Podcast
Questions and Answers
Which of the following personal details is NOT required when applying for a health plan?
Which of the following personal details is NOT required when applying for a health plan?
- Full First Name
- Address (correct)
- Gender
- Date of Birth
Which of the following types of documents can be applied for under the Schedule of Benefits?
Which of the following types of documents can be applied for under the Schedule of Benefits?
- Learner Permit (correct)
- Passport
- Employment Verification
- Social Security Card
What is indicated as a factor that affects whether services are covered under the health plan?
What is indicated as a factor that affects whether services are covered under the health plan?
- The provider's location
- The chosen health plan (correct)
- Age of the applicant
- Personal health history
Which of these details is required regarding the driver's license when applying for the health plan?
Which of these details is required regarding the driver's license when applying for the health plan?
Under the noncovered services section, what do these services depend on?
Under the noncovered services section, what do these services depend on?
What is a defining characteristic of high-deductible plans in Consumer-driven Health Plans?
What is a defining characteristic of high-deductible plans in Consumer-driven Health Plans?
In a high-deductible plan, what typically happens after the deductible is met?
In a high-deductible plan, what typically happens after the deductible is met?
Which of the following statements is NOT true regarding high-deductible plans?
Which of the following statements is NOT true regarding high-deductible plans?
What may be a primary advantage of choosing a high-deductible plan?
What may be a primary advantage of choosing a high-deductible plan?
Which of the following can be a potential drawback of high-deductible plans?
Which of the following can be a potential drawback of high-deductible plans?
What is the first step to be completed before the patient encounter?
What is the first step to be completed before the patient encounter?
Which step is focused on ensuring that a patient is aware of their financial obligations?
Which step is focused on ensuring that a patient is aware of their financial obligations?
During which phase is the coding compliance for services rendered reviewed?
During which phase is the coding compliance for services rendered reviewed?
What is the primary activity performed directly after the encounter is completed?
What is the primary activity performed directly after the encounter is completed?
Which step involves ensuring proper financial reimbursement is processed after the encounter?
Which step involves ensuring proper financial reimbursement is processed after the encounter?
What characteristic of a POS plan combines features of PPO and HMO?
What characteristic of a POS plan combines features of PPO and HMO?
Which of the following statements correctly describes the flexibility of POS plans?
Which of the following statements correctly describes the flexibility of POS plans?
In a POS plan, what is required for a member to access specialized medical services?
In a POS plan, what is required for a member to access specialized medical services?
What is a main difference between POS plans and traditional HMO plans?
What is a main difference between POS plans and traditional HMO plans?
Which of the following statements about POS plans is false?
Which of the following statements about POS plans is false?
What role does the primary care physician (PCP) serve in an HMO plan?
What role does the primary care physician (PCP) serve in an HMO plan?
Which of the following is a requirement imposed by HMO provisions for accessing specialty care?
Which of the following is a requirement imposed by HMO provisions for accessing specialty care?
What is the purpose of requiring preauthorization for an encounter in HMO plans?
What is the purpose of requiring preauthorization for an encounter in HMO plans?
What is typically required before a hospitalization in an HMO?
What is typically required before a hospitalization in an HMO?
In an HMO, which statement accurately reflects the approach to seeing specialists?
In an HMO, which statement accurately reflects the approach to seeing specialists?
What is the primary purpose of provider credentialing?
What is the primary purpose of provider credentialing?
Which of the following is NOT typically assessed during the provider credentialing process?
Which of the following is NOT typically assessed during the provider credentialing process?
Which of these entities primarily require provider credentialing?
Which of these entities primarily require provider credentialing?
What aspects of a provider are evaluated in the credentialing process?
What aspects of a provider are evaluated in the credentialing process?
The verification of a provider's qualifications primarily aims to ensure what?
The verification of a provider's qualifications primarily aims to ensure what?
Which type of insurance policy is typically financed by both the employer and the employee?
Which type of insurance policy is typically financed by both the employer and the employee?
Which insurance policy is designed to provide benefits in case of job-related injuries?
Which insurance policy is designed to provide benefits in case of job-related injuries?
What type of insurance typically covers personal health issues preventing someone from working?
What type of insurance typically covers personal health issues preventing someone from working?
What insurance type is primarily associated with vehicle coverage?
What insurance type is primarily associated with vehicle coverage?
Which insurance policy can be both inclusive of group plans and individualized plans?
Which insurance policy can be both inclusive of group plans and individualized plans?
What is the first step in the revenue cycle before any patient encounters?
What is the first step in the revenue cycle before any patient encounters?
During which step is the financial responsibility of the patient established?
During which step is the financial responsibility of the patient established?
Which step in the revenue cycle involves ensuring that the billing meets compliance regulations?
Which step in the revenue cycle involves ensuring that the billing meets compliance regulations?
What is the purpose of monitoring payer adjudication in the revenue cycle?
What is the purpose of monitoring payer adjudication in the revenue cycle?
At which stage do collection follow-ups occur in the revenue cycle?
At which stage do collection follow-ups occur in the revenue cycle?
What is a primary characteristic of a Preferred Provider Organization (PPO)?
What is a primary characteristic of a Preferred Provider Organization (PPO)?
Which of the following statements accurately describes the payment structure in a PPO?
Which of the following statements accurately describes the payment structure in a PPO?
What distinguishes a PPO from other health plan types?
What distinguishes a PPO from other health plan types?
What does 'no capitation' mean in the context of PPOs?
What does 'no capitation' mean in the context of PPOs?
Which of the following is NOT a feature of a Preferred Provider Organization?
Which of the following is NOT a feature of a Preferred Provider Organization?
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Study Notes
Preferred Provider Organization (PPO)
- Consists of a network of healthcare providers.
- Operates without capitation, meaning no prepayment is made for services.
- Providers negotiate discounts on fees for services rendered.
Consumer-driven Health Plans (CDHP)
- Features high-deductible plans where the policyholder pays a specific amount before insurance coverage starts.
The Revenue Cycle and Insurance Math
- Encompasses all activities needed for collecting payment from patients and insurers.
- Involves understanding key steps before, during, and after patient encounters.
Revenue Cycle Steps
- Before the Encounter: Preregister patients to streamline the process.
- During the Encounter: Establish financial responsibility, check-in patients, ensure coding compliance, and handle billing compliance before checking out patients.
- After the Encounter: Prepare and send claims, monitor payer adjudication, generate patient statements, and follow up on payments and collections.
HMO Provisions
- Health Maintenance Organizations may require preauthorization for certain encounters and procedures.
- Patients must choose a primary care physician (PCP), acting as a "Gatekeeper."
- Referrals from the PCP are needed to see specialists.
Schedule of Benefits
- Health plan applications may involve obtaining a learner permit, ID card, renewing or replacing an existing ID.
- Required personal information includes full name, date of birth, gender, and nationality.
Covered and Noncovered Services
- Coverage for specific services depends on the chosen health insurance plan, outlining what is included and what is excluded.
Point-of-Service (POS) Plans
- Merges aspects of PPO and HMO, offering flexibility while requiring an in-network PCP as a gatekeeper.
Provider Credentialing
- Essential for compliance with insurance carrier requirements.
- Involves assessment and verification of a provider's licenses, training, educational background, and competency.
Types of Insurance Policies
- Group Insurance: Funded jointly by employers and employees.
- Individual Insurance: Purchased by individuals for personal coverage.
- Disability Insurance: Provides income in the event of a disabling injury or illness.
- Automotive Insurance: Covers vehicles and drivers in case of accidents.
- Workers' Compensation: Insurance for employees who are injured on the job.
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