Insurance/ Basic Knowledge Flashcards
Define Scope of Practice
Describes the procedure, actions, and process that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional training, licensure, or certificate
What is within the Medical Assistants Scope of Practice?
- Educating patients on how to take their medication
- Health promotion of the patient
- Performing an EKG
- Taking a patient’s vitals
- Performing a urinalysis and a throat culture
- Patient education
What is outside the Medical Assistants Scope of Practice?
- Diagnosing a patient
- Administering Narcotics
- Interpreting lab results
- Pathogenic identification
- Performing an Arterial Blood Gas (ABG)
Assult
Open threat of bodily harm against another person
Battery
An action that causes bodily harm
Fraud
Deception with the intent to deprive another person of his/ her rights
Invasion of Privacy
Intruding on a patient’s private affairs, or disclosure of private information
Malpractice
The negligent delivery of professional services
Negligence
The failure to do something that a reasonably prudent individual would do under similar circumstances
Spousal Abuse/ Intimate Partner Abuse
Provide a list of organizations within the local community that can assist with the situation
Tort
A civil wrong committed against a person or property
Chain of Custody
In legal context, refers to the chronological documentation showing the paper trail, custody, control, transfer, analysis, and disposition of physical or electronic evidence
Clinical Laboratory Improvement Amendments (CLIA)
Sets quality standards and issues certificates for human clinical laboratories
Health Insurance Portability and Accountability Act (HIPAA)
The right to inspect, review, and receive a copy of your medical records and billing records that are held by health plans and health care providers covered by the privacy rule
Two main purposes of HIPAA
- To provide continuous health insurance coverage for workers who lose or change their job
- To reduce the administrative burdens and cost of healthcare by standardizing the electronic transmission of administrative and financial transactions and protecting the patient’s personal medical info and confidentiality
The Joint Commission
Regulates that correctly identifying patients is crucial to improving patient safety
Occupational Safety and Health Administration
Federal agency that oversees and regulates safety in the workplace
Quality Control (QC)
Promotes accurate test results
True/ False: Always ask patients to confirm their full name and DOB
True
Implied Consent
Extending arm for phlebotomy
Informed Consent
Informing the patient of the risk, possible outcomes, and alternative therapies
Written Consent
Must have a patient’s signature to perform the procedure
Patient’s Bill of Rights
A list of guarantees for those receiving medical care
Problem Oriented Medical Record (POMR)
Should always be filled out in chronological order
Centers for Medicare and Medicaid Services (CMS-1500)
Basic standard claim form used by health care professionals to request reimbursement for services provided to patients
Encounter Form (Superbill)
An itemized for of services submitted to insurance carriers for reimbursements of rendered services
Release Information Form
Allows a patient access to his own medical records and allows the patient control over to whom those records are released
Preferred Provider Organization (PPO)
Managed care organization of providers, hospitals, and other healthcare providers who agreed with an insurer or a third-party administrator to provide health care are reduced rates to the insurer’s or administrator’s clients
Medicaid
Provides health insurance for the medically needy
Medicare
Federal insurance plan that generally covers those over the age of 65
Tricare
Healthcare for military personnel and their dependents to receive care from civilian providers at the expense of the federal government
Workers’ Compensation
Wage replacement and medical benefits for those injured on the job
Advance Beneficiary Notice (ABN)
Waiver of liability is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service
Coinsurance
An amount a policyholder is financially responsible for according to their insurance policy
Copay
A specified sum of money based on the patient’s insurance policy benefits due at the time of service
Deductible
Specific amounts of money a patient must pay out-of-pocket before the insurance carrier begins paying for services in a calendar year
Explanation of Benefits (EOB)
A statement detailing what services were paid, denied, or reduced in payment by the patient’s insurance company
Preauthorization
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary
Precertification
The process of obtaining eligibility, certification, or authorization and collecting information from the health plan prior to inpatient admissions and selected ambulatory procedures and services
Referral
The process of directing or redirecting to a medical specialist or agency for definitive treatment
Verification of Eligibility
Important to confirm how a patient will pay for services
Diagnosis Code
Medical necessity
CPT
Current Procedural Terminology (5-digit code)
International Classification of Diseases (ICD)
Each diagnostic and procedural code allows for submission of services for reimbursement from insurance companies and to provide statistical data for research studies
What does the first character mean for ICD Coding?
Main term when searching in the alphabetical index
What does the second and third character mean for ICD Coding?
Numeric Codes
What does the fourth, fifth, sixth, or seventh character mean for ICD Coding?
Being either alphabetical or numeric
Modifier
Indicates one procedure was used multiple times on a patient
Advance Booking
Making an appointment for a patient in advance
What does clustering mean in terms of scheduling?
Seeing patients on the same day at the same time
Double Booking
2 patients are given the same appointment time
How do you deal with Hard of Hearing or Deaf Patients?
Get an interpreter
How to deal with a Late Provider?
Offer to reschedule a patient’s appointment if the provider is late
New Patient (NP)
A patient who has not been seen by the provider before r who has not been seen in 3+ years is considered a new patient for coding and billing purposes
No Show (NS)
Patients who have missed their scheduled appointment
How do you schedule tests?
Schedule the least invasive test first if a patient is having multiple tests
Wave Scheduling
3 or 4 patients are scheduled every half hour and are seen in the order in which they arrive at the office
