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