Chpt 14 Flashcards

Question

Form locators

Answer 1

The boxes on the CMS-1500 insurance claim form

Answer 2

The tiered list of drugs covered by an insurance company Usually 2 or more tiers with different coverage for each tier

Answer 3

The physician responsible for determining when and if a patient needs specific types of healthcare

Answer 4

A commercial insurance policy with rates based on a group of people, usually offered by an employer

Answer 5

Insurance purchased to cover medical expenses A contract between the insurance carrier and the owner of the policy

Answer 6

A group of physicians or medical centers that provide comprehensive services to members Only covers in network providers PCP required Must have referrals Push preventive healthcare Mist restrictive, lower cost

Answer 7

Healthcare legislation produced to amend the Patient Protection and Affordable Care Act

Answer 8

Natural, drug-free healthcare services

Answer 9

Plan in which insurance companies pay providers fees for each service provided to covered patients 1980s

Answer 10

A commercial insurance policy with rates based on individual health criteria Most expensive, benefits not as good Minimum level of benefit package determined by the state-only some companies offer individual policies General done through insurance exchange system since ACA - online marketplace- varies by state

Answer 11

The person who owns the insurance policy

Answer 12

The type of insurance that covers injuries that occur on, in, or because of the insured’s property.

Answer 13

The monetary amount allowed by an insurance carrier for a member’s covered expenses over the member’s lifetime

Answer 14

Medications patients take on a long-term basis to create a chronic condition such as high blood pressure , arthritis or a heart condition May have a mail-order option, 3 months for 2 copayments 90 day prescriptions with 3 refills for the remainder of the year.

Answer 15

A system of healthcare delivery focused on reducing costs by limiting the type and frequency of care members may receive

Answer 16

A joint federal and state program that helps with medical costs for eligible people with low incomes and limited resources

Answer 17

A federal program that covers expenses for those ages 65 and over, those with end stage kidney disease, and those with long-term disabilities 55 million people in 2015 As of 2014 accounted for 14% of U. S. Federal budget 2015-2030-rise from 52 to 78 million By 2019 part part A will have insufficient funds Administered by CMS (formerly HCFA- health care financing administration) Uptodate on website Submit claims within 365 days of service, later subject to 10% penalty unless you can prove it was beyond the provider’s control Services 1-1 through 9-30: bill by end of next calendar year 10-1 through 12-31: bill by end of 2 calendar years

Answer 18

The person who owns the insurance policy

Answer 19

A unique, 10-digit number assigned to healthcare providers by CMS Replaces UPIN (unique provider identification number) NPI required since 2007, on patient billing forms

Answer 20

The healthcare provider who has not contacted with a particular health insurance carrier

Answer 21

The healthcare provider who has contracted with a particular health insurance carrier

Answer 22

Healthcare legislation passed in 2010

Answer 23

The number that medical offices must include on an electronic claim to identity the insurance company to whom the claim is directed

Answer 24

An insurance offering in which a patient has access to multiple plans, such as an HMO and PPO Not stuck with network doctors but pay more Choose an option each time you use healthcare Contracted network of providers and facilities

Answer 25

The person who owns the insurance policy

Answer 26

The process of obtaining approval from an insurance company for a patient’s procedure

Answer 27

The process of obtaining approval from an insurance company for a patient’s procedure

Answer 28

A condition for which a patient received treatment in a certain period before beginning coverage with a new insurance plan Must be insured for 24 months before joining a new plan to be covered without a waiting period

Answer 29

An organization that contracts with independent providers to perform services for members at discounted rates Major medical expenses require pre authorization Use non-PPO, pay difference to make up usual fee Physicians in a practice might not belong to same PPO Physicians may belong to multiple PPO No PCP No referral required but incentive to use in network specialist Less restrictive, more expensive, than HMO

Answer 30

The dollar amount paid to an insurance company to have coverage in force

Answer 31

Healthcare designed to keep a person healthy

Answer 32

An insurance program in which an employer sets aside funds to pay for employee health expenses

Answer 33

A provider’s fee schedule that charges varying fees for a service based on a patient’s financial ability to pay.

Answer 34

The maximum amount the patient must pay out of pocket for copayments and coinsurance Starts over at the beginning of each year. May not apply to all care the patient pays for

Answer 35

The person who owns the insurance policy

Answer 36

A form used in the medical office for indicating the services rendered to the patient, as well as the diagnosis for the service

Answer 37

Health insurance for active-duty military personnel, retired service personnel, and their eligible dependents Formerly CHAMPUS

Answer 38

The period after a new health insurance plan begins during which certain services are not covered Restricted by HIPAA to no longer than 12 months

Answer 39

A form patients sign agreeing to pay for services that may be denied by Medicare

Answer 40

How managed care plans work How owed amounts are determined for specific procedures In a small office may do billing May outsource billing

Answer 41

1st group policies producing comprehensive benefits- 1847- Massachusetts Health Insurance of Boston Replaced the income of people injured in accidents or with certain kinds of diseases 1890s- 1st individual disability and illness policies

Answer 42

Texas - a group of public school with teachers formed a contract with a hospital to guarantee up to 21 hospital days for a premium of $6/year Eventually known as the Blue Cross plan

Answer 43

Wages frozen so employers started offering group health insurance as a benefit Designed to protect employees from high costs of hospitalization Evolved into today’s healthcare plans

Answer 44

Employee plans became popular Unions bargained for tax-free employer sponsored health insurance

Answer 45

Government programs started to cover healthcare costs 1954-SS Coverage covered disability 1965-Medicare/Medicaid created

Answer 46

Rapid rise in cost of healthcare Majority of healthcare workers move to less expensive managed care plans

Answer 47

Created policies and allowed use of federal funds to promote HMOs

Answer 48

Easier and more attractive for HMOs to contract with the Medicare program

Answer 49

65% of Americans have coverage through employer 90-most Americans with health insurance were enrolled in managed care plans

Answer 50

Prediction that by 2020 Americans with employer health insurance would self insure through healthcare.gov

Answer 51

Phase in over 4 years Targets reform of the insurance industry Eliminate annual and lifetime caps on the amount of coverage an individual is allowed to receive Carriers cannot deny coverage for chronic conditions Expansion of Medicaid coverage financial limits Sliding fee scales enacted with government subsidizing premiums Incentives to employers to provide health insurance

Answer 52

Can’t refuse coverage for preexisting conditions Fines to anyone without insurance

Answer 53

Approximately $43 billion was spent on un reimbursed healthcare to uninsured

Answer 54

Many tries to repeal ACA Reduce people on Medicaid Remove mandate that all Americans must have insurance

Answer 55

Member is the employee

Answer 56

The member is the person who purchased the plan

Answer 57

Must obtain forms from the employer or insurance company to specifically designate dependents Manager should talk to patient and insurance company to determine who is eligible and how each dependent is related to the member

Answer 58

If they contract with the insurance company they agree to a set fee schedule for reimbursement

Answer 59

Contract with providers (usually have contracts with multiple MCOs) MCO contracts with insurance companies Contracts stipulate discounted reimbursement rates, billing guidelines and other rules Patients have lower costs with PP Some allow nonparticipating providers at higher cost, some not at all

Answer 60

Often done online

Answer 61

Certain ones are covered by health insurance Reconstructive surgery Repair after an accident

Answer 62

Must prove medical necessity to have these covered

Answer 63

Separate deductible and different copayments and coinsurance Don’t determine stop loss benefits

Answer 64

Any provider who submits claims to Medicare All must use an NPI

Answer 65

Must place their NPI and name and NPI of referring physician

Answer 66

Enter group NPI and rendering provider NPI

Answer 67

Hospital insurance for patients hospitalized up to 90 days in a given time period; skilled nursing facility; at home; hospice care; psychiatric treatment for a period of time; respite care No premiums but deductibles and coinsurance

Answer 68

Physician care, therapy, and lab testing Premium as of 1-1-2007: income based Deductible and 20% coinsurance for medical services PAR-participating provider must accept fee schedule amounts as payment in full. Not required to be a Medicare provider Must bill all charges even those known to not be covered Accept assignment on all claims Approximately 95% of providers participate

Answer 69

Managed care, medicare advantage plans Formerly, Medicare +Choice Replace parts A,, B and D 2003-2016 went from 5.3-17.7 million in part c The advantage plan is billed, not Medicare Secondary plan: bill advantage plan than secondary plan As of 2015 government paying 14% more for beneficiaries under advantage than traditional

Answer 70

Introduced January 2006 Prescription drug plan Provided by private companies. Not all drugs covered by all companies As of 2017, 90% of beneficiaries have prescription drug coverage Medicare.gov has prediction drug plan finder Annual deductible, copayments or coinsurance and a maximum benefit level Mail order pharmacy options; delivery could take à week or more

Answer 71

Medigap regulated by CMS Not all cover same expenses Basic benefit is to cover coinsurance Billed after Medicare makes a determination usually by Medicare. Payment direct to the provider Medicare is primary to medigap

Answer 72

Commercial health insurance is primary Medicare secondary

Answer 73

File an application with CMS Fee schedule updated each year In person and online workshops about Medicare for providers

Answer 74

Fill out an EFT authorization agreement form Return to Medicare with a voided check Will directly deposit funds within 3 weeks

Answer 75

Maintained by Medicare Search by state or specialty

Answer 76

Run by CMS but states dictate amount and type of services covered As of 2015 covered 70 million people Each state has its own ID card Reimbursement to providers very low Must apply to be a provider Receive a fee schedule of covered events Month to month coverage Must ask patient for proof of coverage

Answer 77

Medicare is the primary Medicaid secondary Often medicare is higher and there is no payment from Medicaid Approximately 6.5 million receive

Answer 78

Requirements of federal government to participate Inpatient/outpatient hospital services Prenatal care Vaccines for children Physician services Nursing facility services ages 21 + Family planning services and supplies Rural health clinic services Home healthcare Lab & radiology Pediatric and family nurse practitioner services Nurse-midwife There are also optional services that can get states matching funds

Answer 79

Federal reimbursement for all costs For native Americans and alaskan natives

Answer 80

Active duty member-sponsor Dependents-beneficiaries 3 benefit types 1. Standard-fee-for-service plan 2. Extra-PPO 3. Prime-HMO 1&2 copayments and deductibles Deductible year begins October 1 not January 1 3 is optional- must specifically enroll Tricare for Life- secondary insurance for those over 65 (Medicare is primary) Pre authorization required Patients must use in-network providers Participating providers must submit claims within 60 days Not network have up to a year to submit claims

Answer 81

Civilian Health and Medical Program of the Department of Veterans Affairs Families of veterans with total permanent service-related covered disabilities And families of veterans who died in the line of duty Use any civilian healthcare provider without prior authorization Other coverage billed first except for Medicaid, victims of crime compensation & supplemental CHAMPVA policies

Answer 82

Organ and bone marrow transplants Hospice care Dental care DME worth more than $300 Most mental health and substance abuse services

Answer 83

No fault coverage-the individual’s own auto insurance pays the medical bills regardless of who is at fault. Paid under the personal injury protection (PIP) portion of the injured person’s policy Then insurance company tries to get money back from at fault insurance Injured person doesn’t have PIP or not enough coverage, at-fault’s insurance is billed If a lawsuit is filed against at-fault’s insurance medical bills may be sent to the patient’s attorney - could take years to get paid Manager should ask practice attorney to file a lien against the at-fault party to establish legal right to be paid on settlement

Answer 84

Payment of 3rd party liability is delayed past specified number of days (45 or 60) insurer will pay provider then pursue the third party insurance

Answer 85

New medical and new financial accounts should be created Gather as much information as possible regarding the accident, patient’s auto coverage, at-fault party’s name and insurance information, & patient’s private health care insurance

Answer 86

Reimburses a patient for lost wages due to non-work related disability Benefits based on percentage of employees wages , often 66%, because benefits are not subject to income tax Does not pay for medical treatment so office doesn’t bill disability plan Manager may need to assist patient by providing information from the medical record May not have medical coverage

Answer 87

Obtain accurate information- need insurance type

Answer 88

Patient will have a claim number and a claims manager or department to handle claims 1st locate the name and number of the claims manager- can contact them easily if the physician orders tests or procedures that require pre authorization

Answer 89

New patient completes form. Verify at each visit and update annually Must have a signed authorization to release patient information to insurance carriers under HIPAA Identify name and birthdate of the insured Determine if there is a secondary policy- must determine which is first and which is second Photocopy both sides of cards- member id number for each insurance company- combination of letters and numbers

Answer 90

After collecting information the manager should verify coverage with the insurance company. 1. Call customer service number listed on card, have patient id number and birthdate 2. Use computer software to contact the insurance company

Answer 91

If covered under more than one plan, there are rules for billing Spouse-own policy primary, spouse’s secondary Children-based on birthday rule most often

Answer 92

Call insurance carrier to obtain permission for patients to receive prescribed procedure In the case of preauthorization numbers, include the numbers on the insurance billing form and make note of them in the patient’s file

Answer 93

Some plans require referrals from a PCP to see a specialist May need to call patient’s pcp to coordinate the patient’s referrals Managers who work for pcp may need to arrange specialist referrals- verify that the specialist are covered under the patient’s managed care plan. To do this call the insurance carriers customer service number or look online In specialist office-make sure the pcp has arranged the referrals

Answer 94

Claims may be denied Physicians can’t bill the patients for denied services Basically doing the services for free Managers must confirm referrals and precertifications

Answer 95

Insurance companies websites- on patient id card Good general info but not for authorization The insurance customer service line is the best place to call for questions about a patient’s insurance Date Time Number used Party on the phone Information obtained Becomes part of the patient’s financial record

Answer 96

Before 1990s-unique forms required to which coder attached a superbill

Answer 97

HCFA ( now CMS) created uniform billing form Used by all health insurance carriers

Answer 98

American Dental Association standard form

Answer 99

Patient and insured info Physician or supplier info Top right-carriers area- print insurance company name and address Use patient registration form Use insurance card Use clinic encounter form Use clinics fee schedule Need clinic address, tax id number and NPI numbers Even a small mistake can cause rejection

Answer 100

Most carriers accept claims for up to a year Some shorter, 90 days Most likely reject claims after timeline-cannot bill these to the patient

Answer 101

No paper Claims saved on the computer only

Answer 102

Attention to detail a must Rejected claim is not processed because there is incorrect information- returned for correction and resubmission Processed but no payment due to problems with benefits or coverage Reason for the denial will be listed

Answer 103

Manager should determine what information the insurance company requires and resubmit the claim

Answer 104

Each state has one Can file a formal complaint if appeals are fruitless Must involve patient because he is the consumer being protected Manager can write a letter on behalf of the patient and have the patient sign it Sometimes the threat of a complaint will encourage the insurance company to review