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Medicare and Medicaid final review
Terms in this set (33)
Advance Beneficiary Notice -
form used to notify patients in advance that a service may not be covered and the patient may be responsible
the amount that must be paid by a beneficiary before an insurer begins to pay for medical services
the Medicare co-pay paid by the patient for services
a person who is eligible to recieve insurance benefits
process to ensure that Medicare reimburses providers based only on cost associated with patient care
provides health care coverage for the categorically needy (is not considered insurance)
Diagnostic Related Groups -
classification of diagnoses used to determine hospital payment for Medicare inpatients
a physician who has entered into a written agreement with an insurance company to accept the plan's fee for service rendered as payment in full
a physician who has NOT entered into a written agreement with an insurance company to accept the plan's fee for services rendered
Assignment of benefits
authorization for the insurance company to send insurance payments directly to the health care provider, also an agreement with Medicare that the provider will accept the remittance as full payment
a physician's listing of all reimbursement fees for all procedures performed in the practice
Resource Based Relative Value System or Scale -
a system that calculates physician reimbursement for services using relative value units
health insurance policies sold by private companies, designed to supplement or fill in the gaps between Medicare and the patient
Health Insurance Claim Number -
a 10-11 digit number assigned by Medicare to its beneficiaries
the amount an insurance carrier deems reasonable for the billed charges
Medicare managed plans
health care choices such as HMO's, part C of the Medicare program
primarily for people over 65 and others eligible for social security; federal insurance program established in 1965 under the social security act
What is it called when a patient gives written permission for the payment to go to the physician?
Coordination of Benefits -
a program for determining which health insurer pays for services first when a beneficiary is covered by more than one health care plan
When is each person responsible for the deductible?
each calendar year before the plan will start to pay
What does Medicare part A cover?
- Inpatient hospital care , but the patient must pay deductible toward hospital expenses,
- skilled nursing facilities,
- home health care,
- hospice services
What does Medicare part B cover?
- outpatient hospital care,
- durable medical equipment,
- physician services,
- other medical services
Requirements for Medicare eligibility
- 65 years or older,
- permanetly disabled or blind,
- receiving dialysis for permanent kidney failure or have undergone a kidney transplant
What is insurance abuse?
when a claim is submitted for an unnecessary procedure that was performed
What does medicare part B NOT cover?
-long term care,
-routine dental care,
-exams for fitting hearing aids
What must a patient have in order to be eligible for Medicare part C?
part A and part B
What is Medicare part D?
a plan that pays for prescription drugs with just a small co-payment from the patient
What is a contractual write off?
the difference between RBRVS (the allowed amount) and the provider's fee (actual amount)
What percentage does Medicare cover for services?
and patient is responsible for 20%
What do third party (insurance companies) guidelines require?
- always collect the co-insurance at time of service,
- verify insurance information and eligibility date,
- send claims to the correct insurance company,
- all services and procedures are within the managed care plan,
- signature is on file for the patient,
- obtain all required forms (ABN, etc)
the committee that will review individual cases to see if they are medically necessary and study how providers use medical resources
Contracted fee schedule
When a fixed fee schedule is established between some payers (particulary PPO's) with their participataing physicians. Terms of plan determine what percentage of charges the patient owes and what is covered by the payer (insurance). Participating providers can bill patients for their usual charges for procedures that are not covered by the plan
the fixed payment for each plan member in capitation contracts is determined by the managed care plan that initiates contracts with providers. The plan's contract with the provider lists the services and procedures that are covered by the cap rate. services are covered in the per-member charge for each plan member who selects the PCP.
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