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What is the purpose of coinsurance in an insurance policy?
What is the purpose of coinsurance in an insurance policy?
- To provide a fixed percentage of the cost that the patient is responsible for paying (correct)
- To ensure the patient receives care only from preferred providers
- To limit the number of services the insurance company will cover
- To require the patient to pay a fixed dollar amount for each service
How does coinsurance differ from a copayment?
How does coinsurance differ from a copayment?
- Coinsurance is a percentage, while a copayment is a fixed dollar amount (correct)
- Coinsurance is only applicable to managed care plans, while copayments can be used in any type of insurance plan
- Coinsurance applies to the total cost of a service, while a copayment applies only to the patient's portion
- Coinsurance is paid by the insurance company, while a copayment is paid by the patient
Which of the following is an example of coinsurance?
Which of the following is an example of coinsurance?
- The insurance company pays 80% of the cost of a service, and the patient pays the remaining 20% (correct)
- The insurance company will only cover services provided by doctors in its preferred provider network
- The patient must receive prior authorization from the insurance company before receiving certain services
- The patient pays a $20 copayment for each doctor's visit
How does coinsurance affect the patient's out-of-pocket costs for medical services?
How does coinsurance affect the patient's out-of-pocket costs for medical services?
Which of the following is a key purpose of coinsurance in insurance plans?
Which of the following is a key purpose of coinsurance in insurance plans?
How does coinsurance differ from a deductible in an insurance plan?
How does coinsurance differ from a deductible in an insurance plan?
What is the purpose of coinsurance in health insurance plans?
What is the purpose of coinsurance in health insurance plans?
How does coinsurance differ from a deductible in health insurance plans?
How does coinsurance differ from a deductible in health insurance plans?
If a health insurance plan has an 80/20 coinsurance rate, what does this mean?
If a health insurance plan has an 80/20 coinsurance rate, what does this mean?
How does coinsurance affect a patient's out-of-pocket costs for covered healthcare services?
How does coinsurance affect a patient's out-of-pocket costs for covered healthcare services?
What is the purpose of a coinsurance maximum or out-of-pocket maximum in a health insurance plan?
What is the purpose of a coinsurance maximum or out-of-pocket maximum in a health insurance plan?
How does coinsurance apply when a patient receives services from an out-of-network provider?
How does coinsurance apply when a patient receives services from an out-of-network provider?
What is the role of a medical assistant in preparing health care claims?
What is the role of a medical assistant in preparing health care claims?
Which of the following is NOT a basic insurance terminology term?
Which of the following is NOT a basic insurance terminology term?
In an insurance contract, who is the 'first party'?
In an insurance contract, who is the 'first party'?
What is the primary responsibility of a medical assistant regarding health care claims?
What is the primary responsibility of a medical assistant regarding health care claims?
Which of the following is NOT a participant in an insurance contract?
Which of the following is NOT a participant in an insurance contract?
What is the purpose of a 'lifetime maximum benefit' in an insurance policy?
What is the purpose of a 'lifetime maximum benefit' in an insurance policy?
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Study Notes
Basic Insurance Terminology
- Deductible is met annually
- Coinsurance is a fixed percentage
- Copayment is associated with managed care plans and preferred provider
- Exclusions are part of insurance coverage
- Formulary is a list of approved medications
Insurance Participants
- Three participants in an insurance contract:
- First party: patient or policy owner
- Second party: healthcare provider (physician or facility)
- Third-party payer: health plan or insurance company
Types of Insurance Plans
- Fee-for-service plans
- HMOs (Health Maintenance Organizations)
- PPOs (Preferred Provider Organizations)
Government Insurance Programs
- Medicare
- Medicaid
- TRICARE
- CHAMPVA
Insurance Claim Process
- Allowed charge: amount approved by insurance company
- Contracted fee: negotiated rate between provider and insurance company
- Capitation: fixed payment per patient
- RBRVS (Resource-Based Relative Value Scale): formula for determining payment
Insurance Claim Submission
- Tasks to obtain information required to produce an insurance claim:
- Review insurance coverage
- Explain fees
- Estimate charges
- Understand payment explanation
- Calculate patient's financial responsibility
- Producing a clean CMS-1500 health insurance claim form
- Submitting an insurance claim electronically
- Understanding information on payer's remittance advice
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