CCMA PRACTICE GUIDE 202O

Insurance Terminology

Advance Beneficiary Notice (ABN)

• A form provided to the patient when the provider believes Medicare will probably not pay for services received.

Allowed Amount

• The maximum amount a third-party payer will pay for a particular procedure or service.

Copayment

• An amount of money that is paid at the time of medical service.

Coinsurance

• A provision in medical insurance where the policyholder and the insurance company share the cost of covered losses in a specified ratio, such as 80:20.

Deductible

• A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying.

Explanation of Benefits (EOB)

• A statement from the insurance carrier detailing what was paid, denied, or reduced in payment; it also contains information about amounts applied to the deductible, coinsurance, and allowed amounts.

Participating Provider (PAR)

• Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer.

Types of Insurance Plans

• Federal and State Plans: Medicare, Tricare, CHAMPVA, Medicaid, managed care, and workers' compensation.

• Medicare: Covers patients age 65 and older, providing benefits primarily through Part A (hospitalization) and Part B (routine medical office visits).

• Tricare: Authorizes dependents of military personnel to receive treatment from civilian providers at federal expense.

• CHAMPVA: Covers surviving spouses and dependent children of veterans who died due to service-related disabilities.

• Medicaid: Provides healthcare to the medically indigent population through a cost-sharing program between federal and state governments, contingent on eligibility criteria.

• Managed Care: An umbrella term covering plans that deliver healthcare in exchange for scheduled payments and coordinated care through a network of providers.

• Workers' Compensation: Protects wage earners against wage loss and medical care costs due to occupational accidents or diseases, provided the employee is not found negligent.

CMS-1500 Form

• Most health care payers utilize the CMS-1500 form for claims from providers or suppliers. Medical assistants must gather:

  • Patient's information (demographic and insurance)

  • Details of diagnostic tests, treatments, or procedures

  • Billing information

• Sections of the CMS-1500 Form:

  • Section 1: Carrier Block - Contains the insurance carrier's address (top of the form).

  • Section 2: Patient/Insured Section - Boxes 1-13; information about the patient or insured.

  • Section 3: Physician/Supplier Section - Boxes 14-33; information about the physician or supplier.

Positions for Physical Examinations

• Supine Position: Lying flat on the back.

• Dorsal Recumbent Position: Lying flat on the back with knees bent.

• Sims' Position: Lying on the left side with the right leg bent at 90 degrees.

• Knee-Elbow Position: Kneeling and leaning forward onto elbows.

• Fowler's Position: Sitting upright, legs extended, back supported.

• Lithotomy Position: Lying flat on the back with feet in stirrups.

Medication Schedules

• Schedule I: High potential for abuse, unlawful (e.g., heroin, LSD). Not prescribed.

• Schedule II: High potential for abuse, dangerous, no refills allowed (e.g., morphine, oxycodone). Locked storage required.

• Schedule III: Moderate potential for dependence, up to 5 refills allowed in 6 months (e.g., steroids, ketamine).

• Schedule IV: Low potential for abuse, can be refilled 5 times in 6 months (e.g., diazepam).

• Schedule V: Contains limited amounts of narcotics, can be refilled 5 times in 6 months (e.g., diphenoxylate with atropine).

Household Measurements

• Household measurements can be converted from apothecary to metric:

  • 1 tsp = 5 mL, 1 tbsp = 15 mL, 1 cup = 240 mL, 1 quart = 960 mL, 1 gallon = 3,830 mL.

Routes of Administration

Parenteral Routes

• Epidural: Epidural space (spine).

• Intra-arterial: Arteries (to break up clots).

• Intra-articular: Inside a joint space.

• Intradermal: Skin (upper chest, forearms, back).

• Intravenous (IV): Major veins (e.g., arms/hands).

• Intramuscular (IM): Injects into major muscle groups.

• Subcutaneous: Under the skin; common in diabetes treatment.

Major Classifications of Vitamins

• Fat-Soluble Vitamins: A, D, E, K

• Water-Soluble Vitamins: B1, B2, B3, B6, folate, B12, C

Erikson's Stages of Psychosocial Development

• Trust vs. Mistrust

• Autonomy vs. Shame/Doubt

• Initiative vs. Guilt

• Industry vs. Inferiority

• Identity vs. Role Confusion

• Intimacy vs. Isolation

• Generativity vs. Stagnation

• Ego Integrity vs. Despair

Common Defense Mechanisms

• Apathy: Indifference to emotional concerns.

• Denial: Refusing to accept reality.

• Projection: Attributing one's unwanted feelings onto others.

• Rationalization: Justifying irrational behavior.

• Suppression: Voluntarily blocking unpleasant feelings.

• Repression: Involuntarily hiding emotional pain.

• Regression: Reverting to an earlier developmental stage.

Legal Fundamentals

Criminal vs. Civil Law

• Criminal Law: Addresses community wrongdoings (misdemeanors, felonies).

• Civil Law: Governs private rights and can include medical malpractice cases.

Federal Laws Affecting Medical Practices

• Affordable Care Act (ACA): Aims to provide affordable health insurance and curb health care spending.

• OSHA: Mandates a safe workplace.

• HIPAA: Protects patient health information privacy.

• Controlled Substances Act (CSA): Regulates narcotics and controlled substances.

Types of Medical Directives

• Living Will: Indicates desired medical treatments.

• Durable Power of Attorney: Names a health care proxy for decision-making.

• Do-Not-Resuscitate (DNR) Orders: Directs medical staff not to attempt resuscitation.

• MOLST: Medical orders for life-sustaining treatment during end-of-life care.