COMPREHENSIVE HEALTH INSURANCE

Question 1

Prepaid health plans (also called prepaid medical plans) are

Answer 1

contracts that cover specific medical expenses for individuals or groups

Question 2

Medical insurance covers specific medical expenses. However, in the healthcare industry, the term health insurance now covers all aspects of medical insurance as well.

To the insurance industry, health insurance now includes medical insurance and means protection against the following:

Answer 2

Income losses for illness or injury (accident insurance)
Disability income
Accidental death or dismemberment (loss of limbs)
Sickness insurance
Medical expense insurance

Question 3

Commercial health insurance is often separated into two categories:

Answer 3

private insurance and employer-based insurance.

Question 4

Private, or individual, insurance

Answer 4

provides healthcare coverage for the policyholder and the policyholder’s family.

Question 5

Employer-based, or group, insurance

Answer 5

provides coverage to a group of people (such as employees).

Question 6

Group insurance policies

Answer 6

generally cost less than private plans and provide a wider range of benefits because the cost is spread across more people and therefore can be offered at a lower rate.

Question 7

Private health insurance (also called non-group insurance)

Answer 7

often used by self-employed people and others who aren’t eligible for group plans.

Private insurance holders pay premiums, or regular, pre-established amounts. The insurance company uses the money collected to pay claims submitted by those who have purchased insurance.

Question 8

FEP

Answer 8

Federal Employee Program

Question 9

Underwriting

Answer 9

is the process whereby an insurer reviews applications submitted for insurance coverage and decides whether to accept or reject all or part of the coverage requested.

Question 10

Blue Cross and Blue Shield (BC/BS) covering over ______ Americans.

Answer 10

100 million

Question 11

An insurer’s responsibilities include the following (Underwriting)

Answer 11

Reviewing applications submitted for insurance coverage
Deciding whether to accept or reject all or part of the coverage requested
Fixing the terms of coverage

Question 12

The FEP offers two plans:

Answer 12

the preferred provider organization (PPO) plan and the point-of-service (POS) plan

Question 13

PPOs (preferred provider organizations) provide

Answer 13

discounted healthcare services to members in the plan

Question 14

POS (point-of-service)

Answer 14

members must select providers within their network to receive the discount

Question 15

COB

Answer 15

Coordination of Benefits

Question 16

HDHP

Answer 16

high-deductible health plan

Question 17

UCR

Answer 17

Usual, Customary, and Reasonable

Question 18

X12

Answer 18

reason codes

You can view the codes for remittance advice and codes for claim adjustments. They’ll be listed on the remittance after each patient’s claim

Question 19

EHR

Answer 19

Electronic Health Record

Question 21

RAC

Answer 21

Recovery Audit Contractor

Question 22

Recovery Audit Contractor explained

Answer 22

If the Centers of Medicare and Medicaid (CMS) suspect fraud, waste, abuse, or error in claims that are being billed, they’ll ask for an audit of the claims through a Recovery Audit Contractor (RAC).

These claims are reviewed to make sure they both meet coding standards and documentation standards. They’re also reviewed to make sure the services that are billed are actually being provided. If not, the RAC will ask for the money that was originally paid to be returned to CMS.

Question 23

UPICs

Answer 23

Unified Program Integrity Contractors

Question 24

Unified Program Integrity Contractors explained

Answer 24

Medicare uses UPICs.

These contractors use data analysis to identify billing trends that are outside of the norm.

If a provider bills consistently at a higher level of service than what’s typically provided for their specialty or routinely adds services that don’t go together, then their practice may be flagged.

The UPIC may request medical records or may even visit the provider’s practice in person.

Question 25

The OIG

Answer 25

The Office of the Inspector General

Question 26

OIG Provider Self-Disclosure Protocol

Answer 26

providers can reduce the number of penalties they’ll need to pay. The OIG will investigate instances of fraud and abuse and pursue legal action against providers, if appropriate. They often take the results of the UPIC and RAC organizations and study their findings. They’ll investigate if the broad, sweeping increases are due to some legislative change in billing patterns, or if there’s another cause.

Question 27

Some indicators of fraud and abuse that the OIG, UPIC, and RAC may look for:

Answer 27

An overuse of modifiers that override NCCI edits
Billing services more frequently than other providers of the same specialty
Billing E/M codes with every surgical procedure may raise red flags with an audit.

Even if your practice bills exactly the same as others of the same kind, you still may get RAC audits, everyone does. It’s your chance to prove that you have the documentation to support the patient’s visit and that you’re in compliance with all laws.

Question 28

Medicare was formerly known as?

Answer 28

Title XVIII of the Social Security Act

Question 29

Title XVIII of the Social Security Act signed into law by who and when?

Answer 29

President Johnson

1965

Question 30

Medicare eligibility criteria:

Answer 30

• At least 65 years or older
• U.S. citizenship or permanent residence
• At least 10 years of Medicare-covered employment for individual or spouse
• Under 65 End-stage renal disease (or permanent kidney failure that requires dialysis or transplantation)
• Under 65 Received disability benefits under Social Security or Railroad Retirement (that is, benefits for railroad workers and their families for 24 months

Question 31

BBA

Answer 31

The Balanced Budget Act of 1997

Question 32

The Balanced Budget Act (BBA) explained

Answer 32

amended Medicare and made the most legislative changes to the program since it was established. The BBA established a Part C (in addition to Parts A and B) of the Medicare program to create new managed care and other health plan choices for beneficiaries.

This act includes the following:

New payment system for Medicare services to improve accuracy and reduce healthcare spending.

Expanded preventive-care benefits

Establishment of a new State Children’s Health Insurance Program (SCHIP)

New eligibility options for Medicaid
Expanded assistance for low-income Medicare beneficiaries

New quality standards for Medicaid managed-care programs

In 2006, a Part D was added to cover prescription drugs.

Question 33

Medicare Part A is

Answer 33

Hospital insurance

Question 34

Medicare Part A explained

Answer 34

People who meet the eligibility requirements can automatically receive Medicare Part A without paying a premium because they or their spouse paid Medicare taxes while they were working. Medicare is financed almost entirely by a nearly universal tax on employee pay.

Some people who don’t automatically receive coverage because they didn’t pay Medicare taxes while they were employed voluntarily pay for Medicare Part A coverage. In this case, they can purchase Medicare Part A coverage just like any other insurance coverage.
Because Medicare Part A is hospital insurance, it covers specific healthcare services normally related to hospital care.

Question 35

Inpatient hospital care

Answer 35

covers patients who are expected to remain in the hospital for at least 24 hours or more to receive treatment from a physician.

Question 36

Long-term care

Answer 36

covers persons with chronic disease or disabilities (diseases that persist for a long period or for the rest of the person’s life).

This coverage includes a wide range of health and social services provided under the supervision of medical professionals.

Question 37

Medicare Part A covers inpatient hospital care and long-term care when these services are

Answer 37

medically necessary; that is, when lack of such service or treatment could adversely affect the patient’s condition.

Question 38

Skilled nursing facility (SNF) care

Answer 38

includes rehabilitation, 24-hour nursing coverage, and physical, occupational and speech therapy.

Question 40

HHA

Answer 40

home health agency

Question 41

home health agency (HHA)

Answer 41

is a certified facility approved by a health plan to provide services under contract.

Question 42

Hospice care

Answer 42

is primarily designed to provide pain relief, symptom management, and supportive services for the terminally ill and their families.

Question 43

Medicare Part B is called supplemental insurance because

Answer 43

people don’t automatically receive Part B coverage. Instead, a premium must be paid for this coverage.

Question 44

Medicare Part B is a voluntary program that’s financed through a combination of payments from general federal revenues and premiums paid by beneficiaries who elect to participate. The premium payments are generally deducted from the person’s?

Answer 44

Social Security, Railroad Retirement, or Civil Service Retirement check. If the person doesn’t receive any of those payments, then a bill for the Part B premium is sent every three months.

Question 45

Medicare Part C is also known as the

Answer 45

Medicare Advantage Program

Question 46

Medicare Part C provides

Answer 46

Medicare members with alternative insurance providers instead of the government.

Question 47

Out-of-pocket expenses

Answer 47

are those expenses that aren’t covered by Medicare. These are the expenses that patients must pay themselves.

Question 48

Medigap insurance

Answer 48

is a health insurance plan that fills the “gaps” in Medicare plan coverage. This means that Medigap covers the services that aren’t covered by the Medicare options.

Each state offers standard Medigap plans, with different benefits for each plan.

If a person has a Medicare managed care plan, a private fee-for-service plan, or is covered by Medicaid, then Medigap insurance isn’t necessary.

Question 49

managed care plan

Answer 49

is a plan that involves financing, managing, and delivery of healthcare services. Typically, it involves a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, quality healthcare service.

Question 50

fee-for-service-plan

Answer 50

physicians and other providers receive payment based on their billed charge for each service provided.

Question 51

Medicaid programs provide healthcare coverage for

Answer 51

low-income families who meet specific eligibility requirements.

Question 52

Medicaid eligibility is limited to individuals who fall into specified categories. To be eligible for federal funding assistance, the state Medicaid programs must provide Medicaid coverage for specific groups of individuals as defined by the federal government. The federal statute identifies more than 25 different eligibility categories for which federal funds are available. These categories can be classified into five coverage groups:

Answer 52

Children
Pregnant women
Adults in families with dependent children
Individuals with disabilities
Individuals 65 years and older

Question 53

There are two eligibility groups:

Answer 53

categorically needy and medically needy.

Question 54

Categorically needy eligibility means

Answer 54

that the person and/or dependents fall into one of the categories outlined by the program and are therefore eligible to receive Medicaid coverage.

Question 55

Medically needy means

Answer 55

means that persons would be eligible for Medicaid because they have high medical expenses, except that their income and/or resources are above the eligibility level set by their state. In these cases, specific medical needs make them eligible for Medicaid. Not all states offer medically needy Medicaid programs.

Question 56

SCHIP

Answer 56

State Children’s Health Insurance Program

Question 57

State Children’s Health Insurance Program explained

Answer 57

Initiated by the Balanced Budget Act in 1997.

Is also known as Title XXI of the Social Security Act. SCHIP provides federal funds to states to expand Medicaid eligibility to include a greater number of uninsured children.
You’ll sometimes see SCHIP referred to as simply Children’s Health Insurance Program, or CHIP. Both of these terms refer to the same program .

Question 59

NCD

Answer 59

National Coverage Determinations

where the medically necessary diagnosis code for each procedure can be found and indications when a procedure should be performed.

Question 60

You’ll find how to submit a claim, the rules around time limits, and when to charge a patient. As part of your local _____?

Answer 60

Medicare Administrative Contractor (MAC)’s website

you can find information on how those payers prefer their claims to be submitted, along with special instructions they have on coding or other billing guidance. You’ll find their list of medically necessary diagnoses for specific procedures under their LCD (Local Coverage Determinations).

Question 61

Managed care

Answer 61

is a type of healthcare system that manages utilization, quality, and cost of services. Resources and services are closely monitored to ensure that the costs of services are within the amount that the insurance company will reimburse.

Question 62

HMO

Answer 62

health maintenance organization

Question 63

Examples of managed care plans with which you may be familiar are

Answer 63

HMOs and PPOs

Question 64

Generally speaking, a managed care health plan is a collection of interdependent systems that integrate the delivery of healthcare services to a specific population. Managed care health plans used the following processes:

Answer 64

Arrangements with selected providers to furnish a comprehensive set of healthcare services to members
Credentialing standards for the selection of healthcare providers
Quality assurance and utilization review programs
Financial incentives for member to use providers and procedures associated with the health plan (the network)

Question 65

IDS

Answer 65

Integrated delivery systems

ren’t necessarily nonprofit

Question 66

CCN

Answer 66

community care networks

tends to be community-based and nonprofit

Question 67

MCO

Answer 67

Managed care organization

Question 69

UCR explained

Answer 69

Providers set their Usual, Customary, and Reasonable (UCR) free for each procedure code, for those providers who bill based on fee-for-service.

This is the set amount that’s billed to all insurance companies. The insurance company pays on the contracted rate for each procedure code. The amount the insurance company has contracted with the provider to pay is called the allowed amount. The difference between the allowed amount and the UCR is written off as a contractual discount. If the provider bills $300 and the insurance allowed amount is $100, the provider will receive $100 for that service and the rest will be written off. The patient is never responsible for the contractual discount.