Ch. 8: Insurance

T/F After World War II, group health insurance became a commonly accepted employment benefit.

true

T/F Medicare covers all health care expenses.

false

T/F All claims in the United States will eventually be filed electronically.

true

T/F A copayment is a fixed percentage of covered charges after the deductible is met.

false

T/F Expenses such a routine eye examinations or dental care not covered by an insurance company are called exclusions.

true

T/F A medical assistant has the responsibility to interpret the patient's insurance policy or extent of coverage.

false

T/F Some insurers will not pay a claim unless it is filed within 6 months of the date of service.

true

T/F The concept of usual, customary, and reasonable (UCR) fees was originally developed by Congress to pay medical insurance claims under Medicare.

true

T/F The Health Care Financing Administration (HCFA) is the most common insurance claim form.

true

T/F Fold the HCFA-1500 form for OCR before mailing

false

T/F Generally, disability insurance is less expensive than life, home, or automobile insurance

false

T/F Medicaid is an insurance program

false

T/F Older or disabled patients who have Medicare and cannot pay the difference between the bill and the Medicare payment qualify for Medi/Medi

true

T/F Blue Cross/Blue Shield is one large corporation.

false

T/F The Blue Cross/Blue Shield service benefit policy provides payment in full for all services it covers

true

T/F All medical practices have to cover worker's compensation cases

false

T/F A patient belonging to an HMO does not need pre-approval or authorization for inpatient surgery from the primary care physician or HMO

false

T/F Medicare discourages practices to file claims electronically

false

The first insurance plans began during what war?

Civil

What was the first type of insurance created?

accident

The first health insurance was created to cover

lost income because of disability

The first group policy giving comprehensive benefits emerged in

1847

The prepaid concept became the foundation for _____ insurance

Blue Cross

The goal of Blue Cross/Blue Shield was to

make health insurance accessible to as many people as possible

The first modern group health insurance became an employment benefit because

a group of school teachers in Dallas, Texas joined forces and requested it

The first national health insurance for Americans age 65 and older is

Medicare

The underlying principle of all types of insurance is

the law of probability

The term CO-INSURANCE means

that the insured pays or shares part of the medical bill with the insurance company, usually according to a fixed percentage

The amount required to be paid by the insured under a health insurance contract benefits become payable is referred to as

a deductible

Many patients carry supplementary medical coverage beyond the basic medical and surgical policies. These are commonly referred to as

major medical insurance

Which of the following is true of Part A Medicare?

there is a deductible

Which of the following statements are true regarding Part B Medicare

a. participation in the plan is voluntary

b. a monthly premium must be paid

c. the patient must pay a deductible

d. all of the above

When preparing any Medicare claim form, certain information must be obtained from the patient's ID card. What is NOT recorded on this card?

the beneficiary's address

Which of the following services are NOT covered under Part B Medicare?

1. routine physical examinations

2. prescriptions for eyeglasses and hearing aids

3. radiation therapy

4. rental of wheelchairs

Answer: 1 and 2

The most common reason for Medicare claim forms being rejected without any payment is because

of incomplete information and errors

The federal government participates with each of the individual states in a medical assistance plan for the indigent known as

Medicaid

Medicaid is

a program of medicare care for the needy provided by the title XIX of the Social Security Amendments of 1965

Blue Cross and Blue Shield insurance plans are nonprofit organizations and as such

a. pay no benefits

b. operate at a continual loss

c. are considered as charitable institutions

d. none of the above

Under a law passed in 1956, TRICARE formerly CHAMPUS, provides medical and hospital care for

a. all dependents of members of the armed services on active duty

b. all retired military personnel and their dependents

c. members of the Coast Guard

d. all of the above

The medical assistant should always check the TRICARE beneficiary notification card because loss of eligibility is automatic at

age 65

For retired TRICARE beneficiaries, at age 65

loss of TRICARE benefits is automatic

An insurance contract written for a company for its employees is called

group coverage

A patient who is 68 years old is most likely covered by what type of insurance?

Medicare

Medicare pays

80%

To establish eligibility for Medicaid you must check their

a. current ID

b. policy number

c. social security number

d. all of the above

Persons who are unable to pay for medical care or who have dependent children, may apply for

Medicaid

What kind of insurance provides medical care for job-related accidents and illness

Workers' Compensation

The type of insurance that provides income when the insured is unable to work due to illness or injury is

Disability

The physician or supplier giving medical care or services is called

provider

What is the person called who carries the medical insurance?

subscriber

The word indicating the date medical insurance coverage begins is

effective

Insurance that provides weekly or monthly cash benefits to employed policy holders who become unable to work because of accident or illness is called

loss of income protection

CATASTROPHIC coverage is referred to as

major medical insurance

Hospital insurance is included under Medicare

in Part A

Blue Shield makes direct payments to

physician members

A bed patient in a hospital who is entitled to Medicare benefits is covered for up to

90 hospital days for each benefit period

Within 48 hours after a physician has seen a Workman's Compensation patient for the first time, a report is type in:

quadruplicate

A bill is never sent to the patient in which type of case?

Workers' Compensation

The amount charged for a medical insurance policy is called

premium

Coordination of benefits is also known as

non-duplication of benefits

Blue Cross offers which method of reimbursement?

fee for service

In most cases, the insurer pay an annual cost or _______ for health care insurance

premium

A fixed dollar amount the subscriber must pay or "meet" each year before the insurer begins to cover expenses is the

deductible

Some medical practices may require the subscriber to pay a small fee at the time of service, called a/an

copayment

The Physicians' Current Procedural Terminology (CPT) manual provides

procedure and diagnosis codes

In a typical medical practice, insurance claims are filed:

7 to 10 business days from the date of service

The most likely outcome of a submitted insurance claim with a diagnosis code of a sore throat and a treatment code indicating a cast for a broken leg would be:

denied as a billing error b/c the treatment was not medically necessary based on diagnosis

When an insurance claims department compares the fee the doctor charges with the benefits provided by the patient's health insurance, it is called the:

review for allowable benefits

Which of the following is what the patient owes after the insurance company has paid?

subscriber liability

The most appropriate response from a medical assistant when a patient calls the medical practice questioning why an insurance claim was rejected is:

"Check the explanation of benefits form"

The average fee a physician charges for a service or procedure is the _____ fee.

usual