Insurance Flashcards
When did group health insurance become a commonly accepted employment benefit?
After World War II
Does Medicare cover all health care expenses?
No
All claims in the United States will eventually be filed…
Eectronically
A small fee paid at the time of service
Co-pay
Expenses not covered by an insurance company
Exclusions
Is it the responsibility of the MA to interpret the pt’s insurance policy or extent of coverage?
No
Some insurers will not pay a claim unless it is filed within how long?
Within 6 months from date of service
Originally developed by congress to pay medical insurance claims under Medicare
The concept of usual, customary, and reasonable fees (UCR)
Most common insurance claim form
The Health Care Financing Administration (HCFA)
Should you fold the HCFA-1500 form for OCR before mailing?
No
Is disability insurance less expensive than life, home, or automobile insurance?
No
Federally aided program for medical care for certain low income idviduals
Medicaid
Older or disabled pts who have Medicare and cannot pay the difference between the bill and the Medicare payment qualify for…
Medi/Medi
Is blue cross/blue shield one large corporation?
No
What benefit policy provides payment in full for all covered services?
Blue cross/blue shield
Do medical practices have to cover worker’s comp cases?
No
Does a patient belonging to an HMO need pre-approval or with for inpatient surgery from the pcp or HMO?
Yes
Does Medicare encourage claims to be filed electronically to save time?
Yes
When did the first insurance plans begin?
During the civil war
First type of insurance created
Accident insurance
The first health insurance was created to cover…
Lost income because of disability
When did the first group policy giving comprehensive benefits emerge?
1847
The prepaid concept became the foundation for what insurance?
Blue cross
Who’s goal was to make health insurance accessible to as many people as possible?
Blue cross/blue shield
The first modern group health insurance became an employment benefit because…
A group of school teachers in Dallas joined forces and requested it
The first national health insurance for Americans age 65 and older
Medicare
The underlying principle of all types of insurance
The law or probability
Term meaning that the insured pays or shares part of the medical bill with the insurance company, usually according to a fixed percentage
Co-insurance
Term referring to the amount required to be paid
Deductible
Many pts carry supplemental medical coverage which is also…
Major medical insurance
Is there a deductible is part a Medicare?
Yes
Participation in the plan is voluntary, a monthly premium must be paid, the pt must pay a deductible are all true statements for which part of Medicare?
Part b
Is the beneficiary’s address recorded on the ID card?
No
Are routine physical exams and prescriptions for eyeglasses and hearing aids covered in Medicare part b?
No
The most common reason for Medicare claim forms being rejected
Incomplete information and errors
The federal government participated in a plan for the indigent known as…
Medicaid
A program of medical care for the needy provided by the title XIX of the social security amendment of 1965
Medicaid
Are the following true of blue cross/blue shield?
- pay no benefits
- operate at a continual loss
- are considered as charitable institutions
No
Under a law passed in 1956, who provides medical and hospital care for all dependents of members of the armed services on active duty, all retired military personnel and their dependents, and members of the coastguard?
Tricare formerly champus
At what age does the tricare beneficiary lose eligibility?
65
Is it automatic to lose tricare benefits at age 65?
Yes
An insurance contract written for a company for its employees
Group coverage
A pt 68yo is most likely covered by what insurance?
Medicare
Medicare pays what percent?
80
To establish eligibility for Medicaid you must check…
Current ID, policy number, and ssn
Persons who are unable to pay for medical care or who have dependent children may apply for…
Medicaid
What kind of insurance provided medical care for job related accidents or illness?
Workers comp
What type of insurance provides income when the insured is unable to work due to illness or injury?
Disability
The physician or supplier giving medical care or services
Provider
Person who carries the medical insurance
Subscriber
The word indicating the date medical insurance coverage begins
Effective
Insurance that provides weekly or monthly cash benefits to employed policy holders who become unable to work because of accident or illness
Loss of income protection
Catastrophic coverage is referred to as…
Major medical insurance
Hospital insurance in included in which part of Medicare?
A
Blue shield makes direct payments to…
Physician members
A bed patient in a hospital who is entitled to Medicare benefits is covered for up to…
90 hospital days for each benefits period
Witching 48 hrs after a physician has seen a workmans company pt for the first time, the report is typed in…
Quadruplicate
A bill is never sent to the pt in which type of case
Worker’s comp
The amount charged for a medical insurance policy
Premium
Non-duplication of benefits is also known as…
Coordination of benefits
Blue cross offers which method of reimbursement?
Fee for service
In most cases, the insurer pays an annual cost or what for health care insurance?
Premium
A fixed dollar amount the subscriber must pay or “meet” each year before the insurer begins to cover expenses
Deductible
A small fee at the time of service that some medical practices may require the subscriber to pay
Co-pay
The Physicians’ Current Procedural Terminology (CPT) manual provides…
Procedure and diagnosis codes
In a typical medical practice, insurance claims are filed…
7 to 10 business days from the date of service
The most likely outcome of a submitted insurance claim with a diagnosis code of a sore throat and a treatment code indicating a cast for a broken leg would be…
Denied as a billing error because the treatment was not medically necessary based on diagnosis
When an insurance claims department compared the fee the doctor charges with the benefits provided by the pt’s health insurance
Review for allowable benefits
What the pt owes after the insurance company has paid
Subscriber liability
The most appropriate response from an MA when a patient calls the medical practice questioning why an insurance claim was rejected
Check the explanation of benefits form
The average fee a physician charged for a service or procedure
Usual fee
