Chapter 9 Review Health Care Coverage

Review The largest industry in the United States is? Insurance companies This type of insurance plan offers people affordable health care plans because they are provided through their place of employment at a reasonable cost? Health care organizations(HMOs) HMO’s require what to see a specialist? Referral from their Primary Care Physician HMO’s focus primarily on what type of care? Preventative health care(P.E. mammograms, wcc, immunizations ect..), this keeps costs down What is a co-payment? A payment usually $10 to $25 at every visit, most HMOs require this What is the birthday rule? The parent whose birthday occurs first in the calendar year is primary, and the other parent’s is secondary

Review A request for payment under an insurance organization made by the physician or the patient? Claim Transferring of words into numbers to facilitate the claim processing is called? Coding What is coinsurance? A specific amount that the insured must pay toward the charge for services rendered What is a deductible? A predetermined amount that the insured must pay each year before the insurance company will pay What is a preexisting condition? A condition that existed before the insured’s policy was issued

Review Money paid by an individual for an insurance contract(usually deducted from your pay check) is a?  Premium This insurance plan allows the patient the option of using network or non-network physicians and hospitals? A Preferred Provider Organization (PPO) Another name for a gatekeeper, also responsible for coordinating all care for the patient? Primary Care Physician

Review What is considered an indemnity plan? 80/20 plan(80% the insurance pays and 20% the patient pays) This is when the insurance reimburses the patient for services and then the patient makes the payment directly to the physician? An indirect payment This is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment? Workman's Compensation This is the United States health program for certain people and families with low incomes and resources? Medicaid This is a social security insurance program administered by the United States government, providing health insurance coverage to people who are aged 65? Medicare

Review This is used for the Medicare ID number? Social security number Medicare claims must be filed within how long? 1 year Medicare will not cover what type of service? Physical exams This is a private insurance to supplement Medicare benefits for non-covered services? Medigap Physicians can charge what percentage of Medicare fees if they are not a participating provider? 115% Medicare will reimburse what percentage of all charges? 80% A Medicare patient needs to pay how much yearly before coverage begins? 100 to 124 dollars

Review This insurance is for uniform services and their families? Tricare These codes are used to bill for the disease? ICD-9 (International Classification of Diseases, 9th Revision Codes used for looking up procedures in the office? The Current Procedural Terminology (CPT) What should the medical assistant do if a claim is not made or denied in 3 weeks? Make a follow up call to that insurance company

Review List some common claim errors? -Use of incorrect ICD or CPT codes -Incorrect spelling of patients name, or DOB - The patient, not the policy holder information is billed What is an explanation of benefits? A list of benefits provided by the insurance company Before an insurance claim can be processed, the patient needs to do what? Sign a release form, and the MA should always make a photocopy of their insurance card(front and back)