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a prospective payment to a provider made for each plan member
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the percentage of each claim that an insured person must pay
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GuntermanINS Ch 1
Intro to the Medical Billing Cycle
| Question | Answer |
|---|---|
| a prospective payment to a provider made for each plan member | capitation |
| the percentage of each claim that an insured person must pay | coinsurance |
| an amount that an insured person pays at the time of a visit to a provider | copayment |
| the amount that an insured person must pay before reimbursement for medical expenses begins | deductible |
| a health plan that reimburses policy holders based on the fees charged | fee-for-service |
| an organization that contracts with a network of providers for deliver of health care for aprepaid premium | HMO-health maintenance organization |
| a retroactive reimbursement method based on providers charges | indemnity |
| a managed care network of providers under contract to provide services at discounted fees | PPO-Preferred provider organization |
| the amount of money paid to a health plan to buy an insurance policy | premium |
| a list of medical services covered by an insurance policy | schedule of benefits |
| Spending on health care in the United States is rising due to what 2 factors | the cost of new technology and the aging population |
| Employment for well-trained medical insurance and coding specialists are | increasing due to rising demands. |
| What kind of medical services are annual physical examinations and routine screening procedures | preventive |
| Under an insurance contract the patient is the 1st party, the physician is the 2nd party, who is the 3rd party? | Insurance plan |
| Under a written insurance contract, teh policyholder pays a premium and the insurance company provides what | payments for covered medical services |
| Out-of-pocket expenses must be paid by who | the patient |
| What conditions must be met before payment is made under an indemnity plan? | payment of premium, deductible, and coinsurance |
| A capitated rate is | prospective payment |
| Correctly relating a patient's condition and treatment refers to | medical necessity |
| Which of the following is required with a HMO patient is admitted to the hospital for nonemergency treatment? | preauthorization |
| HMO's are regulated by | both federal and state law |
| Under a capitated rate for each plan member, who shares the risk? | Provider and the 3rd party payer |
| A capitated rate per member per month coveres what | services listed on the schedule of benefits |
| For a patient covered by an HMO, out-of-network means the provider is | not under contract with the payer |
| With a POS option under a HMO organization the patient may choose | to see a provider who is not int he HMO network |
| With a point-of-service type HMO the patient may use the services of | HMO network or out-of-network providers |
| To be covered patients who enroll in an HMO may use the services of | only HMO network providers |
| Under an indemnity plan a patient my use the services of | any provider |
| In a PPO plan referrals to specialists are | not required |
| Consumer-driven health plans combine a health plan with a special savings account that is used to pay the medical bills before what | the deductible is met |
| Employers that offer health plans to employees without using an insurance carrier is called | self-funded health plan |
| What is an example of a private-sector payer | insurance company |
| What government program covers patients who are over age 65? | Medicare |
| What government program covers people who cannot otherwise afford medical care | Medicaid |
| Step 1 of the medical billing cycle | Preregister patient |
| Step 2 of the medical billing cycle | Establish financial responsibility for visits |
| Step 3 of the medical billing cycle | Check in patient |
| Step 4 of the medical billing cycle | Check out patient |
| Step 5 of the medical billing cycle | Review coding compliance |
| Step 6 of the medical billing cycle | Check billing compliance |
| Step 7 of the medical billing cycle | Prepare and transmit claims |
| Step 8 of the medical billing cycle | Monitor payer adjudication |
| Step 9 of the medical billing cycle | Generate patient statements |
| Step 10 of the medical billing cycle | Follow up patient payments and handle collections |
| A patient ledger records what | The patient's financial transactions |
| What characterisitcs is most important when medical insurance specialists work with patients' records and handle finances? | honesty and integrity |
| standards of conduct based on moral principles | professional ethics |
| standards of professional behavior | professional etiquette |
| Registered Medical Assistant (RMA) is awarded by | (AMT) American Medical Technologists |
| Certified Medical Assistant (CMA) is awarded by | (AAMA) American Association of Medical Assistants |
| Certified Coding Specialist, (CCS) and Certified coding Specialist-Physician based (CCS-P) is awarded by | (AHIMA) American Health Information Management Association |
Created by:
monicagunterman