Medical Insurance and Billing

Question 1

What are health care claims used for?

Answer 1

For reimbursement for services

Question 2

What does the medical assistant for medical insurance/billing? (6)

Answer 2

• prepare claims
• review insurance coverage
• explain fees
• estimate changes
• understand payment explanation
• calculate the patient’s financial responsibility

Question 3

What is the first party for an insurance contract?

Answer 3

the patient

Question 4

What is the second party for an insurance contract?

Answer 4

health care provider

Question 5

What is the third party for an insurance contract?

Answer 5

health plan/health insurance

Question 6

What is a deductible?

Answer 6

An amount of money a patient must pay out of pocket before insurance begins paying

Question 7

What is a coinsurance?

Answer 7

the policyholder and the insurance company share the cost of services; 80:20

Question 8

What is a copayment?

Answer 8

amount of money paid at the time of service. Set by insurance company

Question 9

What is the assignment of benefits?

Answer 9

Form signed by the patient to allow the provider to be paid directly by the insurance company

Question 10

What is the participating provider?

Answer 10

Providers that agree to write off the difference b/w the amount changed and the allowed amount by the insurance company

Question 11

What is the allowed amount?

Answer 11

The maximum amount the insurance company will pay for a service or product

Question 12

What is the advanced beneficiary notice (ABN)?

Answer 12

Form provided to patient when the provider believes Medicare will not cover services

• patient would then be responsible for payment

Question 13

What is the explanation of benefits (EOB)?

Answer 13

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

Question 14

What is the preauthorization (precertification)?

Answer 14

Process of contacting the insurance plan to see if a procedure is a covered service under the patient’s insurance plan

Question 15

What does the medicare cover?

Answer 15

Covers patients 65 and over

Question 16

What are the 4 parts of medicare?

Answer 16

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

Question 17

What does medicaid cover?

Answer 17

covers low income and mentally indigent

Question 18

What does Tricare covers?

Answer 18

Covers military personnel and dependants

Question 19

What does the CHAMPVA covers?

Answer 19

Covers surviving spouses and dependent children of veterans who have died as a result of service related disabilities

Question 20

What does the Children’s Health Insurance Program (CHIP) provide?

Answer 20

Provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid

Question 21

What does workers compensation covers?

Answer 21

Covers workers against lost wages due to accidents on the job

• patient does not pay any fees

Question 22

What is the managed care health plans?

Answer 22

Plans that provide healthcare for payments

• uses participating providers

Question 23

What is the HMO health plan?

Answer 23

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)

Question 24

What is the PPO health care plan?

Answer 24

More flexible than HMO

• no referrals needed
• In network providers (cost less)
• out of network providers

Question 25

What is capitation?

Answer 25

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

Question 26

What is the pay-for-performance?

Answer 26

• Compensates providers only if certain measures are met for quality and efficiency

Question 27

What is the fee-for-service?

Answer 27

• Amount charged for services is controlled by the physician
• Amount paid for services is controlled by the insurance carried
• Policy lists covered medical services

Question 28

What is the birthday rule of coordination of benefits?

Answer 28

The insurance plan of the person born earliest in the year becomes the primary payer

Question 29

What does the coordination of benefits prevent?

Answer 29

Prevents the duplication of payment

Question 30

What is the CMS-1500 Form?

Answer 30

The electronic claim form for insurance companies for payment

Question 31

What does the CMS Form require?

Answer 31

requires the use of procedural and diagnostic codes

Question 32

What direct billing?

Answer 32

Insurance carrier allows providers to submit claims directly to carrier electronically

Question 33

What is clearinghouse?

Answer 33

• Allowing providers to submit all insurance claims at one time through software
• audits and sorts claims
• Sends correct invoicing to correct insurance company

Question 34

What is the account balance?

Answer 34

Total balance on account

debit - negative
credit - positive

Question 35

What is the accounts receivable (A/R)?

Answer 35

money owed to the provider for services rendered

Question 36

What is the accounts payable (A/P)?

Answer 36

debt incurred by not paid; supplies or utilities

Question 37

What is a guarantor?

Answer 37

Person with financial responsibility for the patient