Questions and Answers
What is the highest amount a payer will pay any provider for a service or procedure?
What is the rule stating that the primary insurance plan for all dependents will be based on the policyholder whose birthday comes first in the year?
Birthday rule
What is the congressional agency overseeing Medicare and Medicaid?
CMS
What is the yearly dollar amount that must be paid by the insured before any claims are considered by the insurance carrier?
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What are procedures or treatments not covered by the patient's insurance policy called?
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What is the document explaining the total amount of the claim and the amount paid by the insurance company?
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What is the traditional health plan that reimburses policyholders for the costs of healthcare?
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What is a listing of common services and procedures for the practice called?
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Who are physicians that enroll with a managed care plan?
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What is the process by which the provider contacts the insurance carrier to determine if a proposed procedure is covered?
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What is the base or yearly cost for healthcare insurance?
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What is another name for the authorization for a physician allowing a patient to seek treatment from another practice?
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What is the other name for insurance payment for medical services?
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______________ is the national health insurance program for Americans aged 65 and older.
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A managed care organization that establishes a network of providers who care for their patients is called an ______________.
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A(n) ______________ is a managed care organization that provides specific services to their members.
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______________ is a federally funded, state-run healthcare assistance program for low-income patients.
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What do medical assistants collect at the time service is required by the managed care plan?
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Billing a patient for the difference between a higher usual fee and lower allowed charge is called ______________.
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Under Medicare Part B, patients are required to pay an annual ______________.
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What is the legal clause limiting the total payment from all insurance carriers to 100% of the covered charges?
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The explanation of benefits received from the insurance company is often called the ______________.
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Medicare Part A covers only 190 days of psychiatric care.
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Co-payments are made to insurance companies.
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Preferred Provider Organizations (PPO) never allow members to receive care from physicians outside the network.
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Exclusions are expenses covered by an insurance company.
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A deductible is a fixed-dollar amount that must be met in full on the first visit each year to a provider.
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List the three major methods used to transmit claims electronically.
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Explain the purposes of the coordination of benefits clause in insurance policies.
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List five sections of data elements on the X12 837 Health Care Claim.
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What does balance billing refer to?
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What is the company that takes nonstandard medical billing software formats and translates them into the standard EDI format?
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What is the monthly payment received by the provider for each patient covered by an HMO?
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What is the payment system used by Medicare to calculate acceptable fees?
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What is the electronic claim transaction equivalent to the HIPAA paper claim?
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What is the fixed percentage of covered charges paid by the patient after the insurer covers its share?
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What is the other abbreviation for EOB or EOP?
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What is an insurance plan that accepts the risk of covering the cost of medical services provided to a patient?
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______________ is the insurance program covering expenses of dependents of veterans with total, permanent, service-related disabilities.
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Private insurance plans that can be purchased to supplement Medicare are known as ______________ plans.
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______________ is the program that provides healthcare benefits for dependents of active duty and retired military personnel.
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PPOs, HMO, fee-for-service plans, and MSAs are all choices for Medicare beneficiaries in a program known as ______________.
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What is a Medicare plan that charges a monthly premium and a small co-payment for each office visit but no deductible?
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At the time of service, if required by the managed care plan, medical assistants collect ______________.
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What are the three factors that determine the nationally uniform relative value of a procedure?
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Study Notes
Insurance Terminology and Key Concepts
- Allowed Charge: Maximum amount a payer is willing to reimburse a provider for services rendered.
- Birthday Rule: Determines which parent’s insurance is primary for dependent children based on whose birthday occurs first in the calendar year.
- CMS (Centers for Medicare and Medicaid Services): U.S. agency regulating and overseeing Medicare and Medicaid programs.
- Deductible: Annual payment required by the insured before the insurance begins to cover claims.
- Exclusions: Specific treatments or procedures not covered under a patient’s insurance policy.
- EOB/EOP (Explanation of Benefits/Payment): Document breaking down claim details—total amount, allowable charges, patient liability, and non-covered services.
- Fee-for-Service: Traditional health insurance model that reimburses for individual healthcare services provided.
- Fee-Schedule: A list outlining standard charges for specific services and procedures within a practice.
Managed Care Concepts
- Participating Physician: Health care providers who agree to work within the terms and conditions of a managed care plan.
- Preauthorization: Process of obtaining approval from the insurance provider for specific medical services before they are provided.
- Premium: The recurring amount paid for health insurance coverage.
- Referral: Authorization allowing patients to seek services from additional healthcare providers under their insurance policy.
Medicare and Medicaid
- Medicare: National health insurance for individuals aged 65 and above.
- PPO (Preferred Provider Organization): A managed care organization offering a network of healthcare providers; members can seek care outside this network at extra costs.
- HMO (Health Maintenance Organization): A managed care model providing specific services via network providers for a set fee.
- Medicaid: State-run, federally funded insurance program assisting low-income individuals, the disabled, and families with dependent children.
Billing and Claims Processing
- Co-payments: Payments collected from patients at the time of service, usually a fixed fee.
- Balance Billing: Billing a patient for the difference between the provider's usual charge and the insurance's allowed amount, which participating physicians cannot do.
- Coordination of Benefits: Rule ensuring total insurance payouts do not exceed 100% of covered charges.
- Remittance Advice (RA): Another term for EOB that outlines payment details and claims processing.
Claims Submission and Electronic Transactions
- Methods of Electronic Claims Transmission: Direct transmission to the payer, use of clearinghouses, and direct data entry.
- X12 837 Healthcare Claim: Electronic format for submitting healthcare claims, equivalent to traditional paper claims.
- Clearinghouse: An entity that converts conflicting billing formats into standardized electronic data.
Payment Systems and Cost Structures
- Capitation: Fixed monthly payment to a provider regardless of the number of services rendered to a patient.
- RBRVS (Resource-Based Relative Value Scale): System used by Medicare to determine payment rates based on service value.
- Coinsurance: Percentage of costs the insured must pay after meeting their deductible.
Specialized Insurance Programs
- CHAMPVA: Covers healthcare expenses for dependents of veterans with service-related disabilities.
- Medigap: Supplementary insurance for Medicare beneficiaries designed to cover out-of-pocket expenses.
- TRICARE: Provides healthcare benefits for dependents of active-duty and retired military personnel.
- Medicare Advantage Plans: Options available to Medicare beneficiaries include PPOs, HMOs, fee-for-service, and MSAs.
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Description
Test your knowledge on key terms related to insurance and billing in healthcare. This quiz covers important concepts such as allowed charge, birthday rule, and CMS. Master these terms to enhance your understanding of the medical billing process.
