Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

MA STUDY > insurance and billing > Flashcards

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”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

policy

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

group policy

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

HMO*

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

beneficiary

A

a designated person who receives finals from an insurance policy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

network( stay)

A

stay in your network
connect between providers designated group

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Utilization review

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

allowed charge

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

gate keeper

A

THE PRIMARY

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

referral

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

claim

A

a request for reimbursement from the insurance company for services provided

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

indigent
A ppd
B. financially needy
C. HOB

A

financially needy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

commercial insurance

A

a type of lability coverage purchased by companies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Medicaid

A

low income

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

CO-PAYMENT

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

co-insurance*

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

deductible*

A

a set dollar amount of the policy holder must before the insurance company starts to pay services

26
Q

vtlization managment

A

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
Q

mediacy necessary

A

are those that are necessary to improve the pt current health “ justification for payment”

28
Q

tricane

A

is a program for active duty and retried members of the uniform services

29
Q

what is always verified

A

at time appointment is made insurance,dob,full name

30
Q

gatekeeper

A

the primary care providers pcp who is in charge of patient treatment

31
Q

who pays after Medicaid

A

nobody pays it

32
Q

what are other managed healthcare plans besides EPO and PPO

A

preffered provider EPO exclusive provider

33
Q

pcp

A

patient primary care giver

34
Q

health insurance exchange an online marketplace where you can compare and buy indivual health insurance plans

A

It’s an online marketplace that provides a website to chat with others to help find
an insurance plan.

35
Q

what are amb’s qualified Medicare beneficiaries

A

low income Medicare pt who also qualify for Medicaid for their secondary insurance

36
Q

Long Term Care Insurance

A

New type of insurance that covers a broad range of maintenance and health
services for chronically ill, disabled, or developmentally delayed individuals.

37
Q

responsibilites

A

referrals to a specialist

38
Q

preauthorization

A

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
Q

Gatekeeper Responsibilities?

A

Patient’s Primary Care Provider (PCP)
○ Referrals to a specialist

40
Q

what does precertification determine?

A

Insurance determines how much they will pay for a procedure once the insurance
pays for a procedure.

41
Q

VA Healthcare?

A

○ The Veterans Health Administration (VHA)
○ Insurance for the current or previous Reserves and National Guard.

42
Q

What are other managed healthcare plans besides HMO?

A

○ Preferred Provider Organization (PPO)
■ More flexibility, pay may be higher
○ Exclusive Provider Organization (EPO)
■ Limited and cheaper

43
Q

Workers Compensation - employees who are injured or become ill from work-related
issues.

A

○ 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
Q

Medi Gap

A

○ Insurance that the patient can purchase
○ Patient pays the 20%
Medicare Supplement Insurance that covers the payment “gaps” in Medicare for
a person.

45
Q

Participating Provider - when a provider accepts the patient’s insurance

A

Can be government-related or private

46
Q

Health Maintenance Organization (HMO) - a health plan that is regulated by HMO
laws.

A

○ “Managed Healthcare”
○ Patient has limited choices/flexibility
○ Insurance company tells where the patient will go for appointments and
procedures

47
Q

what is the part A of a medicare type?

A

covers inpatient, hospital charges

48
Q

what is the part B of medicare type?

A

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
Q

what is the part C of the medicare type? Private

A

turns Part A and Part B into a private plan
○ also known as the managed healthcare plan (HMO) under medicare.
○ 80/20

50
Q

what is the part D of the medicare type?

A

prescription drug program
○ (medications)

51
Q

What is ALWAYS verified at the time the appointment is made?

A

○ Insurance, DOB, Full Name
○ Ask the patient’s effective date on their insurance card
○ Check pt for eligibility
○ Insurance benefits

52
Q

what does phi stand for

A

protected health info

53
Q

demographic information is

A

subjective

54
Q

Copayment should be pay after service true or false

A

True

55
Q

What part of medicare is the hmo plan

A

C!

56
Q

the purpose of diagnostic coding?

A

it shows medical necessity and supports recumbent request

57
Q

what does CM mean?

A

clinical MODIFICATION

58
Q

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

A

password secured sign-on credential for each user in a facility

59
Q

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

A

talk to the health care provider

60
Q

What is cycle billing

A

a system that sends invoices to groups of patients every few days,

MA STUDY (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions