Insurance Flashcards
What percentage does healthcare make up in the GDP?
16%
What is Health Insurance?
A contract between a patient and insurance carrier.
What is an Insurance Carrier?
A company which provides insurance plans which protect the patient against financial loss when in need of health service.
When was health insurance developed?
1920s
What agreement maybe held between an insurance carrier and patient?
If the patient is in need of a health service the insurance carrier will pay a portion of the cost including treating patients with illness, injuries, testing, routine exams, and medications.
How can you enter an insurance contract?
The patient must pay a premium which is like a membership fee to be enrolled in an insurance plan. Usually paid on a monthly basis.
What is the patient entering the contract called?
The Insured
If the members are under the same policy, they are called ________ and the insured must pay higher premiums and deductibles.
The Beneficiaries
Patient must pay this themselves_____
out-of-pocket
Out-of-Pocket can include:
Deductibles
Exclusions (Copayment)
Coinsurance
What is a deductible?
A fixed amount of money the patient must pay before the insurance carrier begins to pay for the benefits. This must be paid yearly.
What is coinsurance?
A fixed insurance that takes responsibility for 80 percent of the cost and the patient pays 20 percent.
What is copayment?
The fee collected at the time of service. This will always remain the same unlike coinsurance.
What is Group Insurance and how is it purchased?
Group insurance is commonly purchased through an employer and the employer pays a portion of the premium. Group Insurance is almost always less cheaper than individual insurance.
What is individual insurance and how is it purchased?
Individual Insurance is when a person purchases a policy and agrees to pay the entire premium for health coverage, while this is the more expensive option this allows more choices in the type of benefits a person gets. Patients can purchase the best coverage suitable for their needs.
What is the Affordable Care Act and how can it impact people?
The Affordable Care Act has opened up more options for individuals to purchase individual insurance through a healthcare marketplace at an affordable price.
If an individual is enrolled in an insurance plan through a benefits package at work, what kind of enrollment is this?
Group Insurance
What is one advantage of individual enrollment over group enrollment in an insurance plan?
More choice of policies
What are the types of funding’s?
Private and Public
Private Insurance
- Private funding comes from enrollees, those who are enrolled in the insurance plan.
- Anyone can enroll in a privately funded program.
- Costs and Coverage will vary widely
- Two types of insurance: Fee-for-service and Managed care.
Public Insurance
- Public funding comes from state to federal governments
- To enroll in public programs, a person will have to meet certain restrictions. These restrictions vary depending on the type of program.
Fee-for-service
Maybe referred as an indemnity pIan or traditional insurance. In early years of health insurance, most policies were fee-for-service plans where patients often pay healthcare costs out-of-pocket. Then they are reimbursed by the carrier for their expenses.
Managed care
Some people cannot afford out-of-pocket and wait for reimbursement, as a result a new type of medical insurance became popular in the 1970s. Managed care is built onto two concepts: to promote good health and to practice preventative medicine.
HMO model that hires physicians directly.
Staff Model
HMO model that utilizes fee-for-service reimbursement instead of capitation.
Exclusive Provider Organization (EPOs)
HMO model that all network physicians practice in the same facility.
Group Model
Why do managed care plans require patients to obtain referrals before visits specialists?
To support medical necessity of the visit
Why does the quality of managed care sometimes come into question?
Its focus on cost-cutting may restrict treatment options.
Which of the following is true of Workers’ Compensation insurance?
It is a legally mandated right.
Who pays the premiums for Workers’ Compensation Insurance?
Employers
Workers’ Compensation Includes:
- Medical Expenses
- Disability Pay
- Vocational Rehabilitation
- Death Benefits
Families of employees killed on the job are eligible to receive benefits.
True
What is vocational rehabilitation?
Job training for people unable to work in their former line of employment.
To Whom must the employer immediately report all Workers’ Compensation incidents?
Company’s Workers Compensation Insurance Agent
When seeking treatment in a Workers’ Compensation case, an employee may choose any healthcare provider.
False
Which of the following indicates temporary disability?
The patient can return to work after recovery.
Which of the following is “medical treatment” only?
The patient can return to work while in recovery.
Which of the following indicates a permanent disability?
The pt. can never work in the same line of employment.
Workers Compensation Form or Claim Form
CMS-1500 (02-12)
What must the first form be filed by a healthcare provider in response to a Workers’ Compensation Case?
First Report of Injury or Illness
What is TRICARE?
Tricare is a health insurance program for military personnel, and was formerly called the Civilian Health and Medical Program for Uniformed Service.
What does TRICARE cover?
- Active and retired military personnel and their families
- Surviving spouses and dependents of military personnel
- Spouses and dependents of military retirees.
Eligible for TRICARE?
Person must be listed in the Department of Defense’s Defense Enrollment Eligibility Reporting Systems (DEERS)
Three form of TRICARE
- TRICARE Standard
- TRICARE Extra
- TRICARE Prime
TRICARE Standard
fee-for-service program providing the most options and convenient for receiving medical service nationwide.
TRICARE Extra
PPO Plan and patient chooses Primary Care Physician from the TRICARE Provider Directory and Co-Pay is lower than TRICARE Standard.
TRICARE Prime
HMO Plan Primary Care Manager (PCM) is assigned and the PCM must refer patient to any specialists for visits.
What is CHAMPVA?
Civilian Health and Medical Program of Veteran’s Administration for disabled veterans and dependents. (cannot be eligible for both CHAMPVA and TRICARE)
CHAMPVA covers:
- veterans with permanent, total disabilities related to service
- Spouses and dependents of veterans with permanent, total disabilities related to service
- Surviving spouses and dependents of veterans who died of such a disability
Which of the following definitions best describes a fiscal intermediary (FI)?
A company contracted to process Medicaid insurance claims
How is Medicare funded?
Through government tax dollars
Who pays the premiums for Workers’ Compensation insurance?
Employers
Which of the following versions of TRICARE is a Health Maintenance Organization?
TRICARE Prime
How often must the medical office assistant confirm a patient’s Medicaid eligibility?
Every visit
Which of the following is true of Workers’ Compensation insurance?
It is a legally mandated right.
Who processes Medicaid claims?
Each state government
Terry is a data entry specialist and works typing data into a computer. Last week, he tripped on the stairs inside his office and broke his right arm AND his left wrist. While he cannot currently work, he is expected to make a full recovery within 6-8 weeks. What level of Workers’ Compensation disability is this?
Temporary, total disability
If a patient is diagnosed with a fractured ankle, which of the following terms should be used as a main term?
Fracture
What kind of central modifiers in diagnostic coding be used for?
Specify the location of an injury, specify the type of illness, specify the cause of an illness or injury, all of the above.
