Ch. 8 Private Payers/Blue Cross Blue Shield

Coinsurance payment Family deductible Individual deductible

An indemnity BCBS plan has which of the following types of payments? (Select all that apply.)

the patient's funding plan options

As more employer-sponsored plan members are covered under CDHPs, physician reimbursement up to the amount of the deductible will come from _____.

subscriber identification cards

Because BCBS offers local and national programs through many individual plans, _____ must be used to determine the type of plan under which a person is covered.

a number of plans in the area

Because managed care organizations are the predominant healthcare delivery systems, most medical practices have contracts with _____.

5

Checking billing compliance is which step of the revenue cycle?

participating in a particular contract

Compiling billing data permits the practice to track how much revenue it has lost as a result of _____.

High deductible health plans One or more tax-preferred savings accounts that the patient directs

Consumer-driven health plans (CDHPs) combine which of the two following components?

reduce

Consumer-driven health plans _____ providers' cash flow because visit copayments are being replaced by high deductibles that may not be collected until after claims are paid.

2

Establishing financial responsibility is which step of the revenue cycle?

health insurance exchanges

Half of the states that were required by the ACA to create a public government-run online marketplace to offer IHPs chose to run their own _____.

first-dollar

Health maintenance organizations were originally designed to cover all basic services for an annual premium and visit copayments under an arrangement called _____ coverage.

Contact the payer.

How can the medical insurance specialist know a patient's eligibility for a procedure?

An outside attorney usually reviews the contract. The managed care organization's business history, accreditation standing, and licensure status are reviewed. A practice manager or a committee of physicians usually leads the team.

Identify all of the correct statements related to an evaluation team.

The preauthorization requirement is usually shown on the patient's insurance card. Elective surgery usually requires preauthorization. Emergency surgery usually must be approved within a specified period after admission was required.

Identify all of the correct statements related to billing surgical procedures.

Practices generally bill from their normal fee schedules. Practices do not typically bill the contracted fees. After the RA is processed, differences can be written off between normal fees and payments.

Identify all of the correct statements related to compiling billing data.

Copayment amounts vary depending on the procedure. Some plans require a copayment when the patient visits the office for any procedure or service. Some plans require a copayment only when an E/M service is provided.

Identify all of the correct statements related to copayments.

Physicians, hospitals, clinics, and pharmacies contract with the PPO plan to provide care to its insured people. Medical providers accept the PPO plan's fee schedule and guidelines for managed care.

Identify all of the correct statements related to preferred provider plans (PPOs).

Local or regional payers are often affiliated with a national plan. Local or regional payers are often affiliated with the BlueCross BlueShield Association. A small number of large companies dominate the national market for commercial insurance.

Identify all of the correct statements related to the role and services of commercial insurance companies.

A subscriber who requires medical care while traveling outside the service area presents the card. The host plan sends the claim via modem to the patient's home plan, which processes the claim. The provider verifies the membership and collects a copayment. After treatment, the provider submits the claim to the local BCBS plan, referred to as a host plan.

Identify all of the correct steps for how the BlueCard program works.

Dental care Vision care Preventive care

Identify services that are usually NOT subject to the deductible under the HDHP plan. (Select all that apply.)

Some plans do require the use of a regular claim with CPT codes. Most HMOs require capitated providers to submit encounter reports for patient encounters.

Identify the correct criteria for encounter reports and write-offs. (Select all that apply.)

CDHPs Fee-for-service options Comprehensive plans

Identify the different types of products offered in MCOs. (Select all that apply.)

agree to pay in writing

If a provider does not participate in a particular health plan, its patients should _____ before scheduling procedures.

Choose their own plans using a specific amount of money the employer allocates

In private exchanges, employees are able to do which of the following in their IHPs?

Deductibles Coinsurance Premiums

Indemnity plans require which of the following types of payments or cost-sharing? (Select all that apply.)

Plan name Subscriber name Type of plan

Most BCBS cards list what information? (Select all that apply.)

HMO

Of the three plan types offered by BCBS, which of the following requires the patient to choose a primary care physician?

fee-for-service

PPOs generally pay participating providers based on a discount from their physician fee schedules, called a discounted _____.

private insurance

People who are not covered by government-sponsored health insurance are often covered by _____.

medical home model plans

Plans that coordinate patients' treatments are referred to as _____.

Individuals Small businesses

Private exchanges are eligible to offer IHPs to which of the following? (Select all that apply.)

financial arrangements offered

Providers must evaluate health plans, and they judge which plans to participate in based primarily on the _____.

4

Reviewing coding compliance is which step of the revenue cycle?

preregistering patients

Step 1 of the revenue cycle is _____.

3

Step _____ of the revenue cycle is checking in patients.

Office of Personnel Management (OPM)

The FEHB is administered by which of the following?

high-deductible

The first part of a CDHP is a ____ health plan.

Names the contracting parties Includes term definitions used in the contract Identifies who the payer is

The introductory section of a participation contract does which of the following? (Select all that apply.)

monthly enrollment

The list that capitated plans send with the payment is called the _____ list.

Patient names Identification numbers Effective date of plan

The monthly enrollment list contains which of the following to show eligibility? (Select all that apply.)

Payment for noncovered services Balance due from previous encounter Deductibles

The patient's financial responsibility is analyzed according to the practice's financial policy for which of the following? (Select all that apply.)

BlueCard

The program that links providers and independent BCBS plans throughout the nation with a single electronic claim processing and reimbursement system is known as the _____ program.

capitated

Under a(n) _____ contract, providers write off services not covered under the cap rate.

pretax payroll deduction

Under income tax law, the employer can collect an employee's insurance costs through a _____.

billable

Using the plan summary grid, you should verify that all charges planned for the claim are _____.

Federal income tax advantages

What is a benefit to employers when offering medical benefits to their employees?

To complete correct claims and transmit them to private payers

What is the purpose of following the first seven steps of the standard revenue cycle?

medical insurance specialist

When a practice's contract evaluation team is considering a participation contract, a _____ may be asked to assist.

It is a procedure that can be scheduled ahead of time but which may or may not be medically necessary.

Which of the following applies to elective surgery?

Once the cap, or max, has been met, charges by nonparticipating providers are paid at 100 percent of the allowed amount. At the beginning of the new benefit year, the out-of-pocket amount resets. Once the deductible has been met, the plan pays a percentage of the charges.

Which of the following apply to BCBS indemnity plans? (Select all that apply.)

CDHPs empower consumers to manage their use of healthcare services. CDHPs eliminate most copayment coverage. CDHPs shift payment responsibility to the individual.

Which of the following apply to CDHPs? (Select all that apply.)

Employer-sponsored HMOs are beginning to replace copayments with coinsurance for some benefits. HMOs may now apply deductibles to family coverage. HMOs have traditionally emphasized preventive and wellness services.

Which of the following apply to HMOs? (Select all that apply.)

The plan's summary grid should indicate the plan's payment method for the additional services to be balance-billed. Under a capitated contract, providers bill patients for services not covered by the cap rate. Medical insurance specialists need to organize this information for billing.

Which of the following apply to billing excluded services? (Select all that apply.)

If the plan summary grid for the patient's plan lists an office visit copay, collect the copay and post it to the patient's account. Be sure the correct copayment has been collected.

Which of the following apply to check-in procedures related to up-front collections? (Select all that apply.)

Good communication between payers and medical insurance staff is necessary for effective contract and claim management. As claims are processed, questions and requests for information go back and forth.

Which of the following apply to communication with payers? (Select all that apply.)

The initial information for a patient's plan is taken from the patient's information form. Changes in insurance coverage for established patients are noted on an update to the PIF. Contact the payer to double-check if the patient is eligible for services.

Which of the following apply to establishing financial responsibility in the revenue cycle? (Select all that apply.)

Often a physician cannot bill for services not delivered, including cancellations and no-shows. Often a physician may bill only for a rendered service. The contract determines whether a provider can charge for a product when there is a no-show.

Which of the following apply to establishing policies for no-shows? (Select all that apply.)

The group is considered the policyholder. Employers' human resource departments manage GHP benefits. The individual is considered the certificate holder.

Which of the following apply to group health plans? (Select all that apply.)

Some have higher deductibles in order to keep costs down. Many have managed care features. They typically cover 70 to 80 percent of costs after the deductible is met.

Which of the following apply to indemnity plan reimbursements? (Select all that apply.)

Primary care physician is responsible for arranging patients' visits to specialists. Emphasize communication among a patient's physicians Replace illness-based primary care with coordinated care

Which of the following apply to medical home model plans? (Select all that apply.)

Like HMOs, POS plans charge an annual premium and a copayment for office visits. A POS may be structured as a tiered plan with different rates for different providers. Monthly premiums are slightly higher than for HMOs.

Which of the following apply to point-of-service (POS) plans? (Select all that apply.)

Claims must be submitted according to the plan's guidelines for timely filing. Private payer claims can be completed using the CMS-1500 paper claim. Private payer claims can be completed using the HIPAA 837P claim.

Which of the following apply to preparing and transmitting claims? (Select all that apply.)

Collecting and entering basic demographic and insurance information Step 1 of the revenue cycle

Which of the following apply to preregistration of patients? (Select all that apply.)

Check that the codes are properly linked and documented. Show the medical necessity for the services. Verify that the diagnosis and procedure codes are current as of the date of service.

Which of the following apply to reviewing coding compliance? (Select all that apply.)

Created by large employers to save money Employers cover the costs of employee medical benefits themselves rather than buying insurance from other companies. Employer assumes the risk of paying directly for medical services.

Which of the following apply to self-funded or self-insured health plans?

Most experts recommend trying to negotiate a phrase in contracts stating the MCO cannot lease any terms of the agreement. They allow a managed care organization to lease its PPO provider network list to another entity. Silent PPOs can lead to a practice accepting a PAR payment.

Which of the following apply to silent PPOs? (Select all that apply.)

BCBS is an association and not a payer. BCBS's national scope means that knowing about its programs is important for all medical insurance specialists. BCBS has both for-profit and nonprofit members.

Which of the following apply to the BlueCross BlueShield Association (BCBS)? (Select all that apply.)

Largest employer-sponsored health program in the United States Covers more than 8 million federal employees, retirees, and their families Contains more than 250 health plans

Which of the following apply to the Federal Health Benefits (FEHB) program? (Select all that apply.)

Update the practice management program to reflect appropriate diagnoses, services, and charges. Analyze the patient's financial responsibility according to the practice's financial policy. Apply collected payments to the patient's account.

Which of the following apply to the check-out process? (Select all that apply.)

Deadlines are based on the date of service. Deadlines are not based on the sent date. Deadlines are not based on the received date.

Which of the following apply to the filing deadlines for claims? (Select all that apply.)

Flexible savings (spending) accounts Health reimbursement accounts Health savings accounts

Which of the following are CDHP funding options? (Select all that apply.)

What conditions establish medical necessity for these services Whether services are correctly coded and linked What services are covered under the plan

Which of the following are addressed by plan summary grids or similar aids? (Select all that apply.)

Kaiser Permanente Anthem Aetna Humana Inc. UnitedHealth Group CIGNA Health Care

Which of the following are among the major national insurance payers? (Select all that apply.)

What the patient is responsible for paying at the time of the encounter Which services are not covered What the plan's billing rules are

Which of the following are answered by plan summary grids or similar aids? (Select all that apply.)

Establishing fees Managing insurance risk Processing claims

Which of the following are insurance services that are supplied by private payers? (Select all that apply.)

Preauthorizations Quality assurance/utilization reviews Other provisions

Which of the following are physician responsibilities in plan contracts? (Select all that apply.)

Acceptance of plan members Referrals Covered services

Which of the following are physicians' responsibilities under plan contracts? (Select all that apply.)

Patients who self-refer to nonparticipating providers may be balance-billed for those services. Both PCPs and specialists may be required to keep logs of referral activities. They may require a PCP for out-of-network provider referrals.

Which of the following are referral requirements for HMOs? (Select all that apply.)

Establish financial responsibility for visits. Check in patients. Preregister patients.

Which of the following are steps in preparing the correct claims? (Select all that apply.)

Consumer-driven health plans (CDHPs) Preferred provider organizations (PPOs) Health maintenance organizations (HMOs)

Which of the following are types of private payers? (Select all that apply.)

PPO HMO POS

Which of the following are types of products offered in MCOs? (Select all that apply.)

A payer can no longer drop a beneficiary from a plan because of a pre-existing illness. A payer cannot discriminate against individuals based on gender, occupation, or employer size.

Which of the following improvements are in effect for patients with private health insurance?

Payers cannot impose lifetime financial limits on benefits. Insurance plan beneficiaries have expanded rights to appeal denials or cancellations. Young adults up to age twenty-six can remain as dependents on their parents' private health insurance plan.

Which of the following improvements are now in effect for patients with private health insurance?

Group health plans (GHP)

Which of the following plan types are purchased from insurance companies by employers for their employees?

Pap smear Physical or occupational therapy Office visits

Which of the following services may need to be specifically verified for eligibility? (Select all that apply.)

Contact the payer to double-check. Accurately enter the patient's name and ID number.

Which of the following should be done to verify insurance eligibility? (Select all that apply.)

Medical insurance specialists should verify whether a copayment is to be collected under the secondary plan. A variable in collecting copayments involves primary and secondary plans.

Which of the following statements apply to copayments? (Select all that apply.)

PPOs are the most popular type of private plan. CDHPs combine a high deductible plan with a funding option of some type. Few employees choose indemnity health plans.

Which of the following statements apply to private payers? (Select all that apply.

Self-insured employers cover more than half of all employees in the United States. Self-funded health plans also may buy other types of insurance, such as vision, instead of insuring the benefit themselves. The employer establishes the benefit levels and the plan types offered.

Which of the following statements apply to self-funded or self-insured health plans? (Select all that apply.)

PMPs can be set up to automatically write off fees for patients under capitated plans. Billing staff knows not to expect additional payment based on a claim for a capitated-plan patient. If the service charges were not written off, the PMP would double-count the revenue.

Which of the following statements apply to write-offs? (Select all that apply.)

A third-party administrator may be responsible for processing and paying claims. A self-funded health plan may create the plan. Payer information must be noted so that claims will be sent to the correct organization.

Which of the following statements are related to the payer information in the introductory section of a participation contract? (Select all that apply.)

Health savings accounts

Which of the following types of CDHP funding options allow unused funds to roll over indefinitely?

HMO PPO POS

Which of the following types of managed care programs are offered by BCBS? (Select all that apply.)

PCPs Specialists

Who may be required to keep logs of referral activities? (Select all that apply.)

individual health plans

A key goal of the ACA is to reduce the number of uninsured citizens and legal residents by providing affordable _____.

handles claims processing only

A patient with a self-funded health plan may have an ID card with a familiar plan that _____.

point-of-service (POS)

A plan that is a hybrid of HMO and PPO networks is called a(n) _____ plan.

network sharing agreement

A silent PPO is also known as a _____.

Section 125 cafeteria

A common way that employers organize employees' choices of plans is by creating a tax structure called a _____ plan.