Health Insurance models Flashcards
What do Medicaid plans Not provide for low income families in all states
Not all Medicaid plans offer HMO options
Who do managed care organizations (MCO) provide managed cost and quality Health Care
Utilize reviews and Non-Emergency weekend admission restrictions
What is the largest healthcare program in the United States
Medicare
What is not involved in the credentialing process
Physicians request for privileges
PPACA is a federal mandate which establishes that covers can no longer be denied for what reason
Pre-existing conditions
If a provider decides not to participate in Medicare what is one of the disadvantages
The patient receives the reimbursement
A claim is denied setting the provider is not credentialed with the commercial insurance which of the following would not be an option for the practice.
Refile the claim under the credentialing provider in the group using the group number
With an HMO what are the responsibilities of the PCP
Manage the members treatment provide referrals to specialist provide referrals to inpatient admissions
When the homeowners accept liability with no-fault or liability insurance how is it billed?
Bill the homeowners first then the Medicare secondary if it is not paid within 120 days
Key provisions covered under the affordable Care act
ACA appeal
Patients have the right to appeal the health plans decisions to deny payment for a claim or treatment of healthcare
The synonym NPI stands for?
National provider identifier
A group contracts with a third party administrator to do paperwork pay operations of the insurance plan and cost of administration what plan does this represent?
Slef-Funded ERISA
NPI numbers have two types of entities what are they?
Sole proprietor and group
What type of HMO contracts with multiple specialty groups individual practice groups and individual positions?
Network model HMO
Who does Medicare provide hospital coverage and voluntary medical insurance to?
Persons aged 65 or older certain disabled individuals under age 65
What donew physicians out of medical School needed to do in order to be able to see Medicare patience and health plans?
The credentialing process
Medicare has four parts which part is responsible for paying Medicare claims?
Medicare part A
A patient presents for care does not have an insurance card and is billed CPT code 99213 for $100 the patient pays $100 to the provider a week later the patient presents verification of coverage through Medicaid for his date of service what process should be followed?
File a claim with Medicaid a refund will completed when the EOB received is showing the patient’s responsibility
A patient presents for immunization when the patient pays his bill he asks for a receipt so that he may turn it in to meet his spin down what type of covers does this patient have?
Medicaid.
Rationale the spin down program under Medicaid is for people that earn too high in income or have too many assets to qualify for regular Medicaid. Spin down a similar to a deductible.
A patient presents to his internist for a visit the patient has a Medicare HMO. To which part of the Medicare program does a patient belong to
Rationale Medicare now has four parts
Part A hospital insurance
Part B Medicare insurance for the things not covered by hospital insurance physician services medical supplies
Part C Medicare advantage plan which are private plans like HMO and PPO ran through Medicare that must at least be equivalent to regular part A and part B
Part D prescription drug coverage
What components make up Medicare physician fee schedules?
RVU relative value units for physician work practice expenses and professional liability insurance the geographical practice cost index and the conversion factor
A Medicare patient is seen in the internist’s office for a checkup the office bills Medicare the patient receives the payment and the office must collect the fee from the patient the office by State law can charge the patient a limited charge that is 10% above the Medicare fee schedule amount what type of Medicare provider is this physician
Non-participating the provider is still required to submit a claim to Medicare for services rendered all money must be collected from the patient
The patient may choose any physician she wishes and does not need a referral for the internist to see the specialist if she chooses an out of network for this and she will have to pay a higher co-insurance amount to see him what type of insurance does this patient have
PPO is a type of insurance plan that allows members to choose the doctor and hospital they want to visit from providers within the network (preferred providers) if they choose not to see a preferred provider the services are still covered but the patient will pay more out of pocket cost as the services provided by non participating providers are reimbursed at a lower rate and HMO requires a gatekeeper and referrals to see a specialist
What medical services are eligible for reimbursement for individuals that is not a citizen or does not have eligible immigration status
Emergency services
To be eligible for Medicaid one must be a US citizen or provide proof of immigration status unless applying for emergency services
What type of insurance is paid for by it employers for employees and takes advantage of purchasing power of having large member groups
Group health plan
Rationale group health plans are those purchased by employers for employees employers are able to take advantage of purchasing power of the group to allow the insurance company to reduce the rates it charges to provide insurance for each individual member of the group.
A patient presents to be seen in the office he does not pay at the time the services are rendered as the provider is a primary care provider or GateKeeper the large group practice has 800 members under his plan as is paid on a monthly basis with a set amount that is based on a number of members covered at their ages what type of plan is this
Capitation rationale competition payments are used by managed Care organizations (MCO) to control costs of healthcare putting the position at financial risk for services provided to patients payments are based on pre-person rates rather than a fee for service rate.
A new patient is seen for a visit with a participating commercial carrier CPT code 9924 is billed for $200 the contracted fee for this carrier is $153.35 the patient has a 20% co-payment after a $1,000 deductible which 500 has been met how much will the patient owe
$153.35
Rationale this is a participating physician and the contracted amount for this visit is $153.35 (“since the deductible has not been met the contracted amount will be applied towards the deductible and will be paid by the patient”)
What is important for a CPB to know regarding Medicare benefits?
Screening services require specific diagnosis to be considered for payment
Rationale screening services require specific diagnosis codes and will have frequent limits on how often the testing can be performed.
The patient has 300 members ages 0 to 1 500 members ages 2 to 4 and 2,000 members ages 5 to 20 that stay with the practice for an entire year if the practice also performs carve out services worth $20,000 how much money will they earn over the course of a year?
$290,000
Had up the monthly amounts and multiply by 12 the fees received would a total $270,000 carve out services are additional services paid on a fee for service basis so that adds to the total received in this case the total the practice would receive over the year is $290,000
A patient is age 65 Medicare eligible the patient signs up for Medicare managed care plan when the patient presents for care where are claims sent
The Manor’s care plan
Rationale when enrolling in managed Care advantage plans the patient is a member of the plan underwriting the policy and the claim is sent to the insurance company not to Medicare
ManorCare organizations (MCO)
Place of the physician at financial risk for the care of the patient how are they reimbursed?
Capitation
Rationale The physician is paid on per- patient method rather than a fee for service method
Medicare coverage is paid for low income individuals and families individual states decide the coverage benefits for their plans however some benefits are mandated by the federal government which of this is not a federal mandate.
Optometry services (the eyes 👀)
Rationale optometry services are listed as one of the 34 optional services that individual states can choose to provide and receive matching funds.
What is not one of the types of coverage that Tricare offers
(Not 🚫 Tricare premium)
(Real ) Yes Rationale :Tricare offers coverage choices for health plans Tricare premium Tricare select Tricare life Tricare reverse select Tricare retired services Tricare youth adult.
