Chapter 17 Flashcards
MA’s Roles in Insurance and Billing
- Insurance verification
- Prepare claims
- Review patient coverage
Premium
The basic annual cost of health care insurance
Deductible
A fixed dollar amount that must be paid by the insured before additional expenses are covered by an insurer
Coinsurance
A fixed percentage of covered charges paid by the insured person after deductible has been met
Copayment
A fixed amount paid for each healthcare or medical service; the remainder is paid by the insurance
Preauthorization
Approval for payment from a third party payer requested in advance for a specific procedure
Workers Compensation
Provide partial medical care and income protection to employees who are injured or become ill from their job.
Payment Methods
Most third party payers use on the three methods for reimbursing providers
- Allowed charges - the max amount the payer will pay for any provider
- Contacted fee schedule - fixed fee schedule with physicians
- Capitation - fixed prepayment for each plan member
New Patient
- Never been seen in the practice
- Has not been seen for 3 years
For Reinsurance Verification
- Best to be done before patient arrive
- Verifiers the active insurance coverage and how much of the visit is covered
Coordination of Benefits
Legal clauses in insurance policies that prevent payment duplication
Medical Necessity
Whether the procedures provided match diagnosis
Allowable Benefits
The max amount a plan will pau for a covered healthcare services
