Ch # 48: Medical Insurance Flashcards
T or F
If a patient has met their annual deductible, Medicare will pay 100% of the allowed charges for office services after this deductible is met.
False-patient is responsible for 20%
T or F
A physician is contracted with Medicare and usually bills patients $285 for a specific procedure. She can only bill Medicare for $228, which is 80% of the charges.
True
T or F
Medicare sets allowable charges for services under Part B using resource-based relative value systems (RBRVS) this is dependent on the amount of work for each procedure with adjustments for overhead and malpractice insurance.
True
T or F
Diagnostic-related groups (DRGs) is the classification system that forms the basis for payments for claims under Medicare Part A.
True
T or F
Medicare Administrative Contractor (MAC) processes Medicare claims.
True
T or F
Patients under Medicare Part A must pay a regular monthly premium.
False-it’s funded through a tax on income
T or F
Medicare Part A, will cover goods and equipment such as canes, wheelchairs and walkers.
False-Part A is 4 inpatient hospital stay
Part B covers goods and equipment
T or F
A Point of Service plan (POS) is where the subscriber belongs to both an HMO and an insurance plan.
True
This insurance plan usually requires the patient to pay a higher percentage of out-of-network services.
a) Network HMO
b) Exclusive provider organization
c) Preferred provider organization
d) Independent physicians association
c) Preferred provider organization
This HMO model allows physicians to be employed by a managed care organization that provides services in its own offices.
a) Independent Practice Association
b) Staff model HMO
c) Group practice model HMO
d) Network model HMO
a) Independent Practice Association
With HMO insurance, the patient usually makes this type of payment:
a) Copayment
b) Deductible
c) Coinsurance
d) Both deductible and coinsurance
d)Both deductible and coinsurance
Vicky’s has a traditional indemnity insurance plan. If she wants to make an appointment with a endocrinologist to treat her hypothyroid, what must she do?
a) Get a referral from her assigned provider.
b) Visit the plan website and fill out a request for referral form.
c) Simply make the appointment
d) None of these are correct.
c) Simply make the appointment
Diego’s insurance plan pays 100% of allowed charges and will not allow balance billing. He has a procedure done that is covered by insurance. He‘s billed for $800 by the physician, but her insurance company only allows $650. How much will he have to pay?
a) $150
b) Nothing
c) 20%
d) 15%
b) Nothing
The physician is reimbursed directly for his/her services by the insurance company when:
a) Always
b) Never
c) If the patient has signed an assignment of benefits form.
d) If the patient has signed a written consent for treatment.
c) If the patient has signed an assignment of benefits form.
Delaney and Bill divorced after a few years of marriage. They both continued to work and have joint custody. The children reside with Delaney and neither parent has remarried. Bill is the “responsible party” for the children. Whose insurance is the primary insurance for the children?
a) Delaney
b) Bill
c) Both
d) None of these
b) Bill
A married couple both work and participate in the family health insurance plan offered by separate employers. What term relates to the rules used by their insurance companies relating to paying for services?
a) Coinsurance
b) Double coverage
c) Birthday
d) Coordination of benefits
d) Coordination of benefits
The insurance company pays 80% of a charge, and the patient pays the other 20%, what is the patient’s portion called?
a) Coinsurance
b) Copay
c) Deductible
d) Co-deductible
a) Coinsurance
A written notification 2 a patient w/original Medicare that a covered service must b paid 4 by the patient if Medicare denies the claim as medically unnecessary
Advanced Beneficiary Notice of Noncoverage
Authorization 4 insurance reimbursement 2 b made 2 the provider of a health service rather than the insured individual
Assignment of benefits
A person who can receive benefits under an insurance plan
Beneficiary
Payment 4 a covered service under a health insurance plan
Benefit
If both parents of a child have a family health plan, the insurance plan of the parent whose birthday comes earlier in the year is defined as the primary insurance plan covering the child. The insurance of the other parent becomes secondary insurance
Birthday rule
A method 4 paying 4 insurance in which a fixed amount is paid 2 the provider per member 4 a specific time period regardless of the amount of care provided
Capitation
An insurance company
Carrier
A government health insurance program that covers dependents of military veterans w/service related disabilities
CHAMPVA
A % of the allowed charge 4 health services, which the patient iOS responsible 4 paying
Coinsurance
Rules followed by insurance companies so that no claim is reimbursed at more than 100% of the charges
Coordination of benefits
A fixed amount of $ that the patient must pay 4 any health care service
Copayment
An amount of $ that an insured person must pay annually b4 health services r covered by the insurance plan
Deductible
A system 2 determine Medicare reimbursement 4 a hospital stay on the basis of the patient’s diagnosis
Diagnosis-related groups
DRG
Enrollment status related 2 a health care insurance plan
Eligibility
A statement issued by the insurance c airier explaining reimbursement 4 specific procedures
Explanation of benefits
EOB
2 names 4 an insurance reimbursement that is directly related 2 the services provided and the amount charged by the provider
Fee-4-service insurance
Indemnity plans
An insurance official list of covered medications 2 b used by network providers
Formulary
1 insurance policy that covers multiple people
Group plan
A person w/financial responsibility 4 a bill who may or may not b a patient
Guarantor
An obligation 2 provide compensation 4 loss or damage
Indemnity
The individual who a specific insurance plan
Insured
A movement in health care based on reducing health care costs while providing high quality care. This may b used 4 techniques used 2 reduce costs or 4 the companies that pay 4 the care provided
Managed care
The government insurance plan 4 low-income individuals and families that is funded both by the federal government and each individual state
Medicaid
The federal government insurance program that provides insurance coverage 4 elderly, permanently disabled, and individuals w/end-stage kidney disease
Medicare
A multistage, regional independent business that administers both Medicare Part A and B claims under a contract w/the centers 4 Medicare and Medicaid Services (CMS)
Medicare Administrative Contractor
MAC
A physician who does not have any contract w/3rd-party payer
Nonparticipating provider
NonPAR
A physician who has a contractual agreement w/a 3rd-party payer
Participating provider
PAR
Verification from a patient’s insurance carrier that a procedure is covered by the patient’s insurance and/or agreement, after review, that the test or procedure is medically appropriate
Preauthorziation
Verification from a patient’s insurance carrier that the procedure is covered by the patient’s insurance and/or agreement, after review, that the test or procedure is medically appropriate
Precertification
An amount of $ paid in a given period 2 purchase health insurance
Premium
The health care practitioner chosen by a patient 2 provide general medical care and also 2 determine and authorize additional medical services the patient may require
Primary care provider
PCP
The insurance that must b billed 1st 4 any individual
Primary insurance
The directing of a patient 2 a specialist physician by the primary care provider. Most managed care plans and some other insurance plans require the primary care provider 2 obtain prior authorization
Referral
The amount paid 4 a procedure by insurance
Reimbursement
A statement issued by Medicare or another 3rd party payer 2 the provider explaining reimbursement 4 specific procedures or denial of an insurance claim
Remittance advice
RA
A system 2 establish the Medicare fee schedule 4 Medicare Part B based on the service provided and the geographic location of the provider
Resource-based relative value scale
RBRVS
Insurance that an individual has inaddition 2 primary insurance
Secondary insurance
The process by which a patient makes an appointment w/a specialist physician w/out requesting authorization from his/her primary care physician, usually because the patient’s insurance plan doesn’t require it
Self-refferal
An indication on the insurance claim form that the signature of t he patient is maintained by the office 2 authorize submission of insurance claims
Signature on file
SOF
Insurance carrier or managed care organization that pays health insurance claims
3rd-party payer
A government insurance plan that provides medical care 2 spouses and dependents of individuals on active duty in the military. Used 2 b called CHAMPUS
TRICARE
A system 4 establishing the amount an insurance carrier will pay 4 a procedure. The charge is set by the insurance carrier on the basis of the physician’s usual charge 4 the procedure and the customary charge of other physicians in the same geographic area
Usual, customary and reasonable
URC
Reviewing proposed or current care 2 determine medical necessity
Utilization review
An insurance program that covers lost wages and health care costs of workers injured on the job or have work related illiness
Worker’s compensation
