18 Questions
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
How does coinsurance differ from a copayment?
Coinsurance is a percentage, while a copayment is a fixed dollar amount
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%
How does coinsurance affect the patient's out-of-pocket costs for medical services?
Coinsurance increases the patient's out-of-pocket costs by requiring them to pay a fixed percentage of the total cost
Which of the following is a key purpose of coinsurance in insurance plans?
To encourage patients to be more cost-conscious consumers of healthcare services
How does coinsurance differ from a deductible in an insurance plan?
Coinsurance is only applicable to managed care plans, while deductibles can be used in any type of insurance plan
What is the purpose of coinsurance in health insurance plans?
To share the cost of covered services between the patient and the insurance provider
How does coinsurance differ from a deductible in health insurance plans?
Coinsurance applies after the deductible has been met, while a deductible applies before any coverage kicks in
If a health insurance plan has an 80/20 coinsurance rate, what does this mean?
The insurance provider pays 80% of covered costs and the patient pays 20%
How does coinsurance affect a patient's out-of-pocket costs for covered healthcare services?
Coinsurance increases the patient's out-of-pocket costs by a percentage of the total cost
What is the purpose of a coinsurance maximum or out-of-pocket maximum in a health insurance plan?
To limit the total amount the patient has to pay in coinsurance costs per year
How does coinsurance apply when a patient receives services from an out-of-network provider?
Coinsurance applies at a higher percentage, requiring the patient to pay a larger share of the costs
What is the role of a medical assistant in preparing health care claims?
All of the above
Which of the following is NOT a basic insurance terminology term?
Deductible
In an insurance contract, who is the 'first party'?
The patient
What is the primary responsibility of a medical assistant regarding health care claims?
Ensuring maximum appropriate payment for services rendered
Which of the following is NOT a participant in an insurance contract?
The government
What is the purpose of a 'lifetime maximum benefit' in an insurance policy?
It sets a limit on the total amount the insurance company will pay for a policyholder's medical expenses over their lifetime
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
Test your knowledge of basic insurance terminology related to deductible, coinsurance, copayment, exclusions, and formulary. Understand concepts like met annually, fixed percentage, managed care plans, and preferred provider.
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