Medical Insurance and Billing Flashcards
What are health care claims used for?
For reimbursement for services
What does the medical assistant for medical insurance/billing? (6)
- prepare claims
- review insurance coverage
- explain fees
- estimate changes
- understand payment explanation
- calculate the patient’s financial responsibility
What is the first party for an insurance contract?
the patient
What is the second party for an insurance contract?
health care provider
What is the third party for an insurance contract?
health plan/health insurance
What is a deductible?
An amount of money a patient must pay out of pocket before insurance begins paying
What is a coinsurance?
the policyholder and the insurance company share the cost of services; 80:20
What is a copayment?
amount of money paid at the time of service. Set by insurance company
What is the assignment of benefits?
Form signed by the patient to allow the provider to be paid directly by the insurance company
What is the participating provider?
Providers that agree to write off the difference b/w the amount changed and the allowed amount by the insurance company
What is the allowed amount?
The maximum amount the insurance company will pay for a service or product
What is the advanced beneficiary notice (ABN)?
Form provided to patient when the provider believes Medicare will not cover services
- patient would then be responsible for payment
What is the explanation of benefits (EOB)?
Statement from insurance company to patient outlining amounts billed, amounts allowed, amounts applied to deductible, coinsurance, and copays
- also outlines what insurance will be paying to provider on patient’s behalf
What is the preauthorization (precertification)?
Process of contacting the insurance plan to see if a procedure is a covered service under the patient’s insurance plan
What does the medicare cover?
Covers patients 65 and over
What are the 4 parts of medicare?
Medicare Part A - hospitalization
Medicare Part B - routine medical office services and outpatient services
Medicare Part C - Optional additional coverage
Medicare Part D - medications/drugs
What does medicaid cover?
covers low income and mentally indigent
What does Tricare covers?
Covers military personnel and dependants
What does the CHAMPVA covers?
Covers surviving spouses and dependent children of veterans who have died as a result of service related disabilities
What does the Children’s Health Insurance Program (CHIP) provide?
Provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid
What does workers compensation covers?
Covers workers against lost wages due to accidents on the job
- patient does not pay any fees
What is the managed care health plans?
Plans that provide healthcare for payments
- uses participating providers
What is the HMO health plan?
Contracts with providers and hospitals to provide preventative and acute care
- costs less than PPO
- requires referrals to specialists
- requires precertification and preauthorizaton
- requires PCP (primary care provider)
What is the PPO health care plan?
More flexible than HMO
- no referrals needed
- In network providers (cost less)
- out of network providers
What is capitation?
Patients are assigned a per member per month payment based on age, race, sex, lifestyle, medical history
- payments are tied to expected usage of services
What is the pay-for-performance?
- Compensates providers only if certain measures are met for quality and efficiency
What is the fee-for-service?
- Amount charged for services is controlled by the physician
- Amount paid for services is controlled by the insurance carried
- Policy lists covered medical services
What is the birthday rule of coordination of benefits?
The insurance plan of the person born earliest in the year becomes the primary payer
What does the coordination of benefits prevent?
Prevents the duplication of payment
What is the CMS-1500 Form?
The electronic claim form for insurance companies for payment
What does the CMS Form require?
requires the use of procedural and diagnostic codes
What direct billing?
Insurance carrier allows providers to submit claims directly to carrier electronically
What is clearinghouse?
- Allowing providers to submit all insurance claims at one time through software
- audits and sorts claims
- Sends correct invoicing to correct insurance company
What is the account balance?
Total balance on account
debit - negative
credit - positive
What is the accounts receivable (A/R)?
money owed to the provider for services rendered
What is the accounts payable (A/P)?
debt incurred by not paid; supplies or utilities
What is a guarantor?
Person with financial responsibility for the patient
