Billing / Coding Flashcards
On what is the PMPM rate usually based?
health-related characteristics of the enrollees
Under an insurance contract, the patient is the first party and the physician is the second party. Who is the third party?
insurance plan
Which term best describes medical services that meet professional medical standards?
medical necessity.
Health care claims report data to payers about ?
the patient; the services provided by the physician
Under a fee-for-service plan, the third-party payer makes a payment
after medical services are provided.
Describe the role of a primary care physician (PCP) in an HMO.
coordinating patients’ overall care
Determine which method a self-funded health plan most often uses in setting up its provider network.
buy the use of existing networks from managed care organizations
Identify another name for a point-of-service (POS) plan.
open HMO
A capitated payment amount is called a
prospective payment.
Identify the type of HMO cost-containment method that requires providers to use a formulary.
controlling drug costs
The capitated rate per member per month covers
services listed on the schedule of benefits.
What is the definition of revenue cycle?
all administrative and clinical functions which ensure that sufficient monies flow into the practice to pay bills
A computerized lifelong health care record for an individual that incorporates data from all sources is known as a(n)
electronic health record (EHR).
Which of the following is required when an HMO patient is admitted to the hospital for nonemergency treatment?
preauthorization
Medical insurance specialists ensure financial success of the medical practice by
using health information technology.
Name the two components of a consumer-driven health plan (CDHP).
a health plan and a special “savings account”
What is a premium?
the periodic payment the insured is required to make to keep a policy in effect
What is a premium?
the periodic payment the insured is required to make to keep a policy in effect
Verifying insurance is part of which revenue cycle step?
Step 2, establish financial responsibility for the visit.
Under an indemnity plan, typically a patient may use the services of
any provider
Review the choices below and select the most appropriate definition for health plan benefits, as defined by American’s Health Insurance Plans (AHIP).
payments for covered medical services
Where do medical insurance companies summarize the payments they may make for medically necessary medical services?
schedule of benefits document
Identify the advantages offered to patients in managed care plans, as compared to indemnity insurance.
lower premiums, charges, and deductibles
Choose the entity(ies) that may form agreements with an MCO.
the patient and provider
What step is used when patient payments are later than permitted under the financial policy?
Step 10, follow up patient payments and collection
What adds up to form a practice’s accounts receivable?
money due from both health plans and patients
The key to receiving coverage and payment from a payer is the payer’s definition of
medical necessity.
To be fully covered, patients who enroll in an HMO may use the services of
only HMO network providers.
To be fully covered, patients who enroll in an HMO may use the services of
only HMO network providers.
How is coinsurance defined?
the percentage of each claim that the insured pays
