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 service rendered?

Only 15 percent above the participating provider fee schedule amount for the service rendered

What percent of the approved amount will Medicare pay after the deductible is satisfied?

80

Which type of claim is automatically forwarded from Medicare to a secondary insurer after Medicare has paid its portion of a service?

Crossover claim

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?

managed care

Part ___ of Medicare is for hospital coverage, and any person who is receiving monthly Social Security benefits is automatically enrolled.

A

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.

B

Part ___ is the segment of Medicare that enables beneficiaries to select a managed care plan as their primary coverage.

C

Waiver

a document outlining services that will not be covered by a patients insurance carrier and the cost associated with those services

Third-party reimbursement

a phrase coined to indicate payment of services rendered by someone other than the patient

Subscriber

the person that has been insured; an insurance policy holder

Third-party liability

refers to the legal obligation of the third parties to pay part or all of the expenditures for medical assistance furnished under a state plan.

Precertification

refers to obtaining plan approval for services prior to the patient receiving them

Quality Assurance

inclusive policies, procedures, and practices

Predetermination

refers to the discovery of the maximum amount of money the carrier will pay for primary surgery, consultation service, postoperative care, and so on

Preauthorization

prior approval of insurance coverage and necessity of procedure

independent practice association

an association of independent physicians, or other organization that contacts 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

Medicaid

a joint funding program by federal and state governments (excluding Arizona) for medical care low-income patients on public assistance

Medicare

a federal program for providing health care coverage for individuals over the age of 65 or those who are disabled.

Medigap

private insurance to supplement Medicare benefits for payment of the deductible, co-payment and coinsurance

Primary

occurring first in time, development or sequence

Health savings account

a tax-sheltered savings account with contributions from the employer and employee, which can be used to pay medical expenses

Indemnity plan

a commercial plan in which the company (insurance) or group reimburses providers or beneficiaries for services; allows subscribers more flexibility in obtaining services

Health reimbursement arrangement

pays for medical expenses; it can be paired with a standard or high-deductible health plan

flexible spending arrangement (FSA)

referred to as the cafeteria plan

Geographic practice cost index

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

Gatekeeper

a PCP who coordinates the patient's referral to specialists and hospital admissions

Fee schedule

a list of predetermined payment amounts for professional services provided to patients

Explanation benefits

a printed description of the benefits provided by the insurer to the beneficiary; provides information to the patient how an insurance claim from a health provider was paid on his or her behalf

Fee-for-service

payment for each service that is provided

Dependent

person covered under a subscriber's insurance policy; refers to spouses and dependent children

Diagnosis-related group

method of determining reimbursement from medical insurance according to diagnosis on a prospective basis

Deductible

an amount to be paid before insurance will pay

Copayment

a specified amount the insured must pay toward the charge for professional services rendered at the time of service

Coordination of benefits

procedures insurers use to avoid duplication of payment on claims when the patient has more than one policy

Coinsurance

a percentage that a patient is responsible for paying for each service after the deductible has been met

Capitation

a health care provider is paid a fixed amount per member per month for each patient who is a member of a particular insurance organization regardless of whether services were provided

Beneficiary

person entitled to benefits of an insurance policy; this term is most widely used by Medicare

Carrier

the company who provides the insurance policy

Birthday rule

a means to identify primary responsibility in insurance coverage.

Advance beneficiary notice

document used to notify a Medicare beneficiary that is either unlikely that Medicare will pay or certain that Medicare will not pay for the service they are going to be provided; beneficiaries are required to sign this document if they wish to have the service with the understanding that they will responsible for payment

Allowed amount

the maximum amount an insurer will pay for any given service

Accept assignment

provider agrees to accept the insurer's payment as payment in full for the service provided

Assignment of benefits

the authorization, by signature of the patient, for payment to be made directly by the patient's insurance to the provider for services