Chapter 3 - Study Guide

True or False? For Medicaid cases, there is no assignment of benefits unless the patient has other insurance in addition to Medicaid.

True

If an insurance policy states that pregnancy is not covered, the policy would list it as a/an

exclusion

An attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered is referred to as a/an

waiver.

List the reasons that health care reform is necessary in the United States.

1. A continuing increase in the number of uninsured Americans 2. Higher health care premiums with less being covered by employers 3. Increased spending in government-sponsored health care programs 4. Inflation, expensive high-tech equipment, expensive medications 5. Inefficiencies in the health care system 6. Fraud 7. Overuse of health care services by patients

What is the minimum number of employees a company must have to meet the criteria of the COBRA for continued medical benefits if an employee is laid off from a company?

20

Provides coverage for spouses and children of veterans with total, permanent, service-connected disabilities or for the surviving spouses and children of veterans who died as a result of service-connected disabilities.

CHAMPVA

A form of health insurance that provides periodic payments to replace income when the insured is unable to work is: __________________________

Disability Income Insurance

A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease.

Disability income insurance

A key provision to the Affordable Care Act is the creation of central clearinghouses that offer "one-stop shopping" for purchasing health insurance coverage, which are known as:

Exchanges

True or False? A coordination of benefits statement in an insurance policy refers to the waiting period.

False

True or False? An insurance billing specialist can escape liability by pleading ignorance.

False

True or False? Basic health insurance coverage includes benefits for skilled nursing facilities.

False

True or False? Health Benefit Exchanges will make the process of researching, comparing, and purchasing health insurance policies more difficult.

False

True or False? If Mary Smith goes to Dr. Baker's office and Dr. Baker gives Mary Smith professional services that she accepts, this is an expressed contract.

False

True or False? Medicare is a program jointly sponsored by federal and state governments for those eligible for public assistance.

False

True or False? Parents of a college student who is living away from home are liable for the medical expenses incurred by their financially dependent child.

False

True or False? Personal insurance is usually less expensive than other health insurance.

False

True or False? Private insurance companies with whom the provider does not have a contractual agreement will send the check to the patient regardless of whether the patient has signed an assignment of benefits.

False

True or False? The Supreme Court deemed the Affordable Care Act's requirement to require individuals to have health insurance coverage or face a penalty as unconstitutional.

False

True or False? The concept of managed care began in the 1930s when Montgomery Ward and Company offered it to their employees.

False

True or False? Workers' compensation insurance covers off-the-job injuries.

False

The act created to protect workers and their families so that they can get and maintain health insurance if they change or lose their jobs is called the

Health Insurance Portability and Accountability Act (HIPAA).

An organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment.

Health maintenance organization (HMO)

A medical capitation plan in which the treatment is delivered via a clinic or independent physician that provides a number of basic medical services for a fixed capitation payment per month

Independent practice association (IPA)

A state and federal program for children who are younger than 21 years of age and have special health care needs is

Maternal and Child Health Programs (MCHP).

A program sponsored jointly by federal and state governments for medically indigent persons, aged individuals who meet certain financial requirements, and the disabled.

Medicaid

A tax-free savings account that allows individuals and their employers to set aside money to pay for health care expenses is known as: _________________________________

Medical savings account (MSA)

The federal government can assess penalties for not collecting coinsurance for patients seen under the ________________ program.

Medicare

The hospital insurance system and supplementary medical insurance for those older than 65 years of age, created by the 1965 Amendments to the Social Security Act.

Medicare

Why would conversion from a group policy to an individual policy be advantageous?

No physician examination is required.

What is the correct term used to determine if a procedure is covered and medically necessary?

Preauthorization

A state-sponsored program that provides free low-cost health coverage for low-income children is: ___________________________

State Children's Health Insurance Program (SCHIP)

Insurance that covers off-the-job injury or sickness and is paid by deductions from a person's paycheck.

State disability or Unemployment Compensation Disability (UCD)

Government-sponsored program that provides hospital and medical services for dependents of active duty uniform service members, military retirees and their families, and survivors of uniformed services

TRICARE

The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA), together, are commonly referred to as:

The Affordable Care Act (ACA)

True or False? A subscriber of an insurance policy may also be known as a policyholder.

True

True or False? A two- or three-part form that incorporates a combination bill, insurance form, and routing document used in both computer- and paper-based systems is called an encounter form

True

True or False? An insurance claims representative also may be known as the claims adjudicator.

True

True or False? If a patient has an individual insurance policy, a release of information does not have to be signed before the physician's office submits a claim to the insurance company.

True

True or False? Information such as the deductible, co-payment, preapproval provisions, and insurance company address and telephone number can usually be found on the insurance card.

True

True or False? State laws may bar the use of a signature stamp.

True

True or False? The Patient Protection and Affordable Care Act (PPACA) will make health care available and affordable to Americans who are currently without insurance coverage.

True

True or False? The efficient medical insurance specialist usually groups together all outstanding charges of patients who have the same type of insurance and processes these insurance claims at the same time.

True

True or False? The insured may not necessarily be the patient seen for the medical service.

True

True or False? Under the Medicare program, the individual is required to assume a percentage of the fee (20%) for covered services, which is referred to as cost sharing.

True

When does the physician/patient contract begin?

When the physician accepts the patient and agrees to treat the patient

A contract that insures a person against on-the-job injury or illness.

Workers' compensation insurance

When the physician's services have been submitted to the patient's insurance company by the physician's office, the patient should be sent...

a monthly statement indicating the insurance company has been billed.

An emancipated minor is?

a person younger than the age of 18 who lives independently.

In a managed care plan, the participating provider is also referred to as:

a preferred provider

The person who is applying for insurance coverage is called the ____________________.

applicant

Many Health Insurance Claim Forms contain a/an ______________________________ that directs the insurance company to pay benefits directly to the provider of care on whose charge the claim is based.

assignment of benefits statement

Most legal issues of private health insurance claims fall under....

civil law.

The cost-sharing amount a managed care patient must pay at the point of arriving in the office is referred to as the ________________.

co payment

When the insured is required to pay a percentage of the covered services' costs, this is referred to as ____________________.

coinsurance

A type of managed care organization created by the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA) that allows for enrollment of Medicare beneficiaries into managed care plans is a/an

competitive medical plan (CMP).

An insurance policy is a legally enforceable agreement called a/an ____________________.

contract

The first legal item in the business of handling medical insurance is the insurance ____________________ or policy.

contract

Mrs. Thompsett leaves her place of employment. She is eligible to transfer her medical insurance coverage from a group to an individual contract. This is known as

conversion privilege

Mr. Talili has two medical insurance policies. To prevent duplication of payment for the same medical expense, the policies include a

coordination of benefits statement

A daily record sheet used to record daily business transactions is called a/an

daysheet.

The amount that must be paid each year by the insured before policy benefits begin is known as the ____________________.

deductible

When a contract is not manifested by direct words but is deduced from the circumstance, the general language, or the conduct of the patient, it is referred to as a/an ____________________ contract.

expressed

Mr. Ott was laid off from his job. He is protected by the Consolidated Omnibus Budget Reconciliation Act (COBRA), which requires his employer to

extend group health insurance coverage for 18 months

An insurance claims register facilitates

follow-up of insurance claims

An organization of physicians, sponsored by a state or local medical association, concerned with the development and delivery of medical services and the cost of health care is known as a/an

foundation for medical care.

If the premium of an insurance policy is not paid, a ____________________ from 10 to 30 days is usually given before insurance coverage is canceled.

grace period

Most physician/patient contracts are?

implied

The patient registration/information form is also called a patient ____________________ sheet.

intake

A financial accounting record that is maintained for each patient who receives professional services is referred to as a/an ____________________.

ledger

Electronic billers are permitted to obtain a ___________________ authorization from the patient to release medical information necessary to process a claim.

lifetime

The five classifications of health insurance policies are (1) cancelable, (2) optionally renewable, (3) conditionally renewable, (4) guaranteed renewable, and....

non cancelable

A policy in which the insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract is a.

noncancelable policy.

The first document obtained in the initial patient visit is a/an

patient information form.

A patient intake sheet is also called a

patient registration form.

An encounter form may also be known as a

patient service slip.

Discovering the maximum dollar amount that the carrier will pay for a procedure is called

predetermination

Conditions that existed and were treated before the health insurance policy was issued are called

preexisting

An insurance policy becomes effective only after the company offers the policy and the person accepts it and then pays the initial ____________________.

premium

The reason for a coordination of benefits statement in a health insurance policy is to

prevent duplication or overlapping of payments for the same medical expense.

The source document for insurance claim data is the

superbill

In cases of divorce, the decision as to which parent should be responsible for payment of the child's services should be made by whom?

the court system

If a child has health insurance coverage from two parents, according to the birthday law

the health plan of the person whose birthday (month and day) falls earlier in the calendar year will pay first.

The insured is always....

the individual enrollee or organization protected.

The contract in a workers' compensation case exists between?

the physician and the insurance company.

When a patient carries private medical insurance, the contract for treatment exists between?

the physician and the patient.

According to the birthday law, if both the mother and the father have the same birthday...

the plan of the person who has coverage longer is the primary payer.

In health insurance, the insured is also known as?

the subscriber, the member, and/or the policyholder.

Assignment of benefits is

the transfer of one's legal right to collect an amount payable under an insurance contract.

Under HIPAA guidelines, physicians must send all claims electronically if,

they have more than 10 full-time employees