Kinn's The Administrative Medical Assistant - Chapter 16 Basics of Health Insurance

A form of insurance that insures the beneficiary's income against the risk that a disability will make working uncomfortable or impossible and provides weekly or monthly cash benefits

Disability

___________________ provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.

Disability Income Insurance

The ___________________ is the date on which the insurance coverage begins so that benefits are payable.

Effective date

Describe the processes available for the verification of eligibility for services

Either by visiting the online insurance Web portal, or that that isn't available, the medical assistant should contact the provider services desk phone number located on the back of the patient's insurance card.

A privately sponsored health plan purchased by an employer for their employees is considered a(n) ____________________ policy.

Employer-sponsored group

A reimbursement model in which the health plan pays the provider's fee for every health insurance claim is called ________________.

Fee-for-service or Indemnity plan

Medicaid and Medicare are examples of ________________ plans.

Government-sponsored

Low- and middle-income Americans can purchase health insurance at a(n) ___________________ for health insurance and not worry about being denied for a pre-existing condition.

Health Insurance Marketplace

A(n) ______________ is a healthcare plan that controls the cost of healthcare delivery by requiring all patients to seek care with a primary care provider to assess if more specialized care is needed.

Health Maintenance Organization (HMO)

___________________ is a third-party system that reimburses a provider when services are rendered for an insured patient.

Health insurance

Pays the cost of all or part of the insured person's hospital room and board and specific hospital services per DRG guidelines

Hospitalization

_________________ pay for all or a share of the cost of covered services, regardless of which physician, hospital, or other licensed healthcare provider is used. Policyholders of these plans and their dependents choose when and where to get healthcare services.

Indemnity plans

A(n) __________ is health insurance coverage for those who are not covered by their employer group plan.

Individual health insurance

Often includes benefits for medical expenses related to traumatic injuries and lost wages payable to individuals who are injured in the insured person's home or in an automobile accident

Liability insurance

Provides payment of a specified amount upon the insured's death

Life insurance

Covers a continuum of broad-range maintenance and health services to chronically ill, disabled, or mentally disabled individuals

Long-term care insurance

Provides protection against especially large medical bills resulting from catastrophic or prolonged illnesses up to a maximum limit, usually after coinsurance and a deductible have been met

Major medical

___________ are a type of healthcare organization that contracts with various healthcare providers and medical facilities at a reduced payment schedule for their insurance members.

Managed Care Organizations

An umbrella term for all healthcare plans that focus on reducing the cost of delivering quality care to patient members in return for scheduled payments and coordinated care through a defined network of primary care physicians and hospitals is _________________.

Managed Care Plan

________________ is a process required by some insurance carriers in which the provider obtains authorization to perform certain procedures or services or to refer a patient to a specialist.

Preauthorization

The fee schedule designed to provide national uniform payment of Medicare benefits after adjustment to reflect the differences in practice costs across geographic areas is called the _______________________________.

Resource-Based Relative Value Scale (RBRVS)

Obtain information from the patient and/or the guarantor, including _______________________ and _______________ data.

employment, insurance

The term for limitations on an insurance contract for which benefits are not payable is __________________.

exclusions

When a provider agrees to become a PAR, they also agree to the health insurance plan's _______________________ for rendered medical services.

fee schedule

The primary care provider who can approve or deny when a patient seeks additional care is referred to as a(n) _____________

gatekeeper

Health insurance plans pay for health services deemed _______________.

medically necessary

A(n) _______________ is a healthcare provider who enters into a contract with a specific insurance company or program and agrees to accept the contracted fee schedule.

participating provider

The intermediary and administrator who coordinates patients and providers and processes claims for self-funded plans is called a(n) ________________.

Third-party administrator

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

Utilization management/utilization review

___________________________ is the process of confirming health insurance coverage for the patient for the medical service and the date of service.

Verification of Eligibility

Provides reimbursement for all or a percentage of the cost of refraction, lenses, and frames

Vision care

________________________ is an insurance plan for individuals who are injured on the job either by accident or an acquired illness.

Workers' Compensation

The ____________ is the maximum that third-party payers will pay for a procedure or service.

allowable charge

Benefits cover the ___________________, or the amount that should be paid to the healthcare provider for services rendered.

amount loss

An alphanumeric number issued by the insurance company giving approval of a procedure or service is a(n) ___________.

authorization code

The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage, is known as _________.

benefits

List three benefits of the Affordable Care Act

2. prohibition of denial due to preexisting conditions 2. retention of coverage on parents' insurance until age 26 3. out-of-network payments for emergency room visits

Medicaid

A federally sponsored health insurance program for the medically indigent

Medicare

A federally sponsored health insurance program for those over 65 years or disabled individuals under 65 years

Medigap

A term sometimes applied to private insurance products that supplement Medicare insurance benefits.

The health benefits program run by the Department of Veterans Affairs (VA) that helps eligible beneficiaries pay the cost of specific healthcare services and supplies is the (give acronym)________________.

CHAMPVA

A benefits program that offers a variety of options (fee-for-service or managed care plans) that reimburse a portion of a patient's dental expenses and may exclude certain treatments.

Dental care

List two different populations who would qualify for Medicare

1. Persons who are 65 years or older; or 2. persons under 65 and on SSDI for longer than two years

List three disadvantages of managed care organizations

1. access to specialized care and referrals can be denied or limited 2. treatment may be delayed because of preauthorization requirements 3. more paperwork may be required

List three advantages of managed care organizations

1. healthcare costs are usually controlled 2. patient's out-of-pocket fees tend to be less 3. authorized services are usually paid for

List two different populations who would qualify for Medicaid

1. individuals who are medically indigent 2. individuals who receive Supplemental Security Income (SSI)

The resource-based relative value scale includes the following three parts:

1. provider work 2. charge-based professional liability expenses 3. charge-based overhead

The ___________________ was passed in 2010 to assist more Americans in obtaining health insurance.

Affordable Care Act

There are resources for patients who have questions on health insurance coverage through the Patient Protection and Affordable Care Act, such as ____________________.

Affordable Care Act Navigators

Pays all or part of a physician's fee for nonsurgical services, including hospital, home, and office visits

Basic medical

Helps defray medical costs not covered by Medicare

Medicare supplement

_______________________ are used by many healthcare facility offices to quickly verify eligibility and benefits.

Online insurance Web portals

Patients have a higher financial responsibility when they access care that is _____________________.

Out-of-Network

Healthcare providers need to apply to become a _____________ through a process called credentialing.

PAR participating provider

Prescription drugs are covered by Medicare ________________.

Part D

A(n) ______________ is funded by an organization with an employee base large enough to fund its own insurance plan.

Self-funded plan

Pays all or part of a surgeon's or assistant surgeon's fees

Surgical

A government-sponsored program under which authorized dependents of military personnel receive medical care was originally called CHAMPUS but now is called ____________________.

TRICARE

Active duty military personnel, family members, military retirees and their eligible family members under the age of 65, and the survivors of all uniformed services are covered by ___________.

TRICARE

Verify the .patient's _______________ for insurance payment with the insurance carrier or carriers, as well as insurance ____________, exclusions, and whether ___________ is required to refer patients to specialists or to perform certain services or procedures, such as surgery or diagnostic tests.

eligibility, benefits, special authorization

Outline managed care requirements for patient referral

patients seeking specialized care must first visit their assigned PCP to obtain a referral to a specialist or for more specialized therapy or care. HMOs will measure how many patients are referred to specialists by individual PCPs. Approval or denial can take anywhere from a few minutes to several days, depending on the urgency

Obtain _______________ for referral of the patient to a specialist or for special services or procedures that require advance permission.

preauthorization

A payment of a specific sum of money to an insurance company for a list of health insurance benefits is called a(n) _____________________.

premium

In the United States, healthcare practitioners render services ______________ receiving payment.

prior to

An insurance term used when a primary care provider wants to send a patient to a specialist is ______________.

referral

A(n) ______________ usually takes 3 to 10 working days for review and approval. This type of referral is used when the physician believes that the patient must see a specialist to continue treatment.

regular referral