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45 Cards in this Set

  • Front
  • Back
Patient Cost Responsibility
*may have to explain to the patient why they are paying extra out of their pocket for insurance
*premium-cost for the coverage-paid on a monthly basis or could be paid on annually basis
*copay-flat rate paid for providers evaulation and management service
*seeing a physician copay is involved
*copay comes into affect when you're actually seeing a provider
*cost of copay depends on rather or not you're seeing your primary physician or a specialist
*deductibles-specified amount of money that must be paid out of pocket by the insured individual
*coinsurance-is a percentage set by the plan that the insurer is responsibile for
*some insurance have all 3 plans
-$15 copay for primary physician
-$30 copay for specialist
-$250 deductible(10% allowed allowance)
Insurance Terminology
*Eligibility-a term used to determine whether patient is covered under listed plan
*Policyholder-individual who carriers and pays for coverage
*Beneficiary-Individual entitled to benefits(subscriber, insured, enrollee, member)
*Insured-and individual or organization covered by an insurance policy
*Dependent-individuals designated by the policyholder that are also covered under the policy(spouse, children, domesticnpartner)
*Rider-a special provision added to the policy to expand or limit the benefits
*Exclusions-benefits that are not payable under the policy
*Pre existing-excluded medical condition that an individual had prior to coverage
*Effective date-date that the individual becomes covered under policy
*is a process more and more insurance companies are asking for
*there are 3 types of approval
-pre authorizations-helps to determine rather or not the procedure is medically covered and necessary
-pre certification-is determining whether or not it is covered under the patients contract
-pre determination-determines the maximum dollar amount that will be paid for the services
*is premission from athird party to have a certain procedure performed
*use authorization number and place it in box 23 of the CMS1500 claim form in the process of billing the procedure out
*authorization form is usually a documentation in the medical record
*authorization does not guarantee payment
*continue to follow the medical coding rules to make sure it is medically nessecary
*Patient is referred from a PCP to a specialist
*Third party usually requires authorization in advance

Types of referrals:
*Regular-3-10 days to obtain
*Urgent-24 hours(not life threatening)
*Stat-immediate, emergency/life threatening
*Self-patient has received permission from third party
Paticipating Physicians
*Has a contractual agreement with the insurance to render care to beneficiaries and bill insurance with direct payment to the provider
*The insurance pays the allowable amount of the negotiated charge
*The provider accepts this as paid in full and adjusts the difference off of the patients account, with exception to patients obligations under the contract(i.e. copay, deductible)
*The difference cannot be billed to the patient for covered services
*Non-covered services or ineligible benefits can be billed to the patient
Non-Participating Physicians
*there is noagreement between the physician and the provider at all
*the provider will be able to get the full dollar amount for the services
*the payment could be sent to the provider or be sent to the patient for non participating
*find out where the payment is to be sent when trying to find out the patients eligibility status
*if the payment is gonna be sent to the patient rather than the provider you may need to accept the payment in full
*the difference between the chargers and the payments for a non participating physician can be balanced billed to the patient-a contract agreement does not exist
*the patient needs to be made aware of the services
In Network
*Insurance companies have contracted with health care providers(doctors and hospitals) to offer services to their insured individuals
*Lower out of pocket cost
*Some insurance contracts will not pay for services if individual does not stay within an insurance network
Out of Network
*The provider is not listed with the insurance company as an in-network physician
*Higher out of pocket costs
*Coverage can be decreased including a loss of benefits
The Purpose of Health Insurance
*primarily to help individuals and families to help offset their health care cost
*it helps protect against financial lost because of the expenses involved
*there are different types of plans, providers, benefits
Group Policies
*Insurance policy is written to cover a large group of individuals
*Usually provides more coverage at lower premiums
*Physicians examinations are usually not necessary
*Pre-existing conditions are usually waived
*Employers often share the cost with the employee
Individual Policies
*Insurance poilcy is written to cover an individual or family
*Usually provides less coverage at higher premiums
*Physical examinations are usually necessary
*Pr-existing conditions usually exist
*individual risks being denied coverage
Government Policies
*large groups of people that are covered by the insurance plans
*medicare is for individuals who are 65 years of age or older-could be disabled, blind or realstage ill diease
*medicaid is for medically individuals both government, federal, and state program
*tricare is a military policy for an active personnel, and eligible family memebers
*CHAMP VA is a health insurance for the spouse or dependents of veterans with a service related diability or the serving spouse of a veteran who died do to a service related disability
*workers comp is designated to protect workers against loss of wages and the cost of medical care or occupatient and illnesses
*Civerage may pay for a all or a portion of hosipital services
*Policy may have a maxium amount payable per day
*Policy may have a maximum number of inpatient days
*coverage may pay for all or a portion of surgeons fee
*surgeries may be performed in different facilities
*coverage may require a specific facility for services to be covered
*there may be a situation were they have to be at a hospital setting, maybe cane be done at an doctors office or an utpatient surgery center
*make sure that if you are working for a physician that does any type of surgical procedures that you do know what the poicies content is to know whether ot not the services are provided or covered for that particular location
*surguires can also be classified into services such as incisions or excisions, removal aform body, suitring, assperation and fraction repair
Basic Medical
*is coverage that is for all or part of physicians services
*patient may have a copay or insurance that is responsible for the services
*the plan may have divisions for diagnosis services to be rendered(x-rays, labortory test, pathology services)
*the plan may or may not cover preventative services, not all insurnce companies cover for patients to have their annual physical done
*make sure they are cover so that you will know whether or not to collect from the patient
*if they are covered make sure that you are billing for a preventative medicine exam vs an evaluation and mangement
Major Medical
*Also referred to Catastrophic coverage
*Provides coverage for Catastrophic or prolonged illnesses
*May be a supplemental to another insurance coverage
*Provides protection against large medical bills
*Provides cash benefits to covered employees who are unable to work as a result of an illness or injury(not work related)
*Short term ranges from 13 weeks to 24 months
*Long term can extend to age 65
*covers cleaning, restoration of teeth, root canal
*policies can vary from the benefits
*covers exams, eye glasses, and even contacts
*policies will vary depending on the benefits determining if copay will be do
Medicare Supplement
*is for patients who have medicare-help defry the cost for what is covered by medicare
*only pays for 80% for the plan and a deductible is do
*the supplemental insurance works as a coordination of benefits with medicare often referred to as a medigap policy and works in conjunction
Special Risk
*Coverage for certain types of accidents and illnesses
*There is usually maximum benefit paid

*Accidents:auto, plane, rock climbing, parachuting
*Illnesses:cancer, tuberculosis
Liability Insurance
*Liability policies cover individual who are injured inor on the insured parties properly(home, auto, business)
Life Insurance
*Policy provides a specified amount in the event of the insured's death
*Designated to a beneficiary
*Many different types of policies are available(Term, Whole Life, Variable Life)
Long Term Care Insurance
*Covers a continuum of a broad range of maintenance and health services to chronically ill, disabled or mentally retarded individuals
*Serivces may be provided and covered on an inpatient basis, outpatient or home
*HIPAA allows some federal income tax advantages for individuals who purchase this type of coverage
*Federal Health Insurance program
*coverage for:
-65 years of age or older
-Permanently disabled
*Part A-hospital insurance(automatic)
-Covers inpatient, skilled nursing home, home health and hospice
-Yearly deductible(can change annually)
-Coinsurance paid depends on facility and length of time

*Part B-medical insurance(voluntary)
-Covers outpatient, DME, provides, diagnostic tests
-Yearly deductible(can change annually)
-80/20 Coinsurance
*is a federal health and state program
*benefits depends on the state that the patient resides in cause they can vary from state to state
*the coverage is design for medical injured patients meaning if they don't have the capablility to pay for their care
*a provider can choose to accept or decline a medicaid patient
*if accepted they have to collect medicaid payment in full
*medicaid patients are low payers
*patients can be billed if medicaid does not cover the visit
*coverage is issued on a monthly basis and verify each month whether or not the patient is covered
*Blue Cross and Blue Shield sre pioneers in private insurance
*Some groups of BCBS have a non-profit status
*Originally, Blue Cross was to cover hospital expenses and Blue Shield was to cover physicians services
*Many different plans are available and vary in each state(traditional, managed care, point of service)
*The patients BCBS identification card will help in determining their benefits
*Providers can bill directly to the local BCBS for out of state BCBS coverage
*Previously known as CHAMPUS(Civilian Health and Medical Program of the Uniformed Services)
*Changed to TRICARE in January 1994
*Coverage is for active duty service members and their eligible family members
*TRICARE offers three coverage options:
*Standard-Fee for Service Plan
*Extra-PPO plan
*Prime-Manage care plan(HMO)
*Civilian Health and Medical Program of the Veterans Administration, Established in 1973
*Coverage for spouses and/or dependent children of vetrans with total, permanent service connected disabilities
*Coverage for surviving spouses and/or dependent children of vetrans who died as a result of a service related disability
*Administered through the VA's Health Administration Center in Denver, CO
*referred to as a private insurance company
*be careful how you work with them cause the plans vary so much
*payment can be sent to a subscriber or can be authorized to be sent directly to a provider
*make sure contact the insurance company prior to the patient being seen to make sure what will be covered and what the patient is responsible for
*we also want to know who the payment goes to so that the payment will be collected up front and later reimbursed
HMO Managed Care
*Health Maintenance Organization
*Providers(physician's & hospitals) have contracted with an insurance company to offer services at a fixed negotiated price
*May be restrictive and have many results
*The patient will be required to select a PCP(Primary Car Physician) that is a memberof the HMO
*HMO plans usually do not pay out of network
*Minimal out of pocket costs
*Must be referred to specialist
*Preferred Provider Organization
*The organization has contractual relationship with the insurance company
*Not as restrictive as HMO's
*Can see an out of network provider, but will increase out of pocket costs
*Do not need referral's to see specialist
*Allows the individual more control over their own healthcare
Workers Comp
*State law to protect employees against loss of wages and cost of medical care from occupational injury or illness
*Laws will differ in each state
*Benefits include medical, loss of income, survivor benefits
*Employer may use third party or be self insured
*May be able to chose provider of services
*Separate chart should be created for a patients work comp claim
Medical Necessity
*services being justified by the patients symptoms or diagnosis and orcordiance with the standards of good medical practice
*prove that the services that were rendered to the patient was necessary
*criteria includes the proper level of care and the appropriate setting
*services that are billed out is in the appropriate place
*insurance companies utilizes the information in making a decision to whether or not the services are going to be paid or denied
Indemnity Schedules
*An Indemnity plan reimburses the insured or the provider of services when a claim is filed
*The indemnity schedule explains the benefit payment amounts under the policy
*Insured may have out of pocket costs that they are responsible for under the policy(copay, deductible, etc)
Fee for Service
*The patient or third party reimburses the provider for each professional service performed
*A fee schedule is used by third parties for reimbursement
Fee Schedule
*has 3 commodities that a physician can actually sell(time, judgement, services)
*the fees of charge for services will vary for each office
*is a listing of those who are accepting charges for those services(depending on the type of insurance)
*practice could utilize more than 1 fee schedule
*will not have a fee schedule for every insurance company
*make sure you do have 1 for the insurance company the provider deals with
*the allowable amount is the full amount to be reimbursed by that insurance company
*if the patient is being paid for on a percentage is gonna be responsible on the allowable amount
Capitated Services
*Capitation is a system where providers are paid by a fixed, per capita amount for each member enrolled in the plan
*The payment is for a specific period of time(monthly, quarterly, annually)
*It is paid regardless of the services the patient receives
*The managed care will limit the number of members each provider can accept
*Providers will be paid even if the member has not received services
UCR Fees
*Usual, Customary and Reasonable Fees
*Method used to establish third party fee schedules
*Usual fee charged by provider
*Customary fee charged by other providers with the same skills and within the same geographic area
*Reasonable fee that is determined from a combination of the Usual and Customary fees
*Resource Based Relative Value Scale
*Consists of three components:
-Physican work
-Charge based professional liability expense
-Charge based overhead
*This system was designed to standardize payment with an adjustment for overhead costs in different geographic areas
Coordination of Benefits
*is a mechanism thats used to desinate the order when multiple carriers are billed in a paid invents
*you do need to know which policy will be billed first
*put together to limit the payment to a maximum of 100%
*a person having more than 1 insurance policy the individual becomes primary
* the use of the plan is to make sure the provider does not get paid more than 100%
The Birthday Rule
*This rule is applied when a minor is covered under more than one policy to determine which payer is primary
*The policyholder who's birthday, month and date, comes first in the year is primary
*This rule is in effect for the parent who has custody of the dependant and not remarried
*If the custodial parent has remarried, that parents plan is primary
*If the court has decreed one parent to be responsible, that parents plan is primary
Medical Savings Account
*In 1996 Congress created tax Medical Saving Accounts(MSA)
*Allows individuals to make tax free deposits into a MSA
*The money is used for health related expenses approved by the MSA program(copays, eyeglasses, vitamins, etc)
*There are advantages and disadvantages to MSA
*Investigate and understand prior to particiapating
The Federal Register
*Official daily publication for rules, propsed rules and notices of federal agencies and organization
*Was designed to centralize filing and publication of rules and regulations