Wednesday - Insurance And Law Flashcards
Primary insurance
Insurance plan responsible for paying health coverage FIRST
Secondary Insurance
The insurance plan that is billed after the primary plan has paid its contracted amount
Tertiary insurance
Insurance coverage in addition to primary and secondary which covers gaps in the first two coverages
Define coinsurance
The % of the allowed amount the patient will pay once the deductible is met
Define copayment
A set amount determined by the insurance plan that the patient pays for specific services usually office visits
Define deductible
The amount that must be paid before benefits are paid by the insurance company
What is apart of HMO plan
Lower out of pocket cost
Fixed annual fee
Stays in network besides ER
What is apart of PPO plan
Higher out of pocket cost
Multiple providers
Can receive special services without referrals, pre certification, or pre authorization
What is a pre certification with insurance
A request to determine if a service is covered by the patients policy
What is a pre authorization with insurance
Formal approval from the insurance company that it will cover the test or procedures
Define Medicare
It is federal
For patients 65+
Disability
Renal disease (end of life)
Define Medigap
Coverage that picks up where Medicare coverage leaves off
Define Medicaid
It is within State
For families, children, pregnancy
Limited income
*an individual can qualify for both Medicaid and Medicare and it is considered “Medi-Medi”
Medicare Part A Covers…
Hospital Coverage
Medicare Part B covers…
Outpatient and professional care
Medicare part C covers…
Managed care plans
Medicare Part D covers…
Pharmaceutical coverage
What is CHAMPVA insurance
Provides coverage for families of veterans who were permanently disabled or killed in the line of duty.
What is an EPO and what does it cover
Exclusive Provider Organization:
Combines features of HMO & PPO but will not be covered for services outside the designated network of providers. But they may not need to obtain a referral for specialized care.
What is Tort Law
Tort law enforces rules that we have in our society. If these rules are violated, then an individual can sue another individual, business, or government.
What is Good Samaritan law
The Good Samaritan law vary in each state, with some states providing protection if the provider acts in “good faith”
Needs to be performed in emergency situations
What are the four Ds of negligence
- Duty of care
- Dereliction (breaches the duty of care to patient)
- Damages (patient suffers a legal injury)
- Direct cause
What is predetermination
A form or letter that is sent from your medical provider to your insurance before undergoing treatment.
Basically if the insurance will be able to cover procedures
What defines private fee for service
Plan that allows patients to go to any physician
Allowable Amount
The limit that most insurance plans allow for reimbursement for a service or procedure
Subpoena
A legal binding request for records
DEA number
required on all controlled drug prescriptions; identifies the prescriber.
If a claim is submitted by a facility and not paid by the carrier the first step would be to
Call insurance company
Medicare covers physicals once every
12 months
Touching a person without permission
Battery
First person to contact when a breach of confidentiality
Office manager
