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Essential Med Coding & Billing > CH 8 > Flashcards

CH 8 Flashcards

1
Q

What are entitlement programs

A

government insurance

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2
Q

Employee Sponsored Medical Insurance

A

Group Health Plan (GHP)

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3
Q

Group Health Plan regulated by who?

A

State

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4
Q

Largest Employer Sponsored plan

A

Federal Employees Health Benefits (FEHB) Program

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5
Q

Law providing incentives and protection for companies with employees health and pension plans

A

Employee Retirement Income Security Act (ERISA)

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6
Q

Required document for self-funded plans

A

Summary Plan Description (SPD)

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7
Q

Self-funded health plans regulated by who?

A

Department of Labor

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8
Q

Business associate of health plan

A

Third Part Claims Administrator (TPA)

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9
Q

Waiting Period

A

time from being hired to being eligible for insurance

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10
Q

late enrollee

A

enrolled outside of open enrollment due to special circumstances

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11
Q

List of a plans approved drugs

A

formulary

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12
Q

tiered network

A

system that reimburses more for quality cost effective providers

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13
Q

COBRA Consolidated Omnibus Budget Reconciliation Act

A

allows terminated employees to pay for health coverage (for employers with more than 20 employees)

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14
Q

Equality with medical/surgical benefits

A

Parity

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15
Q

PPO Providers based on?

A

discounted fee for service

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16
Q

HMO and POS may be?

A

capitated or salary

17
Q

Consumer Driven Health Plans (CDHP)

A

High Deductible and Savings Account

18
Q

Health Savings Account only employer contributes

A

Health Reimbursement Account (HRA)

19
Q

Either employer or employee can contribute

A

Health Savings Account (HSA)

20
Q

Both employer and employee can contribute. Allows money to be used for a few other things such as childcare

A

Flexible Savings (Spending) Account (FSA)

21
Q

credentialing

A

period verification of a prover or facility

22
Q

BCBS

A

Blue Cross Blue Shield

23
Q

BCBS Pay-for-Performance (P4P)

A

financial incentitives program based on provider performance

24
Q

BlueCard

A

program that provides benefits for subscribers away from their local areas

25
Q

Two parts of BlueCard

A

Host Plan - participating providers local BCBS plan
Home Plan - BCBS plan in subscribers community (where home base is)

26
Q

Flexible Blue

A

BCBS Consumer Driven Health Plan

27
Q

Medical insurance plan purchased by an individual

A

Individual Health Plan (IHP)

28
Q

Government regulated markplace

A

Health Insurance Exchange (HIX)

29
Q

Metal Plans

A

ACA created health plans named after different metals

30
Q

Essential health benefits (EHB)

A

required benefits that must be offered by metal plans

31
Q

5 parts of participation contract

A

Intro Section
Contract purpose and covered med services
physicians responsibilities
plans responsibilities
compensation and billing guidelines

32
Q

utilization review

A

process for determining medical necessity

33
Q

provider protection against large losses with capitation payments

A

stop-loss prevention

34
Q

billing for elective surgeries requires what?

A

precertification

35
Q

elective surgery

A

nonemergency surgical procedure

36
Q

Utilization review organization (URO)

A

organization hired by payer to evaluate medical necessity

37
Q

Plan Summary Grid

A

quick reference table for health plans / organized job aid

38
Q

7 steps of revenue cycle

A

preregister patients
establish financial responsibility
check in patients
review coding compliance
review billing compliance
check out patients
prepare and transmit claims

39
Q

document of eligible members of a capitated plan for a monthly period

A

monthly enrollment list

Essential Med Coding & Billing (3 decks)

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