Medical Insurance- Chapter 8
A physician practice lists a service at $130, but in the participating contract it has with a payer, the service is listed at $95. Calculate the amount that the practice will need to write off if balance billing is not permitted.
$35
The seven steps of the revenue cycle into the order that will lead to completion of correct private payer claims
1. Preregister patients 2. Establish financial responsibility for visits 3. Check in Patients 4. Review coding compliance 5. Check billing compliance 6. Check out patients 7. Prepare and transmit claims
Approximately what percentage of all consumers with health insurance are enrolled if a PPO?
50%
Utilization review organization
A company hired by a payer to evaluate the appropriateness and medical necessity of hospital-based health care services
Which type of consumer-driven health plan funding option is set up by individuals rather than employers?
A health savings plan (HSA)
Consumer-driven health plans have what effect on a practice's cash flow?
A high-deductible payment from the patient takes longer to collect than does a copayment
repricer
A vendor that processes a payer's out-of-network claims
Referral requirements
An HMO may require a PCP to refer a patient to an in-network provider or to get authorization from the plan to refer a patient to an out-of-network provider. 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.
UnitedHealth Group
Another large health insurer; owns other major regional insurers, such as Oxford Health Plans
Which of the following is one of the nation's largest health insurers?
Anthem
Subcapitation
Arrangement by which a capitated provider prepays an ancillary provider
Coventry
Based in Bethesda, Maryland; operates health plans, insurance companies, network rental/managed care services, and workers' compensation services companies; provides a full range of risk and fee-based managed care products and services
Patient eligibility
Because patients must choose PCPs each month, the insurance plan sends a monthly enrollment list that should list the current members. Verify that the patient is eligible for services
Which laws govern the portability of health insurance?
COBRA and HIPAA
Claim write-offs
Charges for service under capitated plans are written off as an adjustment to the patient's account. The 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 practice-management program would double-count the revenue for these patient encounters. Thus, the regular charges for the services that are included in the cap rate are written off by the biller.
stop-loss provision
Contractual guarantee against a participating provider's financial loss due to an unusually large demand for high-cost services
monthly enrollment list
Document of eligible members of a capitated plan register with a particular PCP for a monthly period
Self-funded health plans are regulated by
ERISA
The health insurance program for federal government employees is
FEHB
The largest employer-sponsored health program in the United States is
Federal Employees Health Benefits program
What type of private payer offers lower costs, but also has the most stringent guidelines and the narrowest choice of providers?
Health Maintance Organizations (HMOs)
home plan
In a BlueCard program, the provider's local BCBS plan
high-deductible health plan
Insurance plan, usually a PPO, that requires a large amount to be paid before benefits begin; part of a consumer driven health plan
CIGNA Health Care
Large health insurer with strong enrollment in the Northeast and the West
Kaiser Permanente
Largest nonprofit HMO; a prepaid group practice that offers both health care services and insurance in one package; runs physician groups, hospitals, and health plans in western, midwestern, and southeastern states pus Washington, D.C.
Encounter reports
Most HMOs require capitated providers to submit encounter reports for patient encounters. Some do not require regular procedural coding and charges on the reports. However, some plans do require the use of a regular claim with CPT codes.
Health Net
Operates health plans in the West and has group, individual, Medicare, Medicaid, and TRICARE programs
carve out
Part of a standard health plan that is changed under a negotiated employer sponsored plan
Humana Inc.
Particularly strong in the South and Southeast; offers both traditional and consumer-driven products; handles TRICARE operations in the Southeast
Precertification
Payer pre-authorization for elective hospital-bassed services and outpatient surgeries
Identify the type of managed care structure that is usually the first component of a consumer-driven health plan.
Preferred Provider Organization (PPOs)
Which of the following is the most popular type of group health plan?
Preferred Provider Organization (PPOs)
Which of the following steps come after checking billing compliance in the standard revenue cycle?
Prepare and transmit claims
Which of the following steps comes first in the standard revenue cycle?
Preregister patients
Billing for excluded services
Providers bill patients for services not covered by the cap rate. Medical insurance specialists need to organize this information for billing. The plan's summary grid should indicate the plan's payment method for the additional services to be balance-billed, such as discounted fee-for-service.
Plan summary grid
Quick-reference table for health plans
Aetna
Serves more than 44 million members; benefits include health care, dental, pharmacy, group life, behavioral health, disability and long-term care benefits
elective surgery
Surgical procedure that can be scheduled in advance
metal plans
Term for the new designs of health plans created by the ACA
Anthem
The nation's largest health insurer in terms of enrollment; the largest owner of BlueCross and BlueShield plans, serving as the BlueCross licensee in California and the BlueCross and BlueShield licensee in Georgia, Missouri, and Wisconsin; also serves Colorado, Connecticut, Indiana, Kentucky, Maine, Nevada, New Hampshire, Ohio, and Virginia under Anthem BlueCross and BlueShield
What term refers to the payer's process for determining medical necessity?
Utilization review
Providers who participate in a PPO are paid
a discounted fee-for-service
Which type of consumer-driven health plan funding option is set up and funded by employers?
a health reimbursement account (HRA)
Under a capitated HMO plan, the physician practice receives
a monthly enrollment lists
Which of the following is a time between the date of an employee's hire and the earliest effective date of insurance coverage?
a waiting period
BlueCross BlueShield Association member plans offer
all major types of health plans
Elective surgical procedures are done on a a(n)
both in-patient or out-patient basis
Which term describes the periodic verification that a provider or facility meets professional standards?
credentialing
rider
document that modifies for elective hospital-based services and outpatient surgeries
Who may be covered under a GHP?
employees, families, and former employees
Stop-loss provisions protect providers against
extreme financial loss.
Which term refers to an individual who enrolls in a health plan after the original enrollment date?
late enrollee
In employer-sponsored health plans, employees may choose their plan during the
open enrollment period
What document is researched to uncover rules for private payers' definitions of insurance-related terms?
participation contract
Emergency surgery usually requires
precertification (preauthorization) within a specified time after the procedure
Determine what law a practice would follow if a state law is more restrictive than the related federal law.
the state law is followed
What is the purpose of the BlueCard program?
to make it easier for patients to receive treatment when outside their local service area
