MA 105 Exam 1 Study Guide Questions And Answers Solved.

Deductible - correct answers a specific amount of money paid before policy benefits begin Copay - correct answers the amount of money a managed care plan requires a patient to pay in the office prior to being seen by a provider Coinsurance - correct answers cost sharing requirement where the insured pays a percentage of the fee Exclusion - correct answers a service never covered within a health insurance policy Preexisting - correct answers conditions existing and treated prior to the effective date of a policy Eligibility verification - correct answers check and confirm that a patient is a member of the insurance plan and the provided identification number is correct Premium - correct answers an amount of money that is usually paid monthly to keep a policy in force. claim adjudicator - correct answers an insurance claim representative Daysheet - correct answers a record sheet used to record daily business transactions Ledger - correct answers a patient's financial accounting record What are some other terms that are used to refer to an insured individual? - correct answers policy holder subscriber member Describe the differences between the terms Preauthorization, Precertification, and Predetermination. - correct answers Preauthorization determines if a procedure is covered and medically necessary Precertification is discovers whether a treatment (surgery, hospitalization, tests) is covered under a patient contract Guarantor - correct answers An individual who promises to pay a medical bill by signing an agreement or by accepting treatment Define the birthday rule - correct answers It indicates which parent has primary coverage for a child; and is determined by the parent who's birthday comes first in the calendar year What is an assignment of insurance benefits? - correct answers It allows the healthcare provider to receive reimbursement directly from the insurance a) The patient must sign an assignment of benefits statement which What is the difference between a participating and non participating physician/provider? - correct answers Participating providers contract with an insurance plan to render care to beneficiaries and bills the third-party payer directly Non par providers do not have a contract to accept an allowed amount. They may or may not file a courtesy insurance claim. They may obtain full payment at the time of service. Legal issues involving private health insurance are considered under what type of law a)What about Medicare, Medicaid, and Tricare? - correct answers civil law a) federal law What does medically necessary refer to? - correct answers A decision made by a health plan that a particularly treatment, test, or procedure is essential for a patient's health or to treat diagnosed medical problem. What two laws, when combined together are commonly referred to as the Affordable Care Act? - correct answers The Patient Protection and Affordable Care Act (PPACA) of 2010 The Healthcare and Education Reconciliation Act (HCERA) of 2010 What are other terms used to describe an encounter form? a) what is an encounter form used for in a medical office? b) what information is included on the form? - correct answers charge slip, routing form, superbill, transaction slip, multi purpose billing form a) a communication tool (routing sheet) and as an invoice to the patient, as a routing sheet it becomes a source document for insurance claim data b) procedure and diagnosis codes, patient's name, date, and in some instances the previous balance due In terms of the law, what is an insurance policy? - correct answers A legally enforceable agreement, or contract. Under healthcare reform legislation of 2010, health plans must allow employees to keep their children on their plans until what age? - correct answers 26 years old Define coordination of benefits. - correct answers To prevent duplication of payment for the same expense when a patient has more than one medical policies What are the differences between an implied and expressed contract? a) which type of contract is between a physician-patient? - correct answers Implied is deduced from circumstance, the general language, or the conduct of the patient, not by direct words. Expressed contract can be verbal or written a) Implied Can an insurance billing specialist plead ignorance to escape liability? - correct answers No Define emancipated minor. a) Who is responsible for medical bills of college students living away from home? - correct answers a person younger than 18 y/o who lives independently, is totally self-supporting, is married or divorced, is a parent even if not married, ,or is in the military and possesses decision-making rights. a)The college student because they are considered emancipated if they are not living at home. Describe COBRA. What does the abbreviation COBRA stand for? - correct answers When an employee is laid off from a company with 20 or more workers, federal law requires that the group health insurance coverage be extended to the employee and his or her dependents at group rates for up to 18 months. What are the guidelines for submitting insurance claims when a physician has fewer than 10 employees. - correct answers They must submit electronically unless they have fewer then 10 employees and they can submit s. What are some saving options associated with Consumer Directed Health Plans (High Deductible Health Plans)? - correct answers Medical savings accounts Health savings accounts Health reimbursement arrangements Flexible spending account What does the acronym CDHP stand for? - correct answers Consumer Driven Health Plan Describe a CDHP. - correct answers Patients design their health plan, based on their own needs and circumstances pairing a high-deductible PPO plan with a tax-advantaged savings account What types of funding options are coupled with CDHP's? - correct answers Medical Savings Accounts Health Savings Accounts Flexible Spending Accounts Health Reimbursement Accounts Describe a Flexible Spending Account. - correct answers An employer sponsored account, allowing employees to put a specific amount of wages aside for qualified expenses, but has a "use it or lose it" rule that only allows employees to carry over $500 to the following year Describe a Health Reimbursement Account. - correct answers An employer owned account, in which only the employer is eligible to make contributions to help pay for the employee's eligible medical expenses. The employee submits a bill for the medical services to the employer and receives reimbursement. Describe a Health Savings Account. - correct answers A tax-favored savings account, in which a working person deposits money for use in paying for qualified medical expenses and any unspent funds roll over from year to year. It is regulated much like an IRA and it may be used on non medical expenses once the patient reaches retirement age What is a group contract? - correct answers An insurance plan, by which a group of employees is insured under a single policy issued to an employer with individual certificates given to each insured. What is an individual contract? - correct answers An insurance plan issued directly to an individual and their dependents Define indemnity health insurance. - correct answers Payment is made each time a service is rendered on a fee-for-service basis and allows patients maximum flexibility and choice of providers Define managed care. - correct answers A method to control health care costs where the insurance company helps decide how much care a patient receives, what kind of care he or she receives, and who can provide the service. Describe "Exchanges". - correct answers An organized marketplace where uninsured individuals and small-business owners can find health insurance coverage from private plans in their area. Individual mandate - correct answers Required to have coverage or be penalized Expressed contract - correct answers Verbal written Preauthorization - correct answers Prior approval for treatment and procedures Precertification - correct answers refers to discovering whether a treatment (surgery, hospitalization, tests) is covered under a patients contract Predetermination - correct answers Discovering the maximum dollar amount that the carrier will pay for a procedure is called _______________________.