Kinn's Administrative Medical Assistant - Chapter 15

Medicare

Federal health insurance program that provides healthcare coverage for individuals aged 65 and over, people who are disabled, and people who have been diagnosed with end-stage renal disease.

HMO Model - Independent Practice Association (IPA)

General or family practice provider or provider group the practices independently and may contract with several HMOs. Can see patients outside of the HMO. Capitation or fee-for-service.

Medicaid

Government program that provides medical care for the indigent. Eligibility and coverage vary by state.

HMO Model - Network

HMOs contract with several provider groups. These providers can see patients outside of the HMO. Provides wider geographic coverage for members. Capitation or fee-for-service.

Managed Care Organization (MCO)

Health insurance companies who negotiate reduced rates with contracted hospitals and providers. Typically they require patients to select a PCP to manage their care, and also require referrals for patients seeking care with a specialist.

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

Healthcare coverage for the families of veterans who are permanently disabled or who died in the line of duty.

Which type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own office?

Independent practice association

Healthcare insurance marketplace

Low- to middle-income Americans can compare plans and lower their costs on healthcare coverage.

Qualified Medicare Beneficiaries (QMBs)

Low-income Medicare patients who qualify for Medicaid for their secondary insurance.

Health Maintenance Organization (HMO)

Managed care plan that includes preventive care. Premiums are typically lower than other plans. Patients are required to select a PCP who acts as a gatekeeper to more specialized care. Plan will not pay for services outside of their provider network. No deductible or co-insurance. Copayments are required for office visits and prescriptions.

indigent

Poor, needy, impoverished

elective procedure

Procedures that are not deemed medically necessary

participating provider

Provider who enters into a contract with a specific insurance company or program and agrees to accept the contracted fee schedule.

disability insurance

Provides income replacement if the patient has a disability that is not work related.

life insurance

Provides payment of a specified amount upon the insured's death, either to their estate or to a designated beneficiary.

utilization review committee

Reviews individual cases to ensure that medical care services are medically necessary.

effective date of coverage

The date insurance coverage began.

self-funded plan

The employer collects monthly premiums from the employees which are then deposited into a fund. The employer pays employees healthcare costs from this fund.

waiting period

The length of time a patient waits for disability insurance to pay after the date of injury.

allowable charge

The maximum dollar amount that the insurance plan will pay for a procedure or service.

subscriber

The person responsible for the payment of the insurance premium.

gatekeeper

The primary care provider, who is in charge of a patient's treatment. Additional treatment, such as referrals to a specialist, must be approved by the gatekeeper.

verification of eligibility

The process of confirming health insurance coverage for the patient.

credentialing

The process of confirming the healthcare provider's qualifications.

precertification

The process of proving to the insurance company that the service is medically necessary.

liability insurance

insurance that provides protection from claims arising from injuries or damage to other people or property

Affordable Care Act

law passed in 2010 to expand access to insurance, address cost reduction and affordability, improve the quality of healthcare, and introduce the Patient's Bill of Rights

TRICARE

medical insurance for dependents of military personnel

A provider who enters into a contract with an insurance company and agrees to certain rules and regulations is called a _____________ provider.

participating

Traditional Health Insurance

These plans pay for all or part of the cost of covered services, regardless of which provider, hospital, or other licensed healthcare provider is used. Also know as fee-for-service plans.

STAT referral

Used in an emergency situation as indicated by the provider. Can be approved online when it is submitted to the utilization review department through the provider's Web portal.

regular referral

Usually takes 3-10 working days for review and approval. Used when the provider believes that the patient must see a specialist to continue treatment.

urgent referral

Usually takes about 24 hours for approval. Used when an urgent but not life threatening situation occurs.

A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job.

Workers' compensation

A policy that covers a number of people under a single master contract issued to the employer or to an association with which they are affiliated and that is not self-funded is usually called ___________

a group policy.

Medigap

a private insurance policy that pays the difference between the medical charge and the amount that Medicare pays

The maximum amount of money third-party payers will pay for a specific procedure or service is called the ___________

allowed amount.

Which of the following is not one of the ten categories of essential health benefits that the federal government requires all healthcare plans to cover?

ambulatory patient services, hospitalization, mental health, and substance use disorder services

A review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called a(n) _____________________

audit committee review.

Which individuals would not normally be eligible for Medicare?

A 23-year-old recipient of Temporary Assistance for Needy Families (TANF)

utilization management

A decision-making process used by managed care organizations to manage health care costs. It involves case-by-case assessments of the appropriateness of care.

beneficiary

A designated person who receives funds from an insurance policy.

explanation of benefits (EOB)

A document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient's financial responsibilities.

claim

A formal request for payment from an insurance company for services provided.

preexisting condition

A health problem that was present before new health insurance coverage started.

fee schedule

A list of fixed fees for services.

Preferred Provider Organization (PPO)

A managed care network that contracts with a group of providers. Uses a fee-for-service concept. Patients typically pays 20-25% of the allowed charge. Referrals from the PCP to specialists are not required. Lower deductible and co-insurance if in-network provider is used. Copayments required for office visits and prescriptions.

capitation

A payment arrangement for healthcare providers.

individual health insurance plan

A private health insurance plan one purchases for themselves that is not part of an employer group plan

group policy

A private health insurance plan purchased by an employer for a group of employees.

preauthorization

A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services.

Copayment

A set dollar amount that the policyholder must pay for each office visit.

Deductible

A set dollar amount the policyholder must pay before the insurance company starts to pay for services.

Children's Health Insurance Program (CHIP)

A state-funded program for low-income children whose family income is above the Medicaid qualifying income limits.

resource-based relative value systems (RBRVS)

A system used to determine how much providers should be paid for services provided. It is used by Medicare and many other health insurance companies.

policy

A written agreement between two parties in which one party (the insurance company) agrees to pay another party (the patient) if certain specified circumstances occur.

A payment method in which providers are paid for each individual enrolled in a plan, regardless of whether the person sees the provider that month.

Capitation plan

Exclusive Provider Organization (EPO)

Combination of HMO and PPO plans. Restrictive in number and type of providers (more like HMO). Most will not pay anything if you use out of network providers. Usually no deductible or co-insurance. Copayments are required for office visits and prescriptions.

long-term care insurance

Covers a broad range of maintenance and health services for chronically ill, disabled, or developmentally delayed individuals.

workers' compensation insurance

Covers employees who are injured or become ill due to work-related issues.

Co-insurance

After the deductible has been met, the policy holder may need to pay a certain percentage of the bill and the insurance company pays the rest.

What should the medical assistant always verify prior to the patient's appointment?

All of these

provider network

An approved list of physicians, hospitals, and other providers.

health insurance exchange

An online marketplace where people can compare and buy individual health insurance plans. State health insurance exchanges were established as part of the Affordable Health Care Act.

online insurance Web portal

An online service provided by various insurance companies that allows providers to look up a patient's insurance benefits, eligibility, claims status, and explanation of benefits.

referral

An order from a primary care provider for the patient to see a specialist or to get certain medical services.

Third-party administrator (TPA)

An organization that processes claims and provides administrative services for another organization. Often used by self-funded plans.

HMO Model - Group

Multispecialty group with or without a primary care provider (gatekeeper); may contract with several HMOs. Capitation or fee-for-service.

HMO Model - Staff

One or more providers hired by an HMO. Providers only see HMO patients. Salaried.

Which Medicare plan covers inpatient hospital care, skilled nursing facilities, home health care, and hospice services?

Part A

Which Medicare plan covers outpatient hospital care, durable medical equipment, provider's services, and other medical services?

Part B

Which Medicare plan covers expanded inpatient hospital and outpatient hospital care benefits?

Part C

Which Medicare plan covers prescription drugs?

Part D

preventive care

Services provided to help prevent certain illnesses or that lead to early diagnosis.

Beneficiary

Term used by Medicare for those covered by Medicare.

Usual, customary, and reasonable (UCR)

Term used for a process where fee schedule amounts are based on what providers in that geographic area usually charge for a similar service.

Cost-sharing

Term used where patient pays a portion of the healthcare services.

premium

The amount paid or to be paid by the policyholder for coverage under the contract, usually in periodic installments.

Assignment of benefits

patient's written authorization giving the insurance company the right to pay the physician directly for billed charges