Insurance

Question 1

What are the two different types of health insurance

Answer 1

commercial and government

Question 2

What are the features of commercial group health insurance

Answer 2

employer chooses plan, employee gets a discount and has to pay a premium for coverage
to qualify: work for someone, be a full time employee, pass a 90d “probationary period”

Question 3

What are the features of commercial individual health insurance

Answer 3

covers an individual or family, no discount (usually more expensive)
pro: have the freedom to choose ANY insurance company, plan, and options that fit your needs

Question 4

What is an HPO

Answer 4

Heath maintenance organization, type of commercial health insurance plan
access to drs/HCPs within network (providers that have agreed to decrease their rates but maintain quality)
cost= less expensive (copay, premium, deductible, max OOP)
need a referral from your PCP/internist to see a specialist in-network
No need to file any claims

Question 5

What is a PPO

Answer 5

Preferred provider organization
can go out of network for care
higher premiums and deductibles
no referrals necessary
may need to file claims

Question 6

What is a premium

Answer 6

what you pay out of pocket each pay period to have the insurance
think of this like a Netflix subscription

Question 7

What is a deductible

Answer 7

what you pay out of pocket BEFORE your insurance kicks in
annual; resets each year

Question 8

What is a copay

Answer 8

what you need to pay after EACH visit to the doctor

Question 9

What is an out of pocket limit

Answer 9

the most money you’ll spend in a calendar yr

Question 10

What is co-insurance

Answer 10

shared pay between you and the insurance company (ex: 50/50)
kicks in once you hit your deductible but not your OOP max

Question 11

What is a CPT code

Answer 11

procedural code (96040 for GC; for first 30min then q15min after?)

Question 12

What is an ICD-10 code

Answer 12

dx code

Question 13

What is pre-authorization

Answer 13

decision by heath insurer or plan that a health care service, tx plan, prescription drug, or durable medical equipment is medically necessary
point is to see if it will be covered or pt will have to pay but does NOT give specific amount and can still be denied

Question 14

Who gets medicare

Answer 14

ppl over 65, those with a disability

Question 15

Describe part A of Medicare

Answer 15

hospital coverage, home healthcare, hospice

once you work a minimum of 10yrs, you have zero premium for part A- automatically qualified @65 but will have to pay a deductible

Question 16

Describe part B of Medicare

Answer 16

doctor fees, outpatient testing, and labs

DO need to pay for premium and sign up for. Doesn’t cover everything you need- need to pay 20% co-insurance for drs, testing, labs, NO OOP MAX (payment for this comes from our taxes)

Question 17

Who sets the prices for doctors and hospital visits for those on Medicare

Answer 17

centers for medicaid and medicare services
fee for services, no prior auths, no referrals
almost all drs take it, allows for flexibility since you don’t need “extra” to refer out or order tests

Question 18

What is Medicare part C? What else is it called?

Answer 18

Medicare advantage
hospital, doctor, outpatient, dental, vision, hearing, and prescription coverage (mostly); comes from a commercial insurance (UHC, BCBS, Humana, Anthem, Cigna)
premiums are extremely low or no cost
government pays a fixed amount to the heath insurance companies dependent on several different factors
fee for services, capitated payments (almost all are HMO plans OR narrow network PPO (bc medicare only pays 95-105% of costs)
NEED prior auths

Question 19

What are capitated payments

Answer 19

Medicare pays a fixed amount to providers based on the # of pts they have or see

Question 20

What is Medicare part D

Answer 20

sign up only if you’re apart of traditional Medicare (60% of ppl w Medicare)
low to no premiums
is tiered, copays exist, donut holes (may not receive a copay for a while (ex: 10 visits) and then have to pay them all at once
prior auth is required for meds

Question 21

What is considered traditional Medicare

Answer 21

Medicare part A and B

Question 22

What percentage of people on Medicare have Medicare part C

Answer 22

40% are on Medicare Advantage

Question 23

What is considered a disability under Medicare

Answer 23

any condition that prevents you from working more than 1yr
DS, HD, CF, ESRD, ALS

Question 24

What genetic testing is covered under Medicare

Answer 24

will typically only cover cancer genetic testing for ppl WITH a current cancer dx who meets clinical criteria (think NCCN) AND a FH of cancer/AJ ancestry

If there is little to no FH, have to have a cancer suspicious for BRCA
Can also have multigene panel testing if pt has pre/post test GCing, will help w tx, and genes included are relevant based on personal/FH in addition to above requirements

Lynch testing has to start w tumor biomarker testing; testing is only covered for ppl w a Lynch-associated cancer AND a blood relative w a known Lynch PV

Question 25

Who is qualified for Medicaid

Answer 25

for low-income individuals and families, based on income level and family size

Question 26

What does Medicaid cover/not cover

Answer 26

state funded (jointly funded by the state and federal government)
covers “essential health services”- varies by state
state may choose to contract w corporations to administer the plans (think Medicare Advantage) or the state may choose to administer the plan themself

multigene panels are covered by MOST states
prior auth forms may be required
GCing IS covered by Medicaid (NIPS can be covered but NOT for microdel/dup syndromes)

Question 27

What is balanced billing

Answer 27

insurance may not cover the total cost of a tx or test ordered; physician or hospital may bill you for the difference between the amt your insurance pays them and the total amt
hospitals and labs that accept Medicare and Medicaid are typically not allowed to balance bill pts for services covered by Medicare/Medicaid, even if the services were not 100% covered

Question 28

Define a cost estimator/benefits investigation and its utility

Answer 28

provide an estimate of the pt’s out of pocket cost based on their insurance plan

Question 29

define COBRA

Answer 29

consolidated omnibus budget reconciliation act
Group health plans must provide a temporary continuation of coverage when it would be lost due to specific events such as employment termination
18mo coverage

Question 30

Define a health savings account

Answer 30

money set aside that comes out of paycheck before tax and can only be used on medical expenses (excluding insurance premiums)
typically only people w high deductible health plans are eligible

Question 31

Define back billing

Answer 31

Billing a patient for additional charges long after the visit is complete

Question 32

Define cost sharing

Answer 32

Costs of healthcare are shared between the patient and insurance company. Incentive for patients to be cautious with healthcare utilization.

Question 33

Define risk adjustment

Answer 33

Predict a persons likely use and costs of healthcare services. Used in Medicare advantage to adjust the capitated payments to cover expected medical costs of enrollees. This helps to ensure a plans contracted providers Don’t avoid sicker and more costly patients.

Question 34

What is the purpose of HCPCS coding?

Answer 34

The healthcare common procedure coding system is used to bill for products supplies and services not included in CPT coding. This is mainly used in Medicare.

Question 35

What is chip insurance used for?

Answer 35

Children in all states and pregnant women in some states

Question 36

Define up coding

Answer 36

Medical fraud. Billing for more than the actual services provided.

Question 37

Define insurance churning

Answer 37

When a person undergoes multiple changes in insurance coverage in a short period of time. Leads to discontinuity of care, gaps in coverage can be due to changes in income and employment common for individuals with low income.

Question 38

Define unbundling

Answer 38

Dividing each genetic test that you are ordering more than you would expect in order to increase reimbursement through the lab

Question 39

Define WIC

Answer 39

Women, infants, and children
Federal grants two states for food, healthcare, referrals, and nutrition education for low income, pregnant breast-feeding and non-breast-feeding postpartum women into infants and children up to age 5 years old

Question 40

Define snap

Answer 40

Supplemental nutrition assistance program
Previously known as food stamps provides benefits to eligible low income, individuals, and families via an EBT card