Exam
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| 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
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| Needed to help differentiate between technical descriptions of different but similar diagnoses or procedures | Critical Reading Skills
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| The Language of the health care industry | Medical Terminology
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| What are to 2 most important components of effective oral communication? | - Listening
- Speaking
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| 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
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| What are some important humaln relation skills? | - Being friendly to coworkers
- Being calm and supportive of patients
- Being attentive to your supervisors
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| What are some basic computer hardware knowledge? | -monitor
-hard disk
-mouse
-keyboard
-modem
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| 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
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| brain of the computer | CPU
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| porcesses and temporarily holds information | RAM
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| Permanently holds programs and other info used | ROM
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| A collection of related files that serve as a foundation for retreiving data | Database
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| Patient Records Database | referred to as biomedical and clinical databases.
meaning the ability to save, retrieve, and backup files as necessary.
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| Insurance specialist must possess a basic understanding of what 2 major codes? | -ICD-10-CM
-CPT
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| ICD-10-CM | used to code diagnoses
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| CPT | used to code procedures
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| The process of converting verbal and written descriptions of medical conditions and procedure into numeric and/ or alphanumeric codes. | Coding
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| Why is managing insurance payments crucial? | beacause the livelihood of the physician and staff depend on it
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| Responsibilities of an insurance specialist: | -consult with a physician for clarification of data
-code information from medical records
-verify fee schedules or sheets
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| Professional or Medical Etiquette | consideration for others, in conduct, courtesy, and manners
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| The unauthorized release of confidential patient informationto a third party. | Breach of Confidentiality
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| 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.
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| from a legal standpoint what raises critical issues in patient confidentiality? | faxing patient information
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| An intentional deception or misrepresentation that an individual makes, knowing it to be false which could result in some unauthorized benefit | Fraud
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| Submitting Claims for items or services that are not medically necessary to treat the patient's condition | Insurance Abuse
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| Private or Commercial Policies (non-government sponsored) such as Blue Cross Blue Shield operate on a fee-for-service basis | Traditional Insurance
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| Federal insurance program for senior citizens age 65 or older and retired | Medicare (Government Sponsored)
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| 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)
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| Provides civilian health benefits for military personnel, military retirees, and their dependents, including some members of the Reserve Component. | TRICARE (Government Sponsored)
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| Reimbursement for lost income resulting from temporary or permanent illness or injury. | Disability Insurance
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| Examples of Liability Insurance : | -automobile
-business
-homeowner's
-worker's compensation
-malpractice
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| 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)
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| 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
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| 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
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| 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
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| CMS-1500 | Insurance claim form used by Medicare and accepted by nearly all insurance carriers. Formerly known as the HCFA-1500 form
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| 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.
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| 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
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| Who should sign an Authorization for Release of Medical Information Form? | All Patients (with insurance)
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| Encounter form or charge slip | the financial record source document used by health care providers
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| An alphanumerical desination for a specific illness, injury, or disease | Diagnosis Code
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| 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
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| The bottom of the CMS-1500 form is | divided into 33 sections or blocks
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| 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
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| 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.
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| "Stark Law" | 3 seperate provisions that govern phsician self-referral patients.
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| "Stark II" | clarification and modification of both services and items.
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