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51 terms

Health Insurance Ch 3 &11

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Insurance regulated:
False:, Insurance is regulated by state law and is not considered a federal regulated industry
The insured and the patient:
False: The insured (subcriber,member,policy holder, recipient) may not be the patient seen for medical services
Different names for insurance claim representative:
True: Adjustor, Insurance billing specialist, Inssurance claim processor, reimbursment specialist, senior billing specialist
Coodination of benefits:
False: C.O.B. statement means waiting period
Who sponsors Medicare:
False: It is amended to social security, a Federal health insurance program
Information in an insurance card:
True: Group #, member #, primary care physician, insurance ID #, insurance name, co-pay info, RX plan, insurance phone #, billing addressess ect.
Release of information does it need to be signed:
True: No due to HIPPA regulations (block 12 on a CMS 1500 form)
Encounter form, what does it consist of:
True: This is a two -three part form, is a combination bill, insurance form, and routing document used in both computer and paper based systems.
What is capitation:
A system of payment used by managed care plans in which physicians hospitals are paid a fixed or per capita amount for each patient enrolled over a stated period of time regardless of the type and number of services provided
What is a PPO:
Preferred Provider Organization, Managed care plan members have freedom to choose any physician or hospital for services provided
HMO-style cost management with PPO -style of freedom of choice is:
P.O.S. "Point of Service" members choose a primary care physician who manages specialty care and referrals
Collection copayments:
Always collect the copay at the time of the patients office visit.//A predetermined fee paid by the patient to the provider at the time of service is rendered, a form of cost sharing because the managed care plan or insurance company pays the remaining cost
Physician/Patient contract:
Begins when the physician accepts the patient and agrees to treat him or her.
Patient with medical insurance, the treatment contract exists with whom:
A treatment contract is between the physician and the patient, the patient is liable for the entire bill
Emancipated minor:
A person younger than 18 y.o.a. who lives independently, self supporting,military,married,or divorced parent or possesses decission making rights
Workmans's Compensation:
Referred to a industrial accident or illness/ contract is between physician and insurance company
Insured is also known as:
Subscriber or Member is a policy holder or recipient
Coordination of benefits statement:
When a patient had more than one insurance policy this clause requires insurance companies to coordinate the reimbursement of benefits to determine which carrier is going to be primary and seconday this preventing duplication or overlapping of payments for the same medical expense
Birhtday law:
The father or mother may be primary, the person whose birthday (month and day not year) falls earlier in the calendar year pays first then the other parent pays second.
Preexisting conditions:
Policies that do not produce benefits for conditions that existed and were treated before the policy was issued.
Patient intake sheet:
Known as patient registration form a comprehensive listing of personal and financial information
Assignment of benefits:
The transfer of ones rights to collect an amount payable under a insurance contract.
Encounter form:
Called: Charge slips, multipurpose billing form, patient services slips, routing forms, super bills, or transaction slips
Day sheet:
Daily record sheet is a register for recording daily business transactions.
"Signature on File" in block 12:
Not required do to HIPPA regulations: Block 12 authorized the release of medical or other information necessary to process the claim. On use when a signature is on file in a patients records
"Signature on File" in block 13:
S.O.F. Required to be signed and held in the patients file: Block 13 authorization for assignment of benefits. A health care provider will not recieve payment if not signed by the patient
Block 31 on the CMS 1500:
Providers/physicains rarely sign the CMS 1500 form, however it can be accepted in several formats: Handwritten, facsimile stamp, physician representative or electronic signature
Denied prior authorization:
Have the primary care physician send a letter to the plan stating the facts and needs of the treatment ie: X-rays lab's, office visits, ect.
Assignment of benifits in worlman's compensation:
D all the above: There is no assignment of industrial cases, the workers compensation carrier pays the fee for service to the physicain, not the patient
Carve-Out:
Medical services not included in the contract benefits,within capitation rate of benifits
Gatekeeper:
A primary care physician (P.C.P) who controls patients access to specialists and diagnotis testing services
Premiums:
To keep the insurance in force, a person must pay a monthly or quarterly fee.
Medical necessity:
Preauthorized, documents must support the level of service and each procedure rendered
What does Quality Improvement Organization (QIO) do:
An organization that reviews and addresses whether the services met professionally recognized standards of health care and may include whether the appropriate services were provided in appropriate settings, resolves disputes..
Tri-Ccare program helps who:
Active military service members and their dependants, retired, surviving, spouces and disabled members. Including dependents of a member who died on active duty.
Divorced mother, sick child,father holds insurance motherat the office with sick child who pays:
Mother pays the co-pay and the fathers insurance will be billed for the remaider/balance
Late new patient to appointment doesn't want to complete forms what do you do:
Assist patient by asking the questions and filling out the form for them. Photo copy both sides of the insurance card, and verify against a photo ID
DNR:
Do Not Resusitate
DOA:
Death on Arrival
DRG:
Diagnosis Related Group
Dx:
Diagnosis
ECG:
Electrocardiogram
ED:
Emergency Department
FDA:
Food and Drug Administration
EEG:
Electroencephalogram
ESRD:
End-Stage Renal Disease
ETOH:
Ethyl Alcohol
DIG:
Diagoxin, Digitalis
ENT:
Ear, Nose, Throat
DVT:
Deep Venus Thrombosis
POS is what:
Provider sponsor organization, managed care plan that is owned and operated by a hospital and provider group instead of an insurance company