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principles of healthcare reimbursement > chapter 3 > Flashcards

chapter 3 Flashcards

1
Q

healthcare insurance companies allow people to purchase healthcare coverage

A
  • a single coverage them selves only or alternatively a self only coverage, individual coverage or an individual plan.
  • themselves and their dependents, which is known as nonsingle coverage or dependent coverage and can be the purchaser plus one coverage or family coverage.
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2
Q

dependents

A

are spouses and other family members

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3
Q

risk pool

A

is a group of individual entities, such as individuals, employers, or associations, whose healthcare costs are combined for evaluating financial history and estimating future costs.

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4
Q

three types of pools

A
  • individual pools
  • large employer pools
  • multiple employer pools
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5
Q

adverse selection

A

is having disproportionate members of sick people.

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6
Q

benefits

A

similar to employer based group plans but at higher costs. also known as covered services, are healthcare services for which the insurance company will pay as outlined in the healthcare plan.

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7
Q

covered services

A

are healthcare services for which the insurance company will pay as outlined in the healthcare plan.

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8
Q

policy holder or insured

A

the individual or entity that purchase an insurance policy or contact.

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9
Q

premiums

A

are the periodic payments that a policy holders or certificate holder must make to an insurer in return for healthcare coverage.

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10
Q

deductible

A

is an annual amount of money that policy holder must pay before the healthcare plan will assume its share of liability for the remaining charges or covered expenses.

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11
Q

cost sharing provision

A

are policy points that require the insured to pay for a portion of their healthcare services.

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12
Q

certificate holder, member

A

additional terms used for policy holder also known as subscriber and beneficiary. most of the policy holder of individual healthcare insurance pay higher premiums to obtain and maintain healthcare insurance.

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13
Q

state health insurance plans

A

state legislatures in 35 have established the purpose is to provide access to healthcare insurance coverage to the medically uninsured. and often called high- risk pools.

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14
Q

high-risk pools

A

state healthcare insurance plans

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15
Q

medically uninsured

A

people who have a pre-existing condition or chronic disease or both.

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16
Q

preexisting condition (state)

A

is a health condition status, or injury that was diagnosed before the application for healthcare insurance.

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17
Q

policy

A

is a formal contract between the healthcare insurance company and the individuals or groups for whom the company is assuming risk.
this contract is called a certificate of insurance also known as a certificate of coverage, evidence of coverage or summary plan description.

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18
Q

covered conditions

A

are all health conditions, illness, injuries, diseases, or symptoms that the healthcare insurance company will reimburse for treatment that attempt to maintain , control, or cure said conditions.

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19
Q

summary of benefits and coverage

A

is a document that, in plain language, concisely details information about a healthcare insurer’s benefits and its coverage of health services.

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20
Q

a medical emergency

A

life-threatening event a concept that is more extreme and less likely than demanding immediate attention.

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21
Q

terms of definition cosmetic services

A
  • accidental injury
  • medical emergency
  • medical necessity
  • prior approval
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22
Q

prudent layperson standard

A

is the decision whether symptoms required urgent or emergent treatment is based on an ordinary laypersons reasonable judgement

23
Q

eligibility

A

section of a healthcare insurance policy specifies the individuals who are eligible to apply for the healthcare insurance.

24
Q

enrollment

A

section specifies the procedures for obtaining healthcare insurance.

25
Q

eligible dependents include the following

A
  • legally married spouses
  • children and young adults until they reach age 26.
  • dependent with disability.
26
Q

guaranteed issue

A

healthcare insurers are required to accept every qualified individual who applies for health care coverage.

27
Q

waiting period

A

is the period must pass before coverage for an employee or dependent who is otherwise eligible to enroll under the terms of a group health plan (including grandfathered plans)

28
Q

late enrollees

A

are people who apply after the earliest date on which coverage is available

29
Q

open enrollment (election) periods

A

are specific periods when applications are received and processed.

30
Q

types open enrollment periods are

A
  • within 30 days of hire for initial coverage.

- during defined periods that occur annually ( often between October and December)

31
Q

special enrollment (election) periods

A

are unique (special) to certain circumstances and occur without regard to the healthcare insurance companies regularly scheduled, annual open enrollment period in the lives of individuals (not employers or health insurers) qualifying life events (QLEs)

32
Q

the QLEs that make an individual eligible for special enrollment are

A
  • loss of other healthcare coverage (self, spouse, or dependent)
  • marriage
  • divorce
  • birth
  • adoption
  • placement for adoption
33
Q

benefit period

A

is length of time for which the policy will pay benefits for the member (and family and dependents, if applicable).

34
Q

stop loss benefits

A

is a specific amount in certain time frame such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan. also known as maximum out- of- pocket cost and catastrophic expense limit.

35
Q

10 essential benefit categories include

A
  • ambulatory patient services, also referred to as outpatient care.
  • prescription drugs
  • emergency care
  • behavioral health services
  • hospitalization
  • rehabilitative and habilitative services.
  • preventive and wellness services.
  • laboratory services
  • pediatric care
  • maternity and new born care
36
Q

medigap

A

Medicare supplemental health insurance policies are designed to coordinate their payments with payment from Medicare.

37
Q

limitation

A

are qualifications or other specifications that limit the extent of the benefits.

38
Q

coinsurance

A

is a preestablished percentage of eligible expenses after the deductible has been met.

39
Q

copayment

A

is a fixed dollar amount (flat fee).

40
Q

tier

A

level of coverage

41
Q

formulary or preferred drug list

A

a continually updated list of safe, effective, and cost-effective drugs that the healthcare plan prefers that insured use.

42
Q

center of excellence

A

is a healthcare organization that performs high volumes of a service at a correspondingly high quality.

43
Q

exclusion

A

are situations, instances, conditions, injuries, or treatments that the healthcare plan states will not be covered and for which healthcare plan will not pay benefits.

44
Q

rider

A

is a document that is added to a policy to provide details about coverage or lack of coverage for special situations.

45
Q

endorsement

A

is language or statement within policy itself that adds information or detail about coverage or lack coverage for special situations.

46
Q

precertification or prior approval

A

is the process of obtaining approval from a healthcare insurance company before receiving a healthcare services.

47
Q

types of services that often require prior approval include

A
  • outpatient surgeries
  • diagnostic, interventional, and therapeutic outpatient procedures.
  • physical, occupational, and speech therapies.
  • behavioral health and substance abuse.
  • inpatient care, including surgery, home health, private nurses, and nursing home.
  • organ transplant
48
Q

coordination of benefits COB or other party liability OPL

A

these procedures are used when multiple insurance companies are involved.

49
Q

primary insurer (prayer)

A

is the healthcare insurance responsible for the greatest proportion or majority of the healthcare expenses.

50
Q

secondary insurer (prayer)

A

is responsible for the remainder of the healthcare expenses.

51
Q

some common rules to follow

A
  • a patient’s healthcare insurance is primary over a spouse’s healthcare insurance.
  • a dependent child’s primary insurer is the insurance of the parent whose birthday comes first in the calendar year. called birthday rule.
  • a legal decree, such as a divorce agreement, dictates determination
52
Q

appeal

A

is a request for reconsideration of denial of coverage for healthcare services or rejection of claim.

53
Q

claim

A

is bill for healthcare services submitted by a hospital, physician’s office, or other healthcare provider or facility.

principles of healthcare reimbursement (1 decks)

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