front 1 What phrase was coined to indicate payment | back 1 third-party reimbursement |
front 2 You can verify a patient's coverage in a number of ways. Which of the following is the best way to verify coverage? | back 2 Use online technologies to obtain the information, such as the eligibility check feature in the EHR |
front 3 Which type of insurance plan requires their member to choose a primary care provider (PCP) to oversee their medical care, where the PCP is responsible for referring the patient to a specialist and approving additional services if needed? | back 3 health maintenance organization (HMO) |
front 4 Health savings accounts (HSAs) were created by the federal government in 2003 and are know as: | back 4 consumer-driven health plans (CDHPs) |
front 5 What is the name of the program of health insurance administered under the social security administration for people over the age of 65 who meet the eligibility requirements and have filed for coverage? | back 5 Medicare |
front 6 If both parents of a child have equal coverage, another variable might be the determining factor. In this situation, the _______ applies | back 6 birthday rule |
front 7 When patients without health insurance are seen in the provider office, they are classified as which of the following? | back 7 self pay patients |
front 8 Which term refers to an evaluation of health care services to determine the medical necessity, appropriateness, and cost0effecriveness if the treatment plans for a given patient? | back 8 Utilization review |
front 9 Medicare and other carriers enlist physicians and other providers to sign up as approved or preferred providers in their network. This means that the provider agree to treat subscribers enrolled in the network for an agreed-upon, discounted, rate for services. This rate is referred to as: | back 9 Fee schedule |
front 10 What is the term that describes payment by someone other than the patient for services rendered? | back 10 Third party reimbursement |
front 11 If a Medicare patient is being provided with a service that might not be covered, what should the office do? | back 11 have the patient sign an ABN |
front 12 What are the components used to calculate the Medicare physician fee schedule? | back 12 practice expense, malpractice expense, and provider work |
front 13 What is a consumer driven health plan In which only the employer contributes, and the money is not lost at the end of the year called? | back 13 Health reimbursement arrangement |
front 14 What is the government health plan that covers individuals who have a limited or low income? | back 14 Medicaid |
front 15 The percentage a patient pays for services after the deductible has not been met is called? | back 15 Coinsurance |
front 16 In a health maintenance organization (HMO), why is the PCP considered a "gatekeeper? | back 16 Because the PCP must coordinate a patient care and referral to a specialist |
front 17 What is the first step required to verify patient eligibility? | back 17 The medical assistant determines if the insurance is a managed care plan |
front 18 What is the methodology of the resource-based relative value scale? | back 18 To create the Medicare provider fee schedule |
front 19 Which of the following statement best describe utilization review? | back 19 A method of assessing the quality and appropriateness of the care provided to its members. |
front 20 What is the name of the legislation that passed in 2010 which mandates minimum converge that must be offered by every health insurer and requires every American to purchase health insurance, or face fines, taxes and penalties? | back 20 the affordable care act |
front 21 Blue cross and blue shield health insurance plans are generally well-known examples of early years of | back 21 commercial health insurance plans |
front 22 What type of insurance plan typically has high deductibles and lower monthly premiums? | back 22 consumer-driven health plans |
front 23 Medicare part ________ was created to provide coverage for both generic and brand-name drugs | back 23 D |
front 24 Providers who sign a contract with medicare to be a participating provider receive payment directly from medicare for services rendered. Providers who choose not to be a participating provider can charge what amount of the medicare participating provider fee schedule amount for the services rendered? | back 24 only 15 percent above the participating provider fee schedule amount for the service rendered |
front 25 What percent of the approved amount will Medicare pay after the deductible is satisfied? | back 25 80 |
front 26 Which type of claim is automatically forwarded from Medicare to a secondary insurer after Medicare has paid its portion of a service? | back 26 crossover claim |
front 27 Which of the following is a system of health care that integrates the delivery and payment of health care for covered persons by contracting with selected providers for comprehensive health care services at a reduced cost? | back 27 Managed care |
front 28 Part _____ of Medicare is for hospital coverage, and any person who is receiving monthly social security benefits is automatically enrolled. | back 28 A |
front 29 Part ___ of Medicare is for payment of other medical expenses, including office visits, X-Ray and laboratory services, and the services of a provider in or out of the hospital | back 29 B |
front 30 Part _____ is the segment of Medicare that enables beneficiaries to select a managed care plan as their primary coverage | back 30 c |
front 31 The person who has been insured; an insurance policy holder. | back 31 Subscriber |
front 32 A phrase coined to indicate payment of services rendered by someone other than the patient. | back 32 third-party reimbursement |
front 33 A document outlining services that will not be covered by a patient's insurance carrier and the cost associated with those services. | back 33 waiver |
front 34 Refers to the legal obligation of third parties to pay part or all of the expenditures for medical assistance furnished under a state plan. | back 34 Third-party liability |
front 35 Inclusive policies, procedures, and practices. | back 35 quality assurance |
front 36 Prior approval of insurance converge and necessity of procedure. | back 36 Preauthorization |
front 37 refers to obtaining plan approval for services prior to the patient receiving them. | back 37 percertification |
front 38 refers to the discovery of the maximum amount of money the carrier will pay for primary surgery, consultation service, postoperative care, and so on. | back 38 predetermination |
front 39 A federal program for providing health care coverage for individuals over the age of 65 or those who are disabled. | back 39 medicare |
front 40 A joint funding program by federal and state governments (excluding Arizona) for the medical care or low-income patients on public assistance . | back 40 Medicaid |
front 41 An association of independent physicians, or other organizations that contracts with independent physicians, and provides services to managed care organizations on a negotiated per capita rate, flat retainer fee, or negotiated fee-for-service basis. | back 41 independent practice association |
front 42 Private insurance to supplement Medicare benefits for payment of the deductible, copayment, and coinsurance. | back 42 Medigap |
front 43 A tax-sheltered savings account, with contributions from the employer and employee, which can be used to pay for medical expenses. | back 43 health savings account |
front 44 Applying this results in different payment amounts, depending on the location of the provider's practice, and amounts can vary from state to state and even within the same state, depending on whether the location is considered urban or suburban. | back 44 Geographic practice cost index |
front 45 Term given to primary care providers because they are responsible for coordinating the patients care to specialist, hospital admissions, and so on. | back 45 Gatekeeper |
front 46 Method of determining reimbursement from medical insurance according to diagnosis on a prospective basis. | back 46 Diagnosis-related group |
front 47 payment for each service that is provided. | back 47 Fee-for-service |
front 48 Person covered under a subscriber's insurance policy. | back 48 Dependent |
front 49 Providers information to the patient about how an insurance claim from a health provider (such as a doctor or hospital) was paid on his behalf. | back 49 Explanation of benefits |
front 50 A percentage that a patient is responsible for paying for each service after the deductible has been met. | back 50 coinsurance |
front 51 A specified amount the insured must pay toward the charge for professional services rendered at the time of service. | back 51 copayment |
front 52 An amount to be paid before insurance will pay. | back 52 Deductible |
front 53 Procedures insurers use to avoid duplication of payment on claims when the patient has more than one policy. | back 53 coordination of benefits |
front 54 A means to identify primary responsibility in insurance coverage. | back 54 birthday rule |
front 55 Person entitled to benefits of an insurance policy. | back 55 Beneficiary |
front 56 The company who provides the policy. | back 56 carrier |
front 57 The health care provider is paid a fixed amount per member per month for each patient who is a member of a particular insurance regardless of whether services were provided. | back 57 capitation |
front 58 Document used to notify a medicare beneficiary that it is either unlikely that medicare will not pay for the service they are going to be provided. | back 58 Advance beneficiary notice |
front 59 Provider agrees to accept the insurers payment as payment in full or the service provided. | back 59 accept assignment |
front 60 The authorization, by signature of the patient, for payment to be made directly by the patients insurance to the provider for services. | back 60 assignment of benefits |
front 61 The maximum amount an insurer will pay for any given service. | back 61 allowed amount |