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
