Test Review for Chapters 7 and 8: Business Terminology and Definitions

Insurance through employment, with all employees having one master policy.

group insurance

Person who is covered by an insurance policy.

insured

Company that provides insurance benefits.

carrier

Provides reimbursement for income lost because of insured's illness.

disability insurance

Rate charged for policy.

premium

Professional who supplies healthcare.

provider

Ensures that payment for medical expenses will not exceed 100 percent of the medical expenses.

COB

Generally covers hospitalization, lab tests, surgery, and x-rays.

basic insurance plan

A term used to describe an insurance company in the context of the doctor-patient relationship.

third-party payer

Covers medically necessary services while insured is an inpatient.

hospital insurance

Covers physician's services for office visits.

medical insurance

Covers medical expenses in a catastrophic situation.

major medical insurance

In a family with two insurance contracts, determines which policy will be the primary carrier for the children.

Birthday Rule

Covers physician's fee for surgery.

surgical insurance

Person in whose name the policy is written.

policyholder

What is the term for the amount of medical expense that the insured must pay before the insurance carrier begins paying?

deductible

What is the abbreviation for the government agency that administers the Medicare and Medicaid programs?

CMS

In a(n) ______ plan, the patient chooses their provider and the insurance company reimburses medical costs on a fee-for-service basis.

Indemnity

What is the definition of coinsurance?

Percentage of each covered claim that the insured must pay.

Which of the following Medicare benefits are those who are eligible for Social Security benefits automatically enrolled in?

Part A

Billing a patient for any amount due on a provider's bill after the insurance company has taken care of its responsibility is termed what?

balance billing

An individual provider's average charge for a certain procedure.

Usual Fee

Determined by what physicians with similar expertise in a certain geographic location charge for a procedure.

Customary Fee

A fee allowed or approved by the insurance carrier for a difficult or complicated service.

Reasonable Fee

Each time HMO and PPO members visit their physician, they pay a set charge called a ______.

copayment

What type of provider agrees to accept the allowed charge set forth by the insurance company as payment in full if accepting assignment?

PAR

A physician receives $35 per month for each patient assigned to him or her, even if the patient receives no care during that month. What type of payment plan would this be considered?

capitation

A Medicare nonparticipating provider decides whether to accept assignment on a ______________ basis.

claim-by-claim

Which of the following is not a factor for which Resource-based relative value scale (RBRVS) is based upon?

the deductible the patient must pay

When the amount the physician charges is more than the insurance company's allowed charge, the difference in cost must be absorbed by either the ______ or the physician.

patient

Stated amount an insured must pay for an insurance policy

Premium

Physician or other provider who agrees to treat the patient

Provider

Insurance payment that pays a prepaid, stated amount to the provider for covered services within a stated period of time

Capitation

Percentage of a covered claim that the insured must pay

Coinsurance

Provider who agrees to offer covered services per a plan's contract rules and regulations

PAR

Organization that administers Medicare and Medicaid

CMS

Used to record patient encounter diagnoses and procedures

Patient encounter form

Alphanumeric coding system used to record supplies and procedures

HCPCS

Insurance carrier

Third-party payer

Most popular insurance plan in the United States

Managed care

Patient A had a CBC and a PFT performed. Which type of insurance will cover the services?

basic

Noelle's insurance policy states she has a coinsurance of 90/10 of covered services. When she received her notice from the insurance carrier, it stated that the charges for her last office visit were not allowed. How much of the charges is Noelle responsible for?

100 percent

Under his insurance plan, Tyler is required to have prior approval for his upcoming knee replacement. Before the surgery, the surgeon must have which approval document from the insurance plan for the surgery?

preauthorization/precertification approval

Michelle and her husband, Drew, just had a baby. Michelle is laid off from her job and Drew works part-time at a gas station. They are without insurance coverage. The administrative medical assistant should supply Michelle and Drew with the contact information for

Medicaid.

Dr. Abrams receives payment from BCBS for services rendered to patients covered by the plan. This is known as

assignment of benefits.

If the standard fee for a Medicare covered service is $150 and the Medicare nonPAR fee schedule for the service is $142.50, what is the limiting charge for the service?

$163.88

The insurance carrier has requested codes to indicate where its insured's injury took place. Which of the following code categories will be used?

V-Y codes

Luke last visited his physician, which is a single-physician practice, in September 2014. He is at the office today for a sore throat and chest congestion. Since he was already a patient, the medical insurance coder submitted an established patient E/M code to Luke's insurance carrier for payment. The insurance carrier requested additional documentation on the visit. Which of the following may have been the reason?

Luke's visit should have been coded from the new patient E/M category.

During Luke's visit to his physician's office for a sore throat and chest congestion, a CBC was performed. Which type of code(s) should be used for the service?

Bundled code

A claim was submitted with a diagnosis code for a Stage 4 ulcer on the left foot and a procedure code for a hernia repair. Payment was denied. Which of the following is a reason for the denial?

lack of medical necessity

The term ______ payer is used if the patient has a policy with an insurance company in which the insurance company agrees to carry the risk of paying for the medical services rendered.

third-party

Ellen Gold, a traditional-plan Medicare patient, does not understand her last month's medical statement. She already paid her deductible, yet the bill states that she owes $20 on a total bill of $100. How would you explain the bill to her?

It sounds like Ellen has a traditional fee-for service insurance program. The assistant should verify this, and then explain to Ellen that, in such a program, after the deductible has been met, Medicare is only responsible for 80 percent of medical expenses. The patient is responsible for the remaining 20 percent. If she has supplementary insurance, the supplementary insurance will probably pay the remaining 20 percent. Otherwise, she must pay it from her own pocket.

Joe Cantinori inquires about his unpaid bill and asks whether the physician received payment from his insurance company. When you check his record, you find that your office submitted the insurance form on his behalf. However, the physician did not accept assignment on the claim, since he is not a PAR provider in that program. This means that the insurance company will send the payment directly to Joe. How would you explain this to Joe?

Joe needs to understand that, since his doctor did not accept assignment in this case, the insurance company will pay Joe directly, rather than his doctor. Further, since Joe's insurance plan is not one that his doctor has a contract with, his doctor is not obligated to accept whatever amount the insurance company agrees to pay as payment in full. For this reason, Joe will be responsible for making up the difference if his insurance company sends him less than what he has been billed by the doctor.

A patient complained of symptoms usually associated with arthritis. The physician ordered the following tests: rheumatoid factor, uric acid, sedimentation rate, and fluorescent noninfectious agent screening. The insurance claim submitted contained procedure codes for each test. You have not received any response from the insurance carrier, even though payments for other claims sent to the same carrier on that day have been received. What do you think accounts for the delay?

The tests prescribed should have been listed on the insurance claim as a single panel, under procedure code 80072, Arthritis Panel, rather than listed individually as four separate procedures. It is likely that the insurance carrier's claims department reviewed the claim and called for rebundling the services under the appropriate code, which has delayed payment.

The greater the medical insurance coverage, the more ________________ the plan.

expensive

The Birthday Rule ensures that the maximum benefit will not exceed ______ percent of the charge for covered services.

100

According to contract law, when a physician agrees to treat a patient who is seeking medical services, there is a(n) ____________ contract between the two.

unwritten

The rate charged by the insurance policy to the policyholder is the ___________________.

premium

Which type of insurance plan generally includes coverage of hospitalization, lab tests, surgery, and x-rays?

basic

________ payment is made by the insurance carrier after the patient has received medical services.

Fee-for-service

Patient John Parks had a CBC and a PFT performed. Which type of insurance will cover the services?

basic

Which type of payment, by the insurance company to the provider, is made in advance of services rendered?

capitation

The oldest form of managed care is

HMO.

PPOs _______ require referrals to specialists.

do not

Which is one of the largest private-sector payer in the U.S.?

BCBS

A physician who joins an insurance plan is a(n) _____________________.

participating provider

A physician who accepts an assignment of benefits agrees to receive payment directly from the __________.

patient's insurance carrier

The insurance company is also known as the __________________.

carrier

Under his insurance plan, Scott is required to have prior approval for his upcoming knee replacement. Before the surgery, the surgeon must have which approval document from the insurance carrier for the surgery?

preauthorization/precertification approval

Carol and her husband, Greg, just had a baby. Carol is laid off from her job and Greg works part-time at a gas station. They are without insurance coverage. The administrative medical assistant should supply Carol and Greg with information to contact

Medicaid.

Dr. Rodriguez receives payment from BCBS for services rendered to patients covered by the plan. This is known as

assignment of benefits.

If the standard fee for a Medicare covered service is $150 and the Medicare non-PAR fee schedule for the service is $80, what is the limiting charge for the services?

$92

Which type of fee is a provider's average charge for a procedure?

usual

Which type of fee is determined by what physicians with similar training and experience in certain geographic location typically charge for a procedure?

customary

Which type of fee is approved by the insurance carrier for a difficult or complicated service?

reasonable

The payment system used by Medicare is the __________.

resource-based relative value scale

How many coding systems are used to keep track of the many thousands of possible diagnoses and of procedures and services by the physicians, and to simplify the process of verifying the medical necessity of each procedure?

two

Which type of code is used to report what is wrong with the patient or what brought the patient to see the physician?

diagnostic

Which type of code is used for reporting each procedure and service that the physician has documented in treating the patient?

procedural

Codes used for the diagnosis of external causes in ICD-10-CM begin with which letter or letter range?

V-Y

Medical insurance is a policy, or certificate of coverage, between a __________, called the "policyholder," and an insurance company, or ___________.

person; carrier

________________ is a federal health plan that provides insurance to citizens and permanent residents aged 65 and older; people with disabilities, including kidney failure; and spouses of entitled individuals.

Medicare

Medicare Part ____, also known as hospital insurance, covers hospital, nursing facility, home health, hospice, and inpatient care.

A

What part of Medicare is also known as medical insurance?

B

Another name for a patient encounter form is

charge slip.

Encounter forms used by the medical practice should be updated __________ and the codes verified with the current year's diagnostic and procedural codes.

annually

Which item does not go on the patient encounter form?

previous services

Dr. Adams has rendered a non-covered procedure to Mrs. Johnson, who is covered by Medicare. She was not advised before the procedure that it is not covered, and she did not sign the ABN. The medical office should

adjust the procedure charge off Mrs. Johnson's account.

An appointment was scheduled for a new patient, who asked how much the fee would be for the visit. What should the administrative medical assistant do?

Provide an estimate of the exam but explain that the estimate is prior to other services, such as blood work.

Paper insurance claim forms will produce which of the following?

EOB

Which of the following is not necessary information on an insurance claim form?

patient's sexual orientation

To complete the insurance form, the medical biller/coder needs the dates when James Roberts was unable to work. To find this information, the coder would refer to the

patient's chart.

Before mailing patient statements, which of the following reports should be reviewed for delinquent accounts?

aging report

At the end of her visit, Sarah was asked to pay $15, which is her cost for today's visit through her managed care health plan. The $15 represents Sarah's

copayment.

Listed on an account are the father, the mother, and two minor children. One insurance policy, held by the mother, covers all four family members. Who is the guarantor on the account?

mother

What type of agreement becomes a permanent part of the medical record?

hardship agreement

Adult children covered under a patient's policy may continue being covered under the parent's medical insurance policy up to the age of

26.

Attempted collection of a debt by telephone cannot be made after

9 p.m.

Attempted collection of a debt by telephone cannot be made before

8 a.m.

You should not call a patient for the purpose of debt collection on a

sunday.