Week 13- Medical Insurance and Billing

Question 1

In an insurance contract, first party is the

Answer 1

insured/patient

Question 2

In an insurance contract, second party is the

Answer 2

healthcare provider

Question 3

In an insurance contract, third party is the

Answer 3

health plan

Question 4

amount of money patient must pay before health plan kicks in

Answer 4

deductible

Question 5

when the policyholder and insurance share the costs, its called _____ (usually 80/20)

Answer 5

coinsurance

Question 6

amount of money paid at time of service (paid by the insured)

Answer 6

copayment

Question 7

amount of money paid at time of service (paid by the insured)

Answer 7

copayment

Question 8

providers that agree to write off the difference between amount charged and amount allowed by insurance company

Answer 8

participating provider

Question 9

max amount insurance company will pay for services

Answer 9

allowable amount

Question 10

form given to patient when its believed Medicare will not cover the amount patient responsible for payment

Answer 10

ABN (advanced beneficiary notice)

Question 11

covers patients 65 +

Answer 11

Medicare

Question 12

covers hospitilizations

Answer 12

Medicare Part A

Question 13

covers routine visits and outpatient services

Answer 13

Medicare Part B

Question 14

optional and additional coverage offered by private insurance and approved by Medicare

Answer 14

Medicare part C

Question 15

covers prescriptions and medications

Answer 15

Medicare part D

Question 16

covers low income and mentally indigent

Answer 16

Medicaid

Question 17

covers military personnel and dependents

Answer 17

Tricare

Question 18

covers surviving spouses and dependents of veterans who died as a result of service related disabilities

Answer 18

CHAMPVA

Question 19

provides low cost coverage to children who earn too much money to qualify for Medicaid (in some states, CHIP covers pregnant women)

Answer 19

CHIP- Children’s health insurance plan

Question 20

covers workers against lost of wages due to accidents on the job

Answer 20

Workers compensation

Question 21

plans that provide healthcare for payments

Answer 21

Managed Care plans

Question 22

INN plan that costs less than PPO, requires referral, pre auth, and requires PCP

Answer 22

HMO plans

Question 23

plan that offers INN & OON benefits, more flexible than HMO, does not need referral

Answer 23

PPO plans

Question 24

When a provider is INN, they are also considered a

Answer 24

participating provider

Question 25

Birthday rule states

Answer 25

person/parent born earliest in the year becomes primary payer for dependent

Question 26

type of fee schedule that compensates providers only if certain measures are met for quality and efficiency

Answer 26

pay-for-performance

Question 26

type of fee schedule that compensates providers only if certain measures are met for quality and efficiency

Answer 26

pay-for-performance

Question 27

type of claims processing that allows provider to submit all insurance claims at one time through software

Answer 27

Clearinghouse

Question 28

money owed to provider for services rendered

Answer 28

accounts receivable