Health insurance
The standard claim form designed by the Centers for Medicare and Medicaid Services to submit provider services for third-party (insurance companies) payment is known as:
the Affordable Care Act
the CMS-1500
the coordination of benefits
the fee disclosure
What is the requirement to generate a referral for a patient with a managed care insurance plan?
Patient must first see his or her primary care provider (PCP).
The PCP must generate a referral in order for the patient to see a specialist.
The provider (or MA) must obtain verification of eligibility for services.
All of the above
Which of the following would be considered a step or steps to obtain precertification or preauthorization (predetermination) for a procedure for a patient with a managed care plan?
Determine if precertification or preauthorization is required.
Locate the form on the insurance company website (or call the insurance company if you cannot locate or have questions).
Complete the form correctly, fax to the insurance company (or send electronic authorization request).
All of the above are necessary steps.
Medicare pays ____ of the approved medical bill amount once the deductible is satisfied.
20
60
70
80
The following health care model is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be,” and leads to higher quality and lower costs and can improve patients’ and providers’ experience of care:
Accountable Care Organization (ACO)
Health Maintenance Organization (HMO)
Patient-Centered Medical Home (PCMH)
All the above
Health insurance offered by private companies to persons eligible for Medicare benefits and specifically designed to supplement such benefits is called:
Medigap
Medicaid
TRICARE
CHAMPVA
Part ___ of Medicare is for payment of medical expenses such as office visits and X-ray and laboratory services.
A
B
C
D
Medicare will ______ pay for services or supplies considered medically reasonable and necessary for the diagnosis given
Only
Not
Sometimes
None of the above
Because a primary care physician (PCP) in an HMO makes referrals and approves additional care if needed, he or she is known as the:
Gatekeeper
Patient advocate
Specialist
Care manager
In some cases, the Medicare insurance carrier automatically sends the amount not covered on to a private secondary insurance carrier (known as a _______________________), which may pay the deductible and the 20 percent not covered, eliminating the need to fill out additional forms.
Universal claim
Secondary claim
Crossover claim
None of the above
Part ___ of Medicare was created to provide coverage for both generic and brand name drugs.
A
B
C
D
Under the birthday rule, if the parents’ divorce and retain their plans, the parent with _____ is primary.
The greater income
The plan in effect the longest
custody or the birthday closest to the beginning of the year
the parent with the plan that provides the best coverage
When patients without health insurance are seen in the medical practice, they are classified as ____ patients.
Pro bono
Self-pay
Reimbursement
TRICARE
When a provider does not accept assignment from Medicare, the most that can be charged to the patient is ___ percent of the Medicare-approved amount.
85
100
115
150
Under workers’ compensation, a patient who has an industrial injury is billed:
for 20 percent of the cost of treatment
for 80 percent of the cost of treatment
for the entire cost of treatment
if treatment was given without authorization
The only practitioners that can currently bill Medicare with the hard-copy CMS-1500s are businesses with:
less than 10 full-time employees, including physicians
more than 20 full-time employees, including physicians
less than 10 full-time employees, excluding physicians
more than 20 full-time employees, excluding physicians
This form needs to be completed by Medicare patients prior to a surgery or procedure that Medicare may not cover.
EOB
ABN
CMS 1500
RA
Another variable with primary and secondary coverage occurs when a person qualifies for Medicare by virtue of age but remains employed. If the employee continues to work and is employed by a company with 20 or more employees, the group plan:
is the sole payer
does not have to pay
the group plan is billed as primary and Medicare is billed as secondary
Medicare is billed as primary and the group plan is billed as secondary
This is the person entitled to benefits of an insurance policy
Gatekeeper
Carrier
Beneficiary
Subscriber
Match the terms
Relates not only to whether the services are covered but also whether the proposed treatment is medically necessary
Predetermination
Seeking approval for a treatment (surgery, hospitalization, diagnostic test) under the patient’s insurance contract
Precertification
Refers to the discovery of the maximum amount of money the carrier will pay for primary surgery, consultation service, postoperative care, and so on
Preauthorization
Refers to obtaining plan approval for services prior to the patient receiving them
Precertification
Match each health insurance term with its definition.
Predetermined amount that the insured must pay each year before the insurance company will pay for an accident or illness
Assignment of benefits
Specified amount that the insured must pay toward the charge for professional services rendered at the time of service
Co-payment
Established to aid dependents of active service personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty, with a supplement for medical care in military or Public Health Service facilities
Indemnity plan
Payment based upon physician work, practice expense, professional liability and geographical location.
TRICARE
Procedures used by insurers to avoid duplication of payment on claims when a patient has more than one policy
Health maintance organization
Authorization, by signature of the patient, for payment to be paid directly by the patient’s insurance to the provider for services
Gatekeeper
Must have a pcp to oversee referrals; emphasizes preventative care, well child checks and annual exams
Deductible
Established for the spouses and dependent children of veterans who have total, permanent, service-connected disabilities
Coordination of benefits
PCP responsible for referring patient to a specialist and approving additional services if needed
CHAMPVA
Commercial plan in which the insurance company reimburses providers or beneficiaries; patients can see the provider of their choice and do not need a referral. Standard plan has an 80/20 coverage.
Graphic practice cost index
Match the Part of Medicare to its definition. Note: Answers may be used more than once.
A benefit that was introduced for beneficiaries as of January 1, 2005, was the Initial Preventive Physical Exam, otherwise known as the Welcome to Medicare visit
Part a
Enables beneficiaries to select a managed care plan as their primary coverage
Part c
Also known as Medicare Advantage
Part b
For payment of other medical expenses, including office visits, X-ray and laboratory services, and the services of a provider in or out of the hospital
Part d
Provide coverage for both generic and brand-name drugs
Part b
For hospital coverage
Part c
Match each health insurance term with it's correct definition
Money paid generally monthly for an insurance
Diagnosis related group
Maximum amount an insurance will pay for any given services
Co-insurance
Providers are paid a set fee each month for a patient whether they see them a lot or not at all for the month.
Explanation of benefits
Form of insurance providing wage replacement, medical and possibly death benefits to an employee who has developed work-related disorders, disabilities, illness or death.
Capitation
Provider who has contracted with an insurance and accepts whatever the insurance pays
Worker's compensation
Printed description of the benefits provided by the insurance to the beneficiary
Premium
A payment weight scale developed by Medicare, where payment is weighed upon average resources from diagnosis.
Exclusive provider organization
Provider who is not contracted with insurance and can collect cost of total charges billed.
Participating provider
Percentage owed by patient for services rendered after a deductible has been met and co-payment has been paid
Allowed amount
Insurance that is similar to HMO, can only use their network, no PCP required, no referral necessary but must use an in-network provider.
Non-participating provider
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