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MA: Chp 24 - Insurance > Cengage > Flashcards

Cengage Flashcards

1
Q

what is another name for a subscriber

A

insurance policy holder

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2
Q

Medicare only pays for services or supplies that are considered ______ & ____

A

medically reasonable & necessary

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3
Q

What does Medigap generally not cover?

A

long-term care, vision/dental care, hearing aids, eyeglasses, private-duty nursing

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4
Q

when would a pt be possibly eligible for medicaid to be a secondary insurance

A

pt does not have commercial supplemental insurance & unable to pay deductible/coinsurance

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5
Q

When can Medicare be a secondary insurance

A
  • pt qualifies by age but remains employed
  • pts receive VA benefits
  • pts are eligible and dependent on working spouse’s insurance
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6
Q

why should both sides of all the insurance cards be scanned

A

prevents any denied claims for services

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7
Q

what is the difference between medicare advantage plan and traditional medicare

A

medicare advantage = primary insurer & pts are covered through medicare A & B, requiring them to pay part B’s premium & advantage’s premium

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8
Q

what are pts w/no insurance classified as?

A

self-pay

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9
Q

can a provider not accept assignment

A

yes

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10
Q

what happens when a provider does not accept assignment

A

pt must pay entire bill to provider even if higher than Medicare approved amnt

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11
Q

what is the most a provider can charge if they do not accept assignment

A

115% of medicare approved non-participating provider amnt

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12
Q

what are examples of third-party

A
  • 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)
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13
Q

when is verifying insurance done

A

when pt arrives

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14
Q

what are the steps to verifying insurance

A
  1. ask for current/all current insurance cards
  2. scan/make copies of both sides & notate dates
  3. make sure pt demographics current & correct
  4. use point of service/specific phone line/insurer website to confirm
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15
Q

why is verifying insurance important

A

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

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16
Q

why are services denied by insurance even when insurance coverage is verified

A

generally from retroactive adjustments to pt’s coverage bc job change/nonpayment of premiums

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17
Q

what are the benefits of doing an EHR Eligibility Check

A
  • 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
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18
Q

define MANAGED CARE

A

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

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19
Q

define National Commission on Quality Assurance (NCQA)

A

independent organization that assess quality of care provided by managed care

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20
Q

are assessments from NCQA required

A

no, but shows plan’s commitment to providing care & accountability

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21
Q

define HEALTH PLAN EMPLOYER DATA & INFORMATION SET (HEDIS)

A

measures health care performance & determines improvement

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22
Q

what are the components of HEDIS

A
  • effectiveness of care
  • access/availability of care
  • utilizations
  • risk-adjusted utilization
  • measurers collected using electronic data systems
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23
Q

what are the future focuses of HEDIS

A
  • allowable adjustments
  • licensing & certification
  • digital measures
  • electronic clinical data systems (ECDS)
  • schedule change
  • telehealth
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24
Q

define allowable adjustments in HEDIS

A

lets users modify measurers w/o changing clinical intent

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25
Q

describe licensing & certification in HEDIS

A

updated requirements ensure accuracy of measure results

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26
Q

describe digital measurers in HEDIS

A

specifications downloaded into users’ data sytems

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27
Q

describe electronic clinical data systems in HEDIS

A

new reporting method helping clinical data create insight for managing health

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28
Q

describe schedule change in HEDIS

A

gives users more time by giving complete measure specs sooner

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29
Q

define COMMERCIAL HEALTH INSURANCE

A

typically provided by employers as part of benefits & often have annual deductible & coinsurance

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30
Q

give an example of a commercial health insurance

A

blue cross blue shield

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31
Q

what types of insurance fall under the umbrella of commercial health insurance

A

HMO, PPO, EPO, POS, HSA, HRA, Indemnity

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32
Q

describe INDEMNITY INSURANCE

A
  • insurance w/least structural guidelines
  • able to see provider of choice
  • annual deductible & higher premiums
  • no referrals required
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33
Q

aka: indemnity insurance

A

80/20

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34
Q

why is the indemnity insurance called 80/20

A

carrier pays 80% and insured pay 20% after deductible satisfied

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35
Q

describe HEALTH MAINTENANCE ORGANIZATIONS (HMOs)

A
  • requires PCPs & need referrals
  • use provider networks
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36
Q

describe STAFF-MODEL HMOS

A
  • 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
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37
Q

define GROUP-MODEL HMOs

A

multispecialty practice contracted to give care to members & providers may be reimbursed by capitation

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38
Q

describe PREFERRED PROVIDER ORGANIZATION (PPO)

A
  • 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
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39
Q

describe EXCLUSIVE PROVIDER ORGANIZATION (EPO)

A
  • must use network exclusively
  • no PCP or referral required
  • preauthorization required for expensive services
  • more affordable than PPOs
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40
Q

describe POINT OF SERVICE

A
  • allow greater freedom in choice of care
  • NO PCP required & can self refer
  • nonpanel & panel providers
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41
Q

what are the benefits of nonpanel providers in POS

A

indemnity plan w/deductible & coinsurance

42
Q

what are the benefits of panel providers

A

only pay copay

43
Q

aka: independent practice association

A

individual practice associations

44
Q

describe INDEPENDENT PRACTICE ASSOCIATIONS

A
  • providers practice in own office w/own staff & operations
  • more equitable leverage in contracts w/HMOs and other insurance
45
Q

what insurance companies do not require referrals

A

indemnity, PPO (referrals for out of network tho), EPO, POS

46
Q

define CONSUMER-DRIVEN HEALTH PLANS (CDHP)

A

created as part of Medicare Prescription, Drug, Improvement, & Modernization Act; includes HSA & HRA

47
Q

describe HSA

A
  • 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
48
Q

what are some qualified expenses according through HSA

A
  • ambulance
  • braces
  • home improvements for disabled
  • tv/phone for disabled
49
Q

what plan accrues interest if not used

A

health savings account

50
Q

define HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

A

can be alternative to traditional group health plan provided by employers

51
Q

describe FLEXIBLE SPENDING ARRANGEMENT (FSA)

A
  • 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
52
Q

aka: flexible spending arrangement

A

cafeteria plan

53
Q

describe Medicare

A

health insurance under SS for eligible people, 80/20, four parts

54
Q

who are qualified for medicare

A
  • people at least 65 years
  • disabled
  • receiving SS benefits
  • end stage renal disease
55
Q

describe part A of medicare

A
  • hospital coverage & any person receiving monthly SS benefits
  • annual deductible increases each year
56
Q

describe part B of medicare

A
  • 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
57
Q

describe Part C medicare

A
  • 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
58
Q

aka: part C medicare

A

medicare advantage

59
Q

part D medicare

A

coverage for generic & name-brand drugs

60
Q

define CMS-1500

A

claim form submitted to Medicare & must be submitted electronically

61
Q

when must a CMS-1500 be filed

A

within a year of service rendered

62
Q

how are non-participating providers

A

providers charge only 15% above medicare participating provider fee schedule amount for service & providers are paid 95% of fee schedule amount

63
Q

describe medicare reimbursement

A

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

64
Q

describe MEDICAID

A

funded by federal & state government & give coverage for ppl of limited/low income & pts have to get care from participating provider

65
Q

are pts required to accept medicaid pts or participate with medicaid

A

no

66
Q

define workers comp

A

state or federal insurance covering employees injured/ill bc of work & employers pay premium

67
Q

what effects the premium of workers comp

A

risk involved w/job & company’s loss history

68
Q

t/f: industrial injury should be a separate record for pt

A

true

69
Q

when should a pt be billed for workers comp

A

treatment w/o authorization or was accessive

70
Q

what are the principal types of state benefits of workers comp

A
  • medical
  • income
  • death
  • burial
71
Q

list EHR components regarding workers comp

A
  • 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
72
Q

define TRICARE

A

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

73
Q

define TRIC ARE FOR LIFE

A

wraparound coverage for TRICARE-eligible beneficiaries who have medicare A & B

74
Q

define CIVILIAN HEALTH & MEDICAL PROGRAM OF DEPT OF VETERANS AFFAIRS (CHAMPVA)

A

organization for spouses & dependent children of veterans w/total, permanent, service-connected disabilities/spouses & dependent kids of veterans who died from service-connected disabilities

75
Q

who determines eligibility for CHAMPVA

A

local VA hospital

76
Q

if parents have the same birthdate, how does the birthday rule apply/change?

A

plan in effect the longest is primary

77
Q

if parents divorce & retain their insurance plans, how does the birthday rule change/apply

A

parent w/custody is primary

78
Q

what always supersedes the birthday rule

A

court order

79
Q

what is the difference between prospective and retrospective utilization reviews

A

prospective = done before service
retrospective = done after service

80
Q

define UTILIZATION MANAGEMENT

A

method of controlling costs by review services to determine necessity before care

80
Q

what are the methods of utilization review/management

A

preauthorization, precertification, predetermination, concurrent review, discharge planning

81
Q

define PREAUTHORIZATION

A

determines whether service covered & necessary

82
Q

define PRECERTIFICATION

A

seek approval for treatment under pt insurance contract

83
Q

define PREDETERMINATION

A

discover of max amnt of money carrier will pay for service

84
Q

define UCR BASIS OF PAYMENT

A

determines if charge for services consistent w/avg rate of for similar services in certain areas

85
Q

what does UCR basis of payment stand for

A

Usual, Customary, Reasonable Basis of Payment

86
Q

aka: RBRVS

A

resource based relative value scale

87
Q

define RBRVS

A

method medicare uses to create medicare provider fee schedule

88
Q

what are the RVUs of RBRVS

A

physician work, practice expense, professional liability insurance

89
Q

how are RBRVs calculated into cost

A

RVUs multiplied by geographic practice cost index

90
Q

define PROSPECTIVE PAYMENT SYSTEMS

A

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

91
Q

describe DIAGNOSIS RELATED GROUPS

A

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

92
Q

how do DRGs work

A

each DRG has payment weight based on avg resources used to treat & organized into major diagnostic categories based on body system

93
Q

define CATASTROPHIC PLANS

A

individual & family insurance coverage for hospitalization/serious illness

94
Q

define FEE DISCLOSURE

A

action of provider informing pt of charges before service performed

95
Q

define GROUP INSURANCE

A

insurance offered to all employees by employer

96
Q

define INDIVIDUAL INSURANCE

A

insurance purchased by indiv/family who doesn’t have access to group insurance

97
Q

define LIMITING CHARGE

A

max amnt nonparticipating provider can collect from Medicare pt

98
Q

define LOSS OF INCOME BENEFITS

A

payments made to insured to help replace income lose through inability to work bc insured disability

99
Q

define MEMBER PROVIDER

A

provider contracted to participate w/insurance to be reimbursed for services

100
Q

define PATIENT STATUS

A

pt’s eligibility for benefits, basis on which benefits are provided

MA: Chp 24 - Insurance (2 decks)

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