Chapter 14: Medical Insurance

How many days from the date of service is considered to be timely filing by most insurance carriers?

365

Medicare claims should be submitted with how many days from the date of service?

365

TRICARE requires participating providers to submit claims within how many days from the date the care was provided?

60 days

What is the standard format for electronic transactions?

837P

HIEs offer consumers what?

A choice of health insurance plans and certifies the plans that participate

Health Insurance (Medical Insurance)

A contract between an insurance carrier and the person who owns the insurance policy

National Uniform Conversion Factor (CF)

A dollar amount used to convert RVU and GAF for each service into the price that Medicare allows

Medicare Physician Fee Schedule (MPFS)

A list of approved Medicare fees for each procedure

The causality portion of P/C insurance protects the policyholder against what?

Against legal liability for losses caused by injury to others

NPI must be used by what entities when submitting health insurance claims?

All HIPPA-covered entities

Health insurance exchanges create what?

An organized and competitive market for buying health insurance

Insurance companies are required by law to have what process for when a preauthorization request is denied?

Appeals process for patients to use

Many insurance plans require supporting documentation for what?

Before they agree to pay for certain, usually high-cost, services

Each BCBS plan is separate and unique in terms of what?

Benefits, cost sharing, and other requirements

Where on the CMS-1500 form should the name be entered when the patient is also the insured?

Both item 2 (patient's name) and item 4 (insured's name)

What was TRICARE formerly called?

CHAMPUS

What is the UB-04 claim form also known as?

CMS-1450

What are the only two submitted paper claims?

CMS-1500 and ADA form

To bill secondary insurance MAs create a package to send to the secondary paper that includes what?

CMS-1500 form and a copy of RA from the primary payer

What are the most common physician fee schedules?

Charge-based and Resource-based

What is balance billing and why can physician not do this with Medicaid patients?

Charging patients for amounts not covered by insurance, because it is illegal

What does CHAMPVA stand for?

Civilian Health and Medical Program of the Veterans Administration

What happens when it is after filing timelines have passed?

Claims are considered past timely filing limits and will likely be rejected

Geographic Adjustment Factor (GAF)

Considers the area of the country in which a physician practices, adjusting higher or lower based on the area's cost of living

What is the process of determining which company is primary and which is secondary?

Coordination of benefits

What is the goal of PPACA?

Decrease the number of uninsured people Improve health outcomes Stream line health care delivery Increase overall expenditures on health care

What is the monetary amount patients must pay to the provider for health care services before health insurance benefits begin to pay?

Deductible

Resource-Based Fee Structures (Relative Value Systems)

Determine based on the factors that contribute to a providers costs

Charge-Based Fee Schedule

Determined by comparing the fees that other providers charge for similar services

Fee-Based Reimbursement

Determines the payment amount in relation to the provider's published fee schedule

How often do medical assistants have to verify Medicaid eligibility?

Each month the patient comes in

P/C insurance, which is not regulated by HIPPA, is regulated by who?

Each state's Department of Insurance

How often should to check eligibility?

Each visit

Which type of service may require an authorization from the insurance company? a. Emergency room visit b. Elective joint replacement c. Removal of a foreign body to save an injured worker's vision d. Annual preventative care visit e. Treatment for strep throat

Elective joint replacement

Electronic Transactions

Exchanges involving the computerized transfer of health care information between two parties for specific purposes

Family Medical Leave Act (FMLA)

Federal legislation that entitles eligible employees of covered employers to take unpaid leave for specified family and medical reasons

What two ways does a PPO differ from a HMO?

Fee-for-service program Members or enrollees are not restricted to certain designated providers or hospitals

What are the three major sources of private health insurance?

Group health plans, self-insured plans, and individual insurance

What is usually the cheapest type of insurance?

Group insurance

What provisions of PPACA helps people who need to purchase health insurance to do so?

HIE

using the birthday rule, the parent who is usually primary when billing for a child's services is the parent who _________.

Has a birthday earlier in the year

What are the most common managed care plans?

Health maintenance organizations (HMOs), preferred provider organizations (PPO), and point-of-service plans

What is the role of a medical assistant in health insurance claims?

Help gather information from patients Answer patient's questions about insurance Verify patients' coverage Prepare health insurance claims accurately

Property and Causality Insurance covers what?

Homes, cars, and businesses

Medicare Part A is what type of coverage?

Hospital coverage

Individual Health Insurance Policies

Individuals buy a plan or policy directly through insurance carriers

What is Medicare's per-case reimbursement?

MS-DRGs

Which Medicare program covers physician care, therapy, and laboratory testing on a fee-for-service basis?

Medicaid Part B

Covered services must meet what criteria to be paid?

Medical necessity and frequency

What is the single largest payer of health care services in the U.S.?

Medicare

Medicare Part C is what type of coverage?

Medicare Advantage

What are the four government insurance programs?

Medicare, medicaid, TRICARE, and CHAMPVA

When did health insurance first begin and what was it?

Mid-1800s and disability income insurance

What are RBRVSs three components?

National relative value unit (RVU) Geographic adjustment factor (GAF) National uniform conversion factor (CF)

Permanent Disability (PD) Claim

No further improvement is expected and the worker is unable to return to work

What are the three types of WC Claims?

Nondisability (ND) Claim Temporary Disability (TD) Claim Permanent Disability (PD) Claim

When provides recommend a treatment that varies from the insurance company's standard list, what may the need to do?

Obtain preauthorization and provide special reports to justify the service

What is the first step in receiving proper reimbursement for insurance claims?

Obtaining accurate patient information or demographics

A CMS-1500 should be used with what?

Optical character recognition (OCR)

Medicare Part C usually encompasses what?

Parts A, B, and usually D

A UB-04 form contains 81 form locators that are split into what four sections?

Patient information, billing information, payer information, and diagnosis and procedure information

Per Diem

Per day

In some states, patient choose from what Medigap plans?

Plan A through Plan N

What type of coverage is Medicare Part D?

Prescription drug coverage

Medicare Part B is what type of coverage?

Provide coverage

Optical Character Recognition (OCR)

Reads printed or typed text and converts it to data that a computer can process

National Relative Value Unit (RVU)

Reflects the type of work a physician does, office overhead expense, and the cost of the provider's medical malpractice insurance

Each new patient in the medical office should complete what form that is verified at each visit and updated annually?

Registration form

Disability Income Insurance

Reimburses a patient for lost wages because of nonwork-related disability that prevents the individual from working

MAs need to do what with an ABN with a patient before service is provided?

Review it with the patient and obtain a signature

Open-Panel Health Maintenance Organizations

See both HMO and non-HMO patients

Closed-Panel Health Maintenance Organizations

Sees only HMO patients

Rather than purchasing group health insurance, self-insured employers or unions do what?

Set aside money in a reserve fund and pay for employees' medical expenses from the fund

Price Fixing

Set pricing based on other practice's fees

All enrollees in TRICARE are automatically enrolled in what plans?

TRICARE Standard and TRICARE Extra

What are the three TRICARE plans?

TRICARE Standard, a fee-for-service plan TRICARE Extra, a PPO TRICARE Prime, a HMO

Short-term disability is intended as what?

Temporary income replacement until long-term disability begins

All employers must offer WC, except for where?

Texas

Practice expense involves what?

The amount of office overhead involved in the procedure

Work costs involve what?

The difficultly level for the provider to perform the procedure

What funds cover qualified Medicaid enrollees?

The federal government provides funds to every state, and every state adds in its own funds

Per Diem method

The insurance company pays the facility a flat amount per day the patient is in the hospital, regardless of the services provided

MAs obtain most information for the CMS-1500 from where?

The patient registration form, the insurance card, the encounter form, and the medical record

What is the best place to call when MAs have questions about patients' insurance coverage?

The provider customer service departments of the patients' insurance carrier

Risk- Based Reimbursement

The provider shares the responsibility for minimizing the cost of care

Malpractice costs involve what?

The relative risk that the procedure presents to the patient and the provider

Temporary Disability (TD) Claim

The worker is able to return to previous or modified work at a later time

Nondisability (ND) Claim

The worker was injured and treated by a physician, but no time was lost from work

What are health insurance companies not allowed to do concerning preexisting conditions?

They are not allowed to charge more to people with preexisting conditions or exclude coverage of the condition from the insurance policy

When MAs or patients believe claims were incorrectly processed and appeal attempts have been fruitless, what can they do?

They can file formal written complaints with the state's insurance commissioner

Indemnity

To pay for the loss of another person

After obtaining insurance information from patients, MAs should do what?

Verify coverage with the insurance company

What are the three costs considered in resource-based fee structures?

Work, practice expense, and malpractice

Which type of insurance is not covered under HIPPA? a. HMOs b. Medicare c. TRICARE d. Workers' Compensation e. All of the above are subject to HIPPA

e. All of the above are subject to HIPPA