Insurance final review

To make sure that all patients can follow the financial policy, it should be

displayed on the wall of the reception area or included in new patient information packet.

An indemnity policy states that the coinsurance rate is 80-20. Which of the following is the payer’s portion?

80

Under a capitated rate for each plan member, which of the following does a provider share with the third-party payer?

Risk

An RTA generates

the actual amount the patient will owe.

What must patients who are members of CDHPs do before their health plan makes a payment?

Meet a large deductible.

Identify the means by which practices can be sure that all visits have been entered in the practice management program.

Prenumbering

Which of the following programs covers people who cannot otherwise afford medical care?

Medicaid

What do providers participating in a PPO generally receive in exchange for accepting lower fees?

more patient visits

Identify the information that is not typically included on an encounter form.

the patient's plan benefits

What does COB stand for in medical insurance terms?

coordination of benefits

A provider who directly treats a patient is called a(n) .

direct provider

What type of charges do practices routinely collect at the time of service?

copays, noncovered, and self-pay patients

Determine by which of the following means a practice may receive a “self-refer.”

the patient comes for specialty care without a referral number when one is require

What is the definition of revenue cycle?

all administrative and clinical functions which ensure that sufficient monies flow into the practice to pay bills

A patient has just seen the physician and received two different covered services that normally require copayments. Determine how the payment should be handled.

If the health plan permits multiple copayments, both should be collected.

A patient's insurance card usually shows

member identification number.

What is another name for the HIPAA Eligibility for a Health Plan transaction?

X12 270/271

Describe the role of a primary care physician (PCP) in an HMO.

coordinating patients' overall care

You are working in a practice and a patient arrives for an appointment on November 20, 2019; the patient last visited the practice on March 5, 2014, and is scheduled to see the same physician. Determine what you should ask the patient to do upon arrival.

Complete all required forms before their first encounter with the provider.

In what step does the medical insurance specialist verify that charges are in compliance with insurance guidelines?

Step 5, review billing compliance.

Consumer-driven health plans combine a health plan with a special “savings account” that is used to pay what before the deductible is met?

medical bills

Eligibility for government-sponsored plans where income is the criterion may change as quickly as

monthly.

Which of these documents will the patient not complete?

encounter form

A capitated payment amount is called a

prospective payment.

In what order are benefits typically determined when the parents do not have joint custody arrangements?

plan of custodial parent, plan of spouse of custodial parent, plan of parent without custody

Identify the advantages offered to patients in managed care plans, as compared to indemnity insurance.

lower premiums, charges, and deductibles

Dependents of a policyholder may include his/her

spouse and children.

What provision explains how insurance policies will pay if more than one policy applies?

coordination of benefits

Identify the type of HMO cost-containment method that requires patients to obtain approval for services before they receive the treatment.

requiring preauthorization for services

If a provider has agreed to accept assignment, he/she will

accept the payer’s allowed charge as payment in full.

Charging TOS payments depends on

the provision of a patient’s health plan and practice's financial policy.

Pick the type of use of PHI that a practice would employ to train their staff to improve the quality of their health care.

health care operations

Examine the types of information below and determine which type is NOT important to collect from a new patient.

availability for future appointments

Pick the type of use of PHI that a practice would employ to submit claims on behalf of a patient.

Payment

Identify the best time during which to begin collecting patient information.

preregistration process

Determine how a policyholder can authorize physicians to submit claims on their behalf and receive payments directly from payers.

signing and dating an assignment of benefits statement

Name the two components of a consumer-driven health plan (CDHP)

a health plan and a special “savings account”

You are working in a practice and a patient arrives for an appointment on November 20, 2019; the patient last visited the practice on March 5, 2014, and is scheduled to see the same physician. Determine what you should ask the patient to do upon arrival.

Complete all required forms before their first encounter with the provider.

A patient presents for an appointment and you must locate the information about their health plan. Determine where this information should be located.

patient's information form and insurance card

You are working at a practice and have been asked to document some payer communications. Determine where the communications should be recorded.

financial record

Where do medical insurance companies summarize the payments they may make for medically necessary medical services?

schedule of benefits document

A patient has just seen the physician and received two different covered services that normally require copayments. Determine how the payment should be handled.

If the health plan permits multiple copayments, both should be collected.

What process is used to quickly generate the amount a patient owes?

real-time adjudication

What means are available for completing an encounter form?

paper forms, tablets, laptops

What type of information is included in a patient's social history?

smoking, alcohol use, and exercise habits

A provider such as a pathologist who does not have face-to- face interaction with a patient is called a(n)

indirect provider.

Under an indemnity plan, typically a patient may use the services of

any provider.

What information does RTA allow the practice to view?

the amount the health plan will pay and amount patient will owe

If the practice accepts credit and debit cards it must

pay a fee to a credit card company.

What can be used to verify insurance company information?

Portal

Under a written insurance contract, the policyholder pays a premium, and the insurance company provides

payments for covered medical services.

The most important characteristic for a medical insurance specialist to possess is

professionalism

What does an Acknowledgment of Receipt of Notice of Privacy Practices state?

that the patient understands how the provider intends to protect their rights to privacy under HIPAA

What Medicare form is used to show charges to patients for potentially non-covered services?

Advance Beneficiary Notice

Which of the following is used to send necessary data to payers for a claim?

X12 837

In what format are health care claims sent?

electronic or hard copy

You are working at a practice and need to get prior approval from a payer. Which of the following HIPAA transactions would you use to do so?

Referral Certification and Authorization

Medical insurance specialists use practice management programs to

record payments from insurance companies, collect data on patients’ diagnoses and services, schedule patients.

What information must be documented in the patient’s financial record when communicating with payers?

the representative’s name, date of communication, and outcome

Another term used for a primary care physician (PCP) is

gatekeeper

The employment forecast for well-trained medical insurance and coding specialists is/are

increasing opportunities.

Determine which method a self-funded health plan most often uses in setting up its provider network.

buy the use of existing networks from managed care organizations

For unassigned claims, the payment for services rendered is expected

at the time of service.

The term to describe the person who is financially responsible for the bill is

guarantor

The document patients sign to signify that they have read and understood how the provider will protect their PHI is the

Acknowledgment of Receipt of Notice of Privacy Practices

What step is used when patient payments are later than permitted under the financial policy?

Step 10, follow up patient payments and collections.

Under what rule is a child's primary coverage under the father's plan when both parents have coverage?

gender rule

Under what rule is a child's primary coverage determined based upon which parent's day of birth is earlier in the calendar year?

birthday rule

What type of provider is required to have patients sign an acknowledgment?

direct provider

Calculate the amount of money the insurance company would owe on a covered service costing $850 if there is a $500 deductible (which has not yet been met) and no coinsurance.

$350

What process is used to quickly generate the amount a patient owes?

real-time adjudication

PPO members who use out-of-network providers may be subjected to

higher copayments

If a patient authorizes a provider to accept assignment, what can the provider now do on their behalf?

File claims for the patient and receive payments directly from the payer.

The statement that “coding professionals should not change codes. . .to increase billings” is an example of

professional ethics.

A new patient is defined as one who has NOT seen the provider within the last

three years

Choose the entity(ies) that may form agreements with an MCO.

the patient and provider

Pick the type of use of PHI that a practice would employ to discuss a patient's case with another provider

Treatment

Which of the following characteristics should medical insurance specialists use when working with patients' records and handling finances?

honesty and integrity

Patients who enroll in a point-of-service type of HMO may use the services of

HMO network or out-of-network providers.

Under a fee-for-service plan, the third-party payer makes a payment

after medical services are provided.

Professional organizations generally have a(n) __________ that its members should follow/possess.

code of ethics

The titles of Certified Coding Specialist (CCS) and Certified Coding Specialist–Physician-based (CCS-P) are awarded by

AHIMA

Which HIPAA transaction is used to check patients' insurance coverage?

Eligibility for a Health Plan

Collecting copayments is part of which revenue cycle step?

Step 3, check in patients.

If a POS HMO member elects to receive medical services from out-of-network providers they usually

pay an additional cost.

Identify the person/entity that must authorize providers to release a patient's PHI for TPO purposes.

none of these; they do not need authorization

What type of information is not found on an insurance card?

the date the policyholder first paid a premium

A computerized lifelong health care record for an individual that incorporates data from all sources is known as a(n)

electronic health record (EHR).

Identify the type of HMO cost-containment method that requires the patient to pay a copayment.

cost-sharing

What type of number is assigned to a HIPAA 270 electronic transaction?

trace number

Describe what should be done when incorrect or conflicting data are discovered on encounter forms

Double-check the documentation and communicate with physician.

What is a premium?

the periodic payment the insured is required to make to keep a policy in effect

A patient with no previous balance presents for an encounter and wants to know what their bill will be. Calculate the patient's estimated balance if they will receive a non-covered service worth $127.

$127

What is the formula for calculating an insurance company payment in an indemnity plan?

charge − deductible − coinsurance

What are the procedures that ensure billable services are recorded and reported for payment called?

charge capture

Assignment of benefits authorizes

the physician to file claims for a patient and receive direct payments from the payer.

If a patient authorizes a provider to accept assignment, what can the provider now do on their behalf?

File claims for the patient and receive payments directly from the payer.

If a retired patient with Medicare also has coverage under a working spouse's plan, the primary plan is

the spouse's plan.

For assigned claims, the payment for services rendered is expected

after the patient receives a statement.

What should be verified when someone requests PHI for TPO purposes?

the identity of the person and person's authority to access PHI