Building A Foundation Study Guide
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| Insurance | Financial protection against loss against loss or harm arising out of specified circumstances in return for payment, called a premium.
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| Undesirable Events | Illnesses and Injuries
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| Preventative Medicine | Keeping a person well or catching and treating an emerging illness in its early stages.
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| Indemnity Insurance | Fee-for-service. The standard type of health insurance individuals can purchase, which provides comprehensive major medical benefits and allows insured individuals to choose any physician or hospital when seeking medical care.
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| Groups Plans | A group health insurance plan is one insurance plan to cover its employees; however group plans are not limited to employers. Employed for a set # of hours.
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| Preexisting Condition | Certain illnesses or injuries that exist before an effective date of the insurance policy are not covered.
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| HIPAA | Health Insurance Portability and Accountability Act (1996)-requires most employer-sponsored group health insurance plans to accept transfers from other group plans without imposing a preexisting condition clause.
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| Four main provisions of HIPAA | 1. allows portability of health insurance coverage. 2. protects workers and their families from pre-existing conditions when they change or lose their jobs.
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| Four main provisions of HIPAA | 3. establishes national standards for electronic healthcare transactions and national identifiers. 4. addresses the security privacy of health data.
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| Standard Insurance Form | CMS-1500-used by all government and most commercial insurance payers.
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| Malpractice | Medical malpractice is an act or omission by a health care provider which deviates from accepted standards of practice in the medical community and which causes injury to the patient. Medical malpractice is professional negligence that causes injury.
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| Emanipated minor | Applies to youth older than age 16 and younger than 18 who are: living separate and apart from their parents. Not receiving financial support. Living beyond the parent's custody and control. Not in foster care.
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| Implied Contract | Contract between a healthcare provider and a patient.
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| Federal Privacy Act of 1974 | Protects individuals by regulating when and how local, state, and federal governments and their agencies can request indivduals to disclose their SSN, and if information is obtained, must be held as confidential by those agencies.
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| Ethics | Standards of human conduct-sometimes called "morals" (from the latin word mores, meaning customs" of a particular group or culture. Following rules.
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| Documentation | Determines the level of service, establishes medical necessity, establish fee charges. A medical health record is a clinical scientific,adminstrative, and legal document of facts containing statements relating to a patient.
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| Timeliness | According to JCAHO is within 24 hours of the encounter.
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| Subpoena Duces Tecum | Is a legal document that requires an individual to appear in court with a piece of evidence that can be used or inspected the court.
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| Managed Care | Medical care that is provided by a corporation established under state and federal laws. A managed care provide tells patients which physicians they can see, monitors the medicatios and treatments prescribed, and ensure enrollees that their costs are low
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| UCR | Usual, customary, and reasonable. UCR rates are the part of a provider's change that the insurance carrier allows as covered expenses.
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| Medicare-funded and administered by the Federal government. | A federal health insurance program that provides benefits to individuals 65 years old or older and individual's younger than with certain disabilities. Inacted in 1965 under President Johnson.
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| Medicaid-Federal funded and administered by the state. | Covers some low-income individuals (particularly children and pregnant women) and certain disabled individuals. Medicaid is a joint federal-state health program that is administered by the individual states. Inacted in 1965 under President Johnson.
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| Workers' Comp | Insurance that pays workers who are injured or disabled on the job or have job-related illnesses Laws governing workers' compensation are designed to ensure that employees who are injured or disabled on the job are provided with fixed monetary awards.
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| Securitas | Latin word meaning "insurance".
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| Blue Shield start | The Blue Shield concept grew out of the lumber and mining camps of the Pacific Northwest at the turn of the 20th century.
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| Premium | Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium (meaning payment). To keep insurance active.
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| COBRA | Means-Consolidated Omnibus Budget Reconciliation Act of 1986 allows individuals to purchase temporary continuation of group health plan coverage if they are laid off, are fired for any reason or must quit because of an injury or illness.
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| Medical Savings | Is a special tax shelter set up for the purpose of paying medical bills.
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| NonPar | A nonparticipating provider has no contractual agreement with the insurance carrier; the provider does not have to accept insurance company's reimbursement as payment in full.
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| Deductible | The amount you have to pay out-of-pocket for expenses before the insurance company will cover the remaining costs.
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| Coinsurance | Co-sharing agreement between the insured and the insurer under a health insurance policy which provides that the insured will cover a set percentage of the covered costs after the deductible has been paid. Portion/or percentage.
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| Spelling Words | Confidentiality, Guarantor, Etiquette, Litigious, Reimbursement, Accoutability, Therapeutic, Peripheral, Etiology, Specificity, Disseminated, Emancipated, Preventive, Pharmaceutical, Exorbitant, Diligence, Metamorphosis, Indemnity
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| Flexible Spending Account | Is an IRS section 125 cafeteria plan. A plan falls under the cafeteria category when the cost of the plan (premium) is deducted from the employee's wages before withholding taxes are deducted.
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| Health Insurance Professional | To complete and submit insurance claims, conduct billing and collection procedures, generate as much money for the practice as legally and ethically possible.
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| Respondent Superior | The employer is ultimately responsible for employee actions. "Let the master answer".
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| Negligence | Failure to exercise a reasonable degree of care/
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| Experts believe that increasing healthcare cost are due to: | The "graying of American", advances in medical technology, more demand for healthcare.
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| Individual Policy | More expensive of you go through an employer.
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| All learning institutions offer programs where students can receive extensive hands-on-training and practice in medical insurance billing and coding. | False
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| A 4 year degree is not offered in any medical field except nursing? | False
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| Autonomy-doing things on your own without supervisionis frowned on in medical facilities? | False
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| The career prospects of a health insurance professional are limited to the physicians' offices. | False
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| HIPAA has limited the amount of jobs available in healthcare because of its encourgement of computer-to-computer claim filing? | False
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| Medical laws regulatign insurance are the same from state to state? | False
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| All states require that all types of insurance policies be filed with and approved by the state regulatory authorities before the policy can be sold? | False
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| A contract betwee an insurance company and the insured party cannot be terminated? | False
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| The healthcare provider can terminated the physician/patient contract by simply discharging the patient? | False
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| Records are property of the healthcare provider and must be preserved as long as the patient is alive? | False
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| All patient record documentation must be performed by the physician? | False
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| HIPAA's impact is felt only in medical facilities? | False
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| It is now commonly accepted that patients are the legal owner of their medical records? | False
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| A written release of information is not necessary to proces an insurance claim for a patient's financial benefit? | False
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| There are never any exceptions to patient confidentiality? | False
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| In the world of health insurance, fraud and abuse are techinically the same thing? | False
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| All third party insurers have the same UCR rates? | False
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| Insurance policies that combine basic and major medical coverage are referred to as "managed care plan"? | False
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| Under no circumstances will a third party payer cover services rendered for "preexisting conditions? | False
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