Cengage Flashcards
what is another name for a subscriber
insurance policy holder
Medicare only pays for services or supplies that are considered ______ & ____
medically reasonable & necessary
What does Medigap generally not cover?
long-term care, vision/dental care, hearing aids, eyeglasses, private-duty nursing
when would a pt be possibly eligible for medicaid to be a secondary insurance
pt does not have commercial supplemental insurance & unable to pay deductible/coinsurance
When can Medicare be a secondary insurance
- pt qualifies by age but remains employed
- pts receive VA benefits
- pts are eligible and dependent on working spouse’s insurance
why should both sides of all the insurance cards be scanned
prevents any denied claims for services
what is the difference between medicare advantage plan and traditional medicare
medicare advantage = primary insurer & pts are covered through medicare A & B, requiring them to pay part B’s premium & advantage’s premium
what are pts w/no insurance classified as?
self-pay
can a provider not accept assignment
yes
what happens when a provider does not accept assignment
pt must pay entire bill to provider even if higher than Medicare approved amnt
what is the most a provider can charge if they do not accept assignment
115% of medicare approved non-participating provider amnt
what are examples of third-party
- group health plans
- self-insured plans
- settlements from liability insurer
- managed care organizations
- workers’ comp
- pharmacy benefit managers
- long-term care insurance
- Medicare
- state & fed programs (unless specifically excluded by fed statute)
when is verifying insurance done
when pt arrives
what are the steps to verifying insurance
- ask for current/all current insurance cards
- scan/make copies of both sides & notate dates
- make sure pt demographics current & correct
- use point of service/specific phone line/insurer website to confirm
why is verifying insurance important
ensure provider gets covered & can show insurance proof it did service in good faith & checked eligibility at time of rendered service in case insurance denies bc lack of coverage
why are services denied by insurance even when insurance coverage is verified
generally from retroactive adjustments to pt’s coverage bc job change/nonpayment of premiums
what are the benefits of doing an EHR Eligibility Check
- identify potential payer sources
- reduce number of denied claims
- reduce bad debt write offs
- reduce staff hours required for performing manual checks
- increase revenue through improved collection rates
define MANAGED CARE
system integrating delivery & payment for covered people by contracting w/selected providers for comprehensive care at reduce cost w/specific standards for providers & programs for quality assurance and utilization review
define National Commission on Quality Assurance (NCQA)
independent organization that assess quality of care provided by managed care
are assessments from NCQA required
no, but shows plan’s commitment to providing care & accountability
define HEALTH PLAN EMPLOYER DATA & INFORMATION SET (HEDIS)
measures health care performance & determines improvement
what are the components of HEDIS
- effectiveness of care
- access/availability of care
- utilizations
- risk-adjusted utilization
- measurers collected using electronic data systems
what are the future focuses of HEDIS
- allowable adjustments
- licensing & certification
- digital measures
- electronic clinical data systems (ECDS)
- schedule change
- telehealth
define allowable adjustments in HEDIS
lets users modify measurers w/o changing clinical intent
describe licensing & certification in HEDIS
updated requirements ensure accuracy of measure results
describe digital measurers in HEDIS
specifications downloaded into users’ data sytems
describe electronic clinical data systems in HEDIS
new reporting method helping clinical data create insight for managing health
describe schedule change in HEDIS
gives users more time by giving complete measure specs sooner
define COMMERCIAL HEALTH INSURANCE
typically provided by employers as part of benefits & often have annual deductible & coinsurance
give an example of a commercial health insurance
blue cross blue shield
what types of insurance fall under the umbrella of commercial health insurance
HMO, PPO, EPO, POS, HSA, HRA, Indemnity
describe INDEMNITY INSURANCE
- insurance w/least structural guidelines
- able to see provider of choice
- annual deductible & higher premiums
- no referrals required
aka: indemnity insurance
80/20
why is the indemnity insurance called 80/20
carrier pays 80% and insured pay 20% after deductible satisfied
describe HEALTH MAINTENANCE ORGANIZATIONS (HMOs)
- requires PCPs & need referrals
- use provider networks
describe STAFF-MODEL HMOS
- providers employed by HMO & all services are provided by the practice
- require PCP & referrals
- life-threatening care doesn’t need preauthorization
- must call & obtain preauthorization for any nonemergency care if outside HMO service area
define GROUP-MODEL HMOs
multispecialty practice contracted to give care to members & providers may be reimbursed by capitation
describe PREFERRED PROVIDER ORGANIZATION (PPO)
- network of providers & hospitals contracted @ discounted rate
- PCP required
- Referrals for out of network
- out of network care leads to higher out of pocket costs
- premiums, deductibles, & copays higher than traditional HMOs but less than traditional fee-for-service
describe EXCLUSIVE PROVIDER ORGANIZATION (EPO)
- must use network exclusively
- no PCP or referral required
- preauthorization required for expensive services
- more affordable than PPOs
describe POINT OF SERVICE
- allow greater freedom in choice of care
- NO PCP required & can self refer
- nonpanel & panel providers
what are the benefits of nonpanel providers in POS
indemnity plan w/deductible & coinsurance
what are the benefits of panel providers
only pay copay
aka: independent practice association
individual practice associations
describe INDEPENDENT PRACTICE ASSOCIATIONS
- providers practice in own office w/own staff & operations
- more equitable leverage in contracts w/HMOs and other insurance
what insurance companies do not require referrals
indemnity, PPO (referrals for out of network tho), EPO, POS
define CONSUMER-DRIVEN HEALTH PLANS (CDHP)
created as part of Medicare Prescription, Drug, Improvement, & Modernization Act; includes HSA & HRA
describe HSA
- tax-sheltered savings account for medical expenses
- any amount not used in year stays & gains interest
- high deductible & needs qualified plan
- contribute from either employee/employer
- HSA pays small expenses up to deductible as long as expenses are qualified
what are some qualified expenses according through HSA
- ambulance
- braces
- home improvements for disabled
- tv/phone for disabled
what plan accrues interest if not used
health savings account
define HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
can be alternative to traditional group health plan provided by employers
describe FLEXIBLE SPENDING ARRANGEMENT (FSA)
- qualified expenses are specified & gen qualify for deduction
- gen funded by employee w/pretax dollars or employer in small amounts
- not required to pay federal/SS/state taxes on contributes
- use it or lose it
aka: flexible spending arrangement
cafeteria plan
describe Medicare
health insurance under SS for eligible people, 80/20, four parts
who are qualified for medicare
- people at least 65 years
- disabled
- receiving SS benefits
- end stage renal disease
describe part A of medicare
- hospital coverage & any person receiving monthly SS benefits
- annual deductible increases each year
describe part B of medicare
- payment of other medical expenses
- premiums automatically deducted for those covered/onSS/railroad reitrement/civil service annuity/ppl able to pay premiums
- beneficiaries eligible for annual wellness visits w/no cost sharing
- pts insured pay annual deductible before epxnses paid by medicare
describe Part C medicare
- enables beneficiaries to select managed care plan as primary
- done in many states
- gen offer additional services outside of traditional medicare
- pts can have supplemental insurance
aka: part C medicare
medicare advantage
part D medicare
coverage for generic & name-brand drugs
define CMS-1500
claim form submitted to Medicare & must be submitted electronically
when must a CMS-1500 be filed
within a year of service rendered
how are non-participating providers
providers charge only 15% above medicare participating provider fee schedule amount for service & providers are paid 95% of fee schedule amount
describe medicare reimbursement
medicare reimbursement approves fee 80% after pt paid annual deductible & secondary carriers will pay 80% of the 20% not covered by Medicare and pt will pay rest
describe MEDICAID
funded by federal & state government & give coverage for ppl of limited/low income & pts have to get care from participating provider
are pts required to accept medicaid pts or participate with medicaid
no
define workers comp
state or federal insurance covering employees injured/ill bc of work & employers pay premium
what effects the premium of workers comp
risk involved w/job & company’s loss history
t/f: industrial injury should be a separate record for pt
true
when should a pt be billed for workers comp
treatment w/o authorization or was accessive
what are the principal types of state benefits of workers comp
- medical
- income
- death
- burial
list EHR components regarding workers comp
- any appt related to work injury covered by worker’s comp
- any charges for pt billed to workers’ comp
- add workers’ comp insurance to pt demographic
- create workers’ comp case
define TRICARE
organization gives supplement for med care in military/public health facilities to active service & dependents, retired service personnel & dependents, & dependents of service personnel who died ina ctive duty
define TRIC ARE FOR LIFE
wraparound coverage for TRICARE-eligible beneficiaries who have medicare A & B
define CIVILIAN HEALTH & MEDICAL PROGRAM OF DEPT OF VETERANS AFFAIRS (CHAMPVA)
organization for spouses & dependent children of veterans w/total, permanent, service-connected disabilities/spouses & dependent kids of veterans who died from service-connected disabilities
who determines eligibility for CHAMPVA
local VA hospital
if parents have the same birthdate, how does the birthday rule apply/change?
plan in effect the longest is primary
if parents divorce & retain their insurance plans, how does the birthday rule change/apply
parent w/custody is primary
what always supersedes the birthday rule
court order
what is the difference between prospective and retrospective utilization reviews
prospective = done before service
retrospective = done after service
define UTILIZATION MANAGEMENT
method of controlling costs by review services to determine necessity before care
what are the methods of utilization review/management
preauthorization, precertification, predetermination, concurrent review, discharge planning
define PREAUTHORIZATION
determines whether service covered & necessary
define PRECERTIFICATION
seek approval for treatment under pt insurance contract
define PREDETERMINATION
discover of max amnt of money carrier will pay for service
define UCR BASIS OF PAYMENT
determines if charge for services consistent w/avg rate of for similar services in certain areas
what does UCR basis of payment stand for
Usual, Customary, Reasonable Basis of Payment
aka: RBRVS
resource based relative value scale
define RBRVS
method medicare uses to create medicare provider fee schedule
what are the RVUs of RBRVS
physician work, practice expense, professional liability insurance
how are RBRVs calculated into cost
RVUs multiplied by geographic practice cost index
define PROSPECTIVE PAYMENT SYSTEMS
method of reimbursement where medicare payment for services are based on predetermined, fixed amnt derived from diagnosis-related group’s classification system & is separate for different facility types
describe DIAGNOSIS RELATED GROUPS
basis for inpatient PPS & used as method for reimbursing inpatient care @ hospitals to encourage hospitals to operate more efficiently as length of stay doesn’t affect reimbursement
how do DRGs work
each DRG has payment weight based on avg resources used to treat & organized into major diagnostic categories based on body system
define CATASTROPHIC PLANS
individual & family insurance coverage for hospitalization/serious illness
define FEE DISCLOSURE
action of provider informing pt of charges before service performed
define GROUP INSURANCE
insurance offered to all employees by employer
define INDIVIDUAL INSURANCE
insurance purchased by indiv/family who doesn’t have access to group insurance
define LIMITING CHARGE
max amnt nonparticipating provider can collect from Medicare pt
define LOSS OF INCOME BENEFITS
payments made to insured to help replace income lose through inability to work bc insured disability
define MEMBER PROVIDER
provider contracted to participate w/insurance to be reimbursed for services
define PATIENT STATUS
pt’s eligibility for benefits, basis on which benefits are provided
