plans, managed care plans
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| the insured is also known as a | member, policyholder, subscriber, recipient
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| in an insurance contract, the waiting period is | also called the elimination period and a time frame after the beginning date of a policy before benefits for illness or injury becomes payable
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| unit values for each procedure code are used in which payment method | RVS
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| medical necessity is insured when the insurance carrier mandates | preauthorization
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| the oldest of all prepaid health plans | HMOs
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| medicaid is sponsored by | federal, state and local governments
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| which system does Medicare use to calculate fees | Resource-Based Relative Value System
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| state disability is available in Puerto Rico and in the states of | CA, HA, NJ, NY, RI
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| when working in a Dr's office which Medicare Part will billed | Medicare Part B
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| In the TRICARE program, an enrollment fee is sometimes charged for | TRICARE Prime
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| In a workers' compensation case, who does the MA communicate with | adjuster
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| the CMS-1500 claim form has an assignment of benefits for government program which field | Field 12
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| a standard unique health identifier for health care providers is called | NPI
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| why is the CMS-1500 claim form is printed in red ink | to comply with OCR machines
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| advantages of electronic transmission of claims | fewer errors and omissions, quicker turnaround, increased cash flow, built-in code edit checks
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| claim scrubber | built-in edits in electronic software that prompt the biller to change or enter information on claims
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| Advance Beneficiary Notice | must be completed when it is suspected that Medicare may not deem a service or supply medically necessary
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| suspended claim | claim held by the insurance company as pending because of an error or the need for additional information
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| liability under the False Claims Act can lead to civil monetary penalties for every fraudulent claim filed | $5,500 to $10,000
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| third-party payer | insurance carrier that intervenes to pay hospital or medical expenses on behalf of beneficiaries or recipients
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| indemnity | benefits paid in a predetermined amount in the event of a covered loss
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| carrier | organization that offers protection against losses in exchange for a premium
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| adjuster | employee of an insurance carrier with whom a case is assigned and who follows the case until it is settled
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| fiscal intermediary | contractor that processes payments to providers on behalf of state of federal agencies or insurance companies
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| elimination period | period of time after the beginning of a disability for which no benefits are payable
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| assignment | the transfer of one's rights to collect an amount payable under an insurance contract
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| partial disability | illness or injury preventing the insured from performing one or more functions of their occupation
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| a document from the insurance company that arrives with a check for payment of an insurance claim is called an | EOB = explanation of benefits
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| temporary disability | injured cannot perform all functions of their job for a limited period of time
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| total disability | insured unable to perform major duties of their specific occupation
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| RA | (Medicare) remittance advice - EOB for Medicare
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| MSN | Medicare Summary Notice - EOB for patients
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| HMO | health management organizations
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| PPO | preferred provider organization
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| IPA | independent practice association
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| PPG | physician provider groups
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| POS | point-of-service-plan - combines qualities of PPO and HMO
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| predetermination | maximum dollar amount insurance company will pay for professional services to be rendered to pt
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| preauthorization | used for hospital admissions, inpatient or outpatient surgeries, elective procedures, medication or when pt needs to be seen by specialist aka prior-authorization or pre-approval
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| medical necessity | mainly used for prior-authorizations
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| RBRVS | system to calculate MEDICARE fees
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| How Dr's are paid by HMOs | network, group, staff
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| HMO - Staff | Drs paid by salary - drs must be contracted with insurance co.
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| HMO - Network | Drs. contracted with HMO
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| HMO - Group | Drs paid by salary - contracts are with hospital
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