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Intro to the Medical Billing Cycle
| a prospective payment to a provider made for each plan member | capitation |
| the percentage of each claim that an insured person must pay | coinsurance |
| an amount that an insured person pays at the time of a visit to a provider | copayment |
| the amount that an insured person must pay before reimbursement for medical expenses begins | deductible |
| a health plan that reimburses policy holders based on the fees charged | fee-for-service |
| an organization that contracts with a network of providers for deliver of health care for aprepaid premium | HMO-health maintenance organization |
| a retroactive reimbursement method based on providers charges | indemnity |
| a managed care network of providers under contract to provide services at discounted fees | PPO-Preferred provider organization |
| the amount of money paid to a health plan to buy an insurance policy | premium |
| a list of medical services covered by an insurance policy | schedule of benefits |
| Spending on health care in the United States is rising due to what 2 factors | the cost of new technology and the aging population |
| Employment for well-trained medical insurance and coding specialists are | increasing due to rising demands. |
| What kind of medical services are annual physical examinations and routine screening procedures | preventive |
| Under an insurance contract the patient is the 1st party, the physician is the 2nd party, who is the 3rd party? | Insurance plan |
| Under a written insurance contract, teh policyholder pays a premium and the insurance company provides what | payments for covered medical services |
| Out-of-pocket expenses must be paid by who | the patient |
| What conditions must be met before payment is made under an indemnity plan? | payment of premium, deductible, and coinsurance |
| A capitated rate is | prospective payment |
| Correctly relating a patient's condition and treatment refers to | medical necessity |
| Which of the following is required with a HMO patient is admitted to the hospital for nonemergency treatment? | preauthorization |
| HMO's are regulated by | both federal and state law |
| Under a capitated rate for each plan member, who shares the risk? | Provider and the 3rd party payer |
| A capitated rate per member per month coveres what | services listed on the schedule of benefits |
| For a patient covered by an HMO, out-of-network means the provider is | not under contract with the payer |
| With a POS option under a HMO organization the patient may choose | to see a provider who is not int he HMO network |
| With a point-of-service type HMO the patient may use the services of | HMO network or out-of-network providers |
| To be covered patients who enroll in an HMO may use the services of | only HMO network providers |
| Under an indemnity plan a patient my use the services of | any provider |
| In a PPO plan referrals to specialists are | not required |
| Consumer-driven health plans combine a health plan with a special savings account that is used to pay the medical bills before what | the deductible is met |
| Employers that offer health plans to employees without using an insurance carrier is called | self-funded health plan |
| What is an example of a private-sector payer | insurance company |
| What government program covers patients who are over age 65? | Medicare |
| What government program covers people who cannot otherwise afford medical care | Medicaid |
| Step 1 of the medical billing cycle | Preregister patient |
| Step 2 of the medical billing cycle | Establish financial responsibility for visits |
| Step 3 of the medical billing cycle | Check in patient |
| Step 4 of the medical billing cycle | Check out patient |
| Step 5 of the medical billing cycle | Review coding compliance |
| Step 6 of the medical billing cycle | Check billing compliance |
| Step 7 of the medical billing cycle | Prepare and transmit claims |
| Step 8 of the medical billing cycle | Monitor payer adjudication |
| Step 9 of the medical billing cycle | Generate patient statements |
| Step 10 of the medical billing cycle | Follow up patient payments and handle collections |
| A patient ledger records what | The patient's financial transactions |
| What characterisitcs is most important when medical insurance specialists work with patients' records and handle finances? | honesty and integrity |
| standards of conduct based on moral principles | professional ethics |
| standards of professional behavior | professional etiquette |
| Registered Medical Assistant (RMA) is awarded by | (AMT) American Medical Technologists |
| Certified Medical Assistant (CMA) is awarded by | (AAMA) American Association of Medical Assistants |
| Certified Coding Specialist, (CCS) and Certified coding Specialist-Physician based (CCS-P) is awarded by | (AHIMA) American Health Information Management Association |
In what step does the medical insurance specialist verify that charges are in compliance?
Once a claim reaches a payer, it undergoes a process called adjudication. In adjudication, a payer evaluates a medical claim and decides whether the claim is valid/compliant and, if so, how much of the claim the payer will reimburse the provider for. It's at this stage that a claim may be accepted, denied, or rejected.
What is the process of contacting the insurance carrier and receiving validation of coverage for the patient?
Simply put, insurance verification is the process of contacting the insurance company to determine whether the patient's healthcare benefits cover the required procedures. Also, it is necessary to complete insurance verification before a patient receives medical services.
Which person is responsible for paying the charges?
Includes Review for chapters 1-5.
What are billing terminology?
The terms that indicates when payment is due for sales made on account. Terms are noted by preceding the number of days to pay with the word “Net” (i.e., Net 30 Terms). Invoices note their credit terms in the “Terms” field or the “Due by” field.