What phrase was coined to indicate payment

third-party reimbursement

You can verify a patient's coverage in a number of ways. Which of the following is the best way to verify coverage?

Use online technologies to obtain the information, such as the eligibility check feature in the EHR

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?

health maintenance organization (HMO)

Health savings accounts (HSAs) were created by the federal government in 2003 and are know as:

consumer-driven health plans (CDHPs)

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?

Medicare

If both parents of a child have equal coverage, another variable might be the determining factor. In this situation, the _______ applies

birthday rule

When patients without health insurance are seen in the provider office, they are classified as which of the following?

self pay patients

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?

Utilization review

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:

Fee schedule

What is the term that describes payment by someone other than the patient for services rendered?

Third party reimbursement

If a Medicare patient is being provided with a service that might not be covered, what should the office do?

have the patient sign an ABN

What are the components used to calculate the Medicare physician fee schedule?

practice expense, malpractice expense, and provider work

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?

Health reimbursement arrangement

What is the government health plan that covers individuals who have a limited or low income?

Medicaid

The percentage a patient pays for services after the deductible has not been met is called?

Coinsurance

In a health maintenance organization (HMO), why is the PCP considered a "gatekeeper?

Because the PCP must coordinate a patient care and referral to a specialist

What is the first step required to verify patient eligibility?

The medical assistant determines if the insurance is a managed care plan

What is the methodology of the resource-based relative value scale?

To create the Medicare provider fee schedule

Which of the following statement best describe utilization review?

A method of assessing the quality and appropriateness of the care provided to its members.

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?

the affordable care act

Blue cross and blue shield health insurance plans are generally well-known examples of early years of

commercial health insurance plans

What type of insurance plan typically has high deductibles and lower monthly premiums?

consumer-driven health plans

Medicare part ________ was created to provide coverage for both generic and brand-name drugs

D

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?

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

The person who has been insured; an insurance policy holder.

Subscriber

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

third-party reimbursement

A document outlining services that will not be covered by a patient's insurance carrier and the cost associated with those services.

waiver

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

Third-party liability

Inclusive policies, procedures, and practices.

quality assurance

Prior approval of insurance converge and necessity of procedure.

Preauthorization

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

percertification

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

predetermination

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

medicare

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

Medicaid

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.

independent practice association

Private insurance to supplement Medicare benefits for payment of the deductible, copayment, and coinsurance.

Medigap

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

health savings account

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.

Geographic practice cost index

Term given to primary care providers because they are responsible for coordinating the patients care to specialist, hospital admissions, and so on.

Gatekeeper

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

Diagnosis-related group

payment for each service that is provided.

Fee-for-service

Person covered under a subscriber's insurance policy.

Dependent

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.

Explanation of benefits

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

coinsurance

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

copayment

An amount to be paid before insurance will pay.

Deductible

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

coordination of benefits

A means to identify primary responsibility in insurance coverage.

birthday rule

Person entitled to benefits of an insurance policy.

Beneficiary

The company who provides the policy.

carrier

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.

capitation

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.

Advance beneficiary notice

Provider agrees to accept the insurers payment as payment in full or the service provided.

accept assignment

The authorization, by signature of the patient, for payment to be made directly by the patients insurance to the provider for services.

assignment of benefits

The maximum amount an insurer will pay for any given service.

allowed amount