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insurance and billing Flashcards

1
Q

insurance

A

is something that is purchased to help to protect against loss or harm from specified circumstances
protects you Financial Loss”

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2
Q

policy

A

legal contract and will stay in force as long as the premium is being paid

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3
Q

group policy

A

an employer can pick and choose the benefits it wants for employers such as a vision of dental coverage

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4
Q

premium

A

periodic payment for the insurance policy; can be paid by an individual,
employer, or combination of the employer and individual.
○ “Keeps the insurance enforced/active”

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5
Q

HMO*

A

health maintence organization one health plans that are regulated by “hmolaws managed healthcare”

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6
Q

capitation*

A

a payment arrangement for healthcare providers is paid as a set amount for each enrolled person assigned to them per period of time, whether or not that person has received services

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7
Q

beneficiary

A

a designated person who receives finals from an insurance policy

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8
Q

network( stay)

A

stay in your network
connect between providers designated group

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9
Q

out of network

A

STAY IN YOUR NETWORK
Any doctor, hospital, or other provider of medical services that has not
set up special rates with your insurance company
Insurance coverage may not be possible if a patient goes out of network

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10
Q

participating provider

A

IS A HEALTHCARE PROVIDER WHO SIGNED A CONTRACT WITH AN INSURANCE COMPANY MANAGED CARE PLAN,OR A GOVERMENT HEALTH PLAN TO PROVIDE SERVICES TO POLICY HOLDRERS

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11
Q

Utilization review

A

helps determine if healthcare services are being used efficiently and appropriately to provide patients with the care they need

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12
Q

allowed charge

A

depends on a pt health insurance policy. typically the pt financial responsibilities represent on average 20%-25%

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13
Q

gate keeper

A

THE PRIMARY

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14
Q

referral

A

an order from a primary care provider for the pt to see a specialist or get certain medical service

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15
Q

claim

A

a request for reimbursement from the insurance company for services provided

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16
Q

EOB ( explaining how your bill is gonna be paid)

A

a document sent 6x the insurance company to the providers and the patients explaining the allowed change amount the amount reimbursed for services and the patient financial responsibilities

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17
Q

indigent
A ppd
B. financially needy
C. HOB

A

financially needy

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18
Q

personal insurance

A

insurance of human life values against the risks of the death injury illness or against expenses incidental to the latter

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19
Q

commercial insurance

A

a type of lability coverage purchased by companies

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20
Q

Medicaid

A

low income

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21
Q

medicance

A

age 65 and older or people with disabilities.
Anyone who turns 65yrs, the patient automatically gets Medicare
People who are legally blind, have end-stage renal failure or certain disabilities
can get Medicare early before 65yrs old
CARE for the elderly

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22
Q

A
B
C
D

A

A- COVERS INPATIENT HOSPTIAL
B- COVERS ABULATORY CARE
C -TURNS PLAN A AND PART B INTO A PRIVATE PLAN ( manage healthcare plan under medicare)
D- PRESCRPTION DRUG PROGRAM

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23
Q

CO-PAYMENT

A

a set dollar amount that the policyholder must pay for each office visit

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24
Q

co-insurance*

A

also called co pay a set dollar anount that the policyholder must pay for each office visit

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25
deductible*
a set dollar amount of the policy holder must before the insurance company starts to pay services
26
vtlization managment
a decision making process used by managed care organizations to manage healthcare costs it provides case by case assessments of the appropriateness of care
27
mediacy necessary
are those that are necessary to improve the pt current health " justification for payment"
28
tricane
is a program for active duty and retried members of the uniform services
29
what is always verified
at time appointment is made insurance,dob,full name
30
gatekeeper
the primary care providers pcp who is in charge of patient treatment
31
who pays after Medicaid
nobody pays it
32
what are other managed healthcare plans besides EPO and PPO
preffered provider EPO exclusive provider
33
pcp
patient primary care giver
34
health insurance exchange an online marketplace where you can compare and buy indivual health insurance plans
It’s an online marketplace that provides a website to chat with others to help find an insurance plan.
35
what are amb's qualified Medicare beneficiaries
low income Medicare pt who also qualify for Medicaid for their secondary insurance
36
Long Term Care Insurance
New type of insurance that covers a broad range of maintenance and health services for chronically ill, disabled, or developmentally delayed individuals.
37
responsibilites
referrals to a specialist
38
preauthorization
process that requires* the provider to submit documentation to* the payer to show the service/treatment is medically needed payer determines services*/treatment is a medically necessary
39
Gatekeeper Responsibilities?
Patient’s Primary Care Provider (PCP) ○ Referrals to a specialist
40
what does precertification determine?
Insurance determines how much they will pay for a procedure once the insurance pays for a procedure.
41
VA Healthcare?
○ The Veterans Health Administration (VHA) ○ Insurance for the current or previous Reserves and National Guard.
42
What are other managed healthcare plans besides HMO?
○ Preferred Provider Organization (PPO) ■ More flexibility, pay may be higher ○ Exclusive Provider Organization (EPO) ■ Limited and cheaper
43
Workers Compensation - employees who are injured or become ill from work-related issues.
○ coverage for only work-related injuries ○ workplace will pay for the injury ○ workplace will not pay for injury that is related to breaking facility safety guidelines
44
Medi Gap
○ Insurance that the patient can purchase ○ Patient pays the 20% Medicare Supplement Insurance that covers the payment “gaps” in Medicare for a person.
45
Participating Provider - when a provider accepts the patient’s insurance
Can be government-related or private
46
Health Maintenance Organization (HMO) - a health plan that is regulated by HMO laws.
○ “Managed Healthcare” ○ Patient has limited choices/flexibility ○ Insurance company tells where the patient will go for appointments and procedures
47
what is the part A of a medicare type?
covers inpatient, hospital charges
48
what is the part B of medicare type?
covers ambulatory care ○ patient has to pay for Part B ○ also known as outpatient care ○ Part B covers medical equitment (wheelchairs, walkers, glucometers etc) ○ (doctor office visits, labs, x-rays)
49
what is the part C of the medicare type? Private
turns Part A and Part B into a private plan ○ also known as the managed healthcare plan (HMO) under medicare. ○ 80/20
50
what is the part D of the medicare type?
prescription drug program ○ (medications)
51
What is ALWAYS verified at the time the appointment is made?
○ Insurance, DOB, Full Name ○ Ask the patient’s effective date on their insurance card ○ Check pt for eligibility ○ Insurance benefits
52
what does phi stand for
protected health info
53
demographic information is
subjective
54
Copayment should be pay after service true or false
True
55
What part of medicare is the hmo plan
C!
56
the purpose of diagnostic coding?
it shows medical necessity and supports recumbent request
57
what does CM mean?
clinical MODIFICATION
58
Which of the following represents an important way to maintain the security and integrity of an EHR? A password secured sign-on credential for each user in a facility B. Limited access to anyone but the physician providers C. Single sign-on credentials for the practice office team D. Keeping the data entry device or computer out of sight of patients E. None of the above
password secured sign-on credential for each user in a facility
59
When revising the policies and procedures manual, the medical assistant needs to FIRST А. talk to fellow employees B. chose a color for the manual C. decide on a format D. buy paper for the manual E. talk to the health care provider
talk to the health care provider
60
What is cycle billing
a system that sends invoices to groups of patients every few days,

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