Chapter 1 insurance study guide
Calculate the amount of money a patient would owe for a covered service costing $1800 if their indemnity policy had a $400 deductible (which has not been met) and their coinsurance rate is 80-20
$1400
A physician has a contract to receive a $2000 monthly capitation fee based on a fee of $50 for 40 patients who are in the plan if only 10 patients visited the practice in the last month the capitation payment will be
$2000
Calculate the amount of money a patient would owe for a covered service cost $1200 if their indemnity policy has a coinsurance rate of 75-25, and they have already met their deductible
$300
Calculate the monthly capitation payment a provider should receive from a health plan if they have 80 contracted patients and a capitated payment of $40 per month
$3200
Calculate the amount of money in the insurance company would owe on a covered service costing $850 if there is a $500 deductible which is not been met and no coinsurance
$350
And I definitely policy states that the coinsurance rate is 80 20 which of the following is the payers portion
80
Name the two components of a consumer driven health plan (CDHP)
A health plan and a special "savings account"
Compare the choices below to determine which type of provider service would most likely not be covered by a health plan
A medical procedure that is not included in the plans benefits
The designation of registered medical assistant is awarded by
AAMA
Certification as a certified professional coder is awarded by
AAPC
The titles of certified coding specialist (CCS) and certified coding specialist physician based (CCS-P) are awarded by
AHIMA
Under a fee-for-service plan, the third-party payer makes a payment
After medical services are provided
What is the definition if revenue cycle
All administrative and clinical functions which ensure that sufficient monies flow into the practice to pay bills
Name a benefit a provider usually gets from participation with a health plan
An increased number of patients
In what ways can insurance policies be written
An individual or group
Under in a indemnity plan typically a patient may use the services of
Any provider
When is a deductible paid
Before benefits begin
Determine which method a self-funded health plan is most likely to use in setting up its provider network
Buy the use of existing networks from managed care organizations
One of the advantages of an HMO for patients who face difficult treatments is Disease/Case Management by assisting a
Caseworker
What is the formula for calculating an insurance company payment in an indemnity plan
Charge- deductible - coinsurance
When a POS option is elected under a health maintenance organization the patient may
Choose providers who are not in the HMOs network
Professional organizations generally have a_ that it's members should follow/possess
Code of ethics
What term is used to describe the action of satisfying official requirements
Compliance
When do medical insurance specialists work with patient billing programs, they need?
Computer skills
Imagine you are a patient who wants to regulate your healthcare expenses on your own what type of insurance plan would you use
Consumer-driven health plan
What is typically required of professional organizations
Continuing education sessions
Identify the type of HML cost containment method that requires providers to use formulary
Controlling drug costs
Describe the role of a primary care physician in an HMO
Coordinating patient's overall care
Identify the type of HMO cost containment method that requires the patient to pay a copayment
Cost-sharing
What type of insurance reimburses income lost because of a person's inability to work
Disability insurance
A computerized life long healthcare record for an individual that incorporates the data from all sources is known as
Electronic health record
In what format are healthcare claims sent
Electronic or hard copy
Another term used for a primary care physician is
Gatekeeper
Patients are enrolled in a point of service type of HMO may use the services of
HMO network or out of network providers
In large medical practices a medical insurance specialist is more likely to
Have more specialized duties
On what is the PMPM rate usually based
Health related characteristics of the enrollees
PPO members who use out of network providers may be subjected to
Higher copayments
Which of the following characteristics should medical insurance specialist use when working with patient records and handling finances
Honesty and integrity
The employment forecast for well-trained medical insurance and coding specialists is
Increasing opportunities
Determine which of the following entities is not considered a provider
Insurance companies
Which of the following is an example of a private-sector payer
Insurance company
Under an insurance contract, the patient is the first party and the physician is the second party. Who is the 3rd?
Insurance plan
Identify the advantages offered to patients and managed-care plans as compared to indemnity insurance
Lower premiums charges and deductibles
Which of the following programs covers people who cannot otherwise afford medical care
Medicaid
Pick the rising occupation in the healthcare industry that requires the employee to have the highest level of proficiency in dealing with the public professionally and pleasantly
Medical administrative assistant
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
Correctly relating a patient's condition and treatment refers to
Medical necessity
The key to receiving coverage and payment from payer is the payer's definition of
Medical necessity
Which of the following covers patients who are over age 65
Medicare
What adds up to form a practices accounts receivable
Money due from both health plans and patients
In a preferred provider organization plan, referrals to specialist are?
More expensive
what do providers participating in a PPO generally receive in exchange for excepting lower fees
More patient visits
Determine which of the following types of service a health plan will not pay for
Noncovered services
For a patient insured by an HMO the phrase out of network means providers who are
Not under contract with the payer
To be fully covered patient to enroll in an HMO may use the services of
Only HMO network providers
Identify another name for a point of service plan (POS)
Open HMO
Identify the type service that is not considered to be preventable
Outpatient surgery
If a POS HMO member elects to receive medical services from out of network providers they usually
Pay an additional cost
In a medical practice cash flow is required to
Pay for office expenses
Under a written insurance contract policy holder pays a premium and the insurance company provides
Payments for covered medical services
Review the choices below and select the most appropriate definition for health plan benefits as defined by American's health insurance plans
Payments for medical services
How many managed care plans made a physician participate
Physicians mayb participate in many managed care plans
In general how do the cost of policies written for groups compare to those room for individuals
Policies written for groups are cheaper
Which of the following us required when an HMO patient is admitted to the hospital for nonsurgical treatment
Preauthorization
Imagine you are a medical insurance specialist; illustrate the impact your ability to prepare accurate, timely claims can have on the practice
Preparing accurate and timely claims generally leads to full and timely reimbursement from the health plan
What kind of medical services are annual physical examinations and routine screening procedures
Preventive
The statement that "Coding professionals should not change codes to increase billings" is an example of?
Professional ethics
The most important characteristic for a medical insurance specialist to possess is
Professionalism
A capitated payment amount is called a
Prospective payment
Pick the most accurate definition of certification
Recognition of a superior level of skill by an official organization
Identify the type of HMO cost containment method that requires the patients obtain approval for services before they receive the treatment
Requiring preauthorization for services
Identify the type of HMO cost containment method that limits members to receiving services from the HMOs physician network
Restricting patients choice of providers
Under the capitated rate for each plan member, which of the following does a provider share with the third-party payer
Risk
Where do you medical insurance companies summarize the payments they may make more medically necessary medical services
Schedule of benefits document
medical insurance specialists use practices management programs to
Schedule patients, collect data on patients, keep record payments
Practice management programs may be used for
Scheduling appointments financial record-keeping and billing
Employers that offer health plans to employees without using an insurance carrier are
Self funded health plans
The capitated rate per member per month covers
Services listed on the schedule of benefits
Dependents of a policyholder may include an
Spouse and children
Scheduling appointments is part of which revenue cycle step
Step 1, preregister patient's
Which step is used when patient payments are later than permitted under the financial policy
Step 10, follow up patient payments and collections
Collecting copayments is part of which revenue cycle step
Step 3, check in patient's
In what step does the medical insurance specialist verify that charges are in compliance with insurance guidelines
Step 5, review billing compliance
Examine the list of services and determine which one would most likely be considered a non covered service
Surgical procedure
Out-of-pocket expenses must be paid by
The insured
Higher copayments may be charged for patient visits to/for :
The office of a specialist
Choose the entities that may form agreements with an MCI
The patient and provider
Healthcare claims report data to payers about _ and _
The patient and the services provided by the physician
A patient ledger records?
The patient's financial transactions
Describe the process of adjudication
The payer's process of putting a claim through a series of Steps designed to judge whether it should be paid
Which of the following conditions must be met before payment is made under the indemnity plan
The payment of premium deductible and coinsurance
How is coinsurance defined
The percentage of each claim that the insured pays
What is a premium
The periodic payment the insured is required to make to keep a policy in effect
What resource may medical insurance specialist access to review the correct behavior expected of them
The practice's employee policy and procedure manual
medical insurance specialists ensure financial success of the medical practice by
Using health information technolgy
medical insurance is an _ between a policyholder and a health plan
Written agreement
What skills and attributes are required to successful mastery of the task of a medical insurance specialist
attention to detail and ability to work as a team member