health careiinsuarance and reimbursment Flashcards
What is the primary purpose of healthcare insurance?
To provide financial protection against high medical costs.
True or False: All healthcare insurance plans cover the same services.
False
Fill in the blank: The process of determining the amount of money an insurance company will pay for a claim is called _____.
reimbursement
What is a premium in healthcare insurance?
The amount paid for an insurance policy, typically on a monthly basis.
What does a deductible refer to in healthcare insurance?
The amount a policyholder must pay out-of-pocket before insurance coverage begins.
What are copayments?
Fixed amounts paid by the insured for specific services at the time of care.
What is the difference between in-network and out-of-network providers?
In-network providers have agreements with the insurance company, while out-of-network providers do not.
What is a health maintenance organization (HMO)?
A type of health insurance plan that requires members to use a network of doctors and hospitals.
True or False: PPO stands for Preferred Provider Organization.
True
What is the significance of prior authorization in healthcare insurance?
It is required approval from the insurance company before a service is provided to ensure coverage.
What does the term ‘out-of-pocket maximum’ refer to?
The maximum amount a policyholder has to pay for covered services in a policy period.
Fill in the blank: The Affordable Care Act aimed to increase ____ in healthcare insurance.
access
What does ‘coordination of benefits’ mean?
The process of determining the order in which multiple insurance policies will pay for a claim.
What is a formulary in the context of healthcare insurance?
A list of medications that are covered by a particular insurance plan.
True or False: Medicare is a federal program that provides health coverage primarily for individuals over 65.
True
What is Medicaid?
A state and federal program that provides health coverage for low-income individuals and families.
What is the role of a claims adjuster?
To investigate and evaluate insurance claims to determine the insurer’s liability.
What does ‘network’ refer to in healthcare insurance?
A group of healthcare providers that have contracted with an insurance company.
Fill in the blank: The term ____ refers to the percentage of costs the insured pays after the deductible has been met.
coinsurance
What is a waiting period in healthcare insurance?
The time period during which coverage is not available after enrollment.
True or False: Preventive services are typically covered at no cost under many insurance plans.
True
What is a balance bill?
A bill sent to the patient for the difference between what the provider charges and what the insurance pays.
What does ‘medical necessity’ mean?
Services or treatments that are appropriate and necessary for a patient’s condition.
What is the purpose of an Explanation of Benefits (EOB)?
To provide details about what services were billed, what the insurance paid, and what the patient owes.
