Chapter 1 Insurance In the medical office Seventh ed

Benefits
In excange for the permium that the policyholder pays, the health plan agrees to pay amounts for the medical services called
Coinsurance
Is the percentage of the charges an insured person must pay for health care service after the deductible has been meet
Policyholder
Coinsurance is paid by the
copayment
Is the amount that a person insured in a manged care plan must pay for each office visit
Hold down health care costs
Cost-containment practices are designed to
Deductible
Is the amount the insured must pay before receiving benefits from the insurance policy
Dependent
person who is also covered under an insured person’s policy is called a(n)
Diagnosis
A provider’s analysis of a patient’s illness or injury is called
remittance advice
Is a health plan document that provides details about how a patient’s claim was handled
Remittance advice
RA is the abbreviation for
Fee-for-service
Are benefits paid based on the fees physician charge for the services
health care claim
Is a formal insurance claim, either electronic or hard copy format, witch is filed with the payer (insurance carrier) by many medical offices on behalf of their patients to receive payments
Health Plans
Are orgabizations that offer protection in case of illness or accidental injury
Managed care organizations
are organizations that offer health plans that combine the financing and delivery of health care servies
Medical Insurance
Is a financial plan that covers the cost of hospitalization and medical care due to illness or injury
Patient information form
is a form that contains demographic information about a patient
Policyholder
is a person who buys an insurance plan
Preauthorization
When a health plan has apporved a procedure before it is done, this process is called
Provider
A _____ is a person or entity that supplies medical or health services
Schedule of benefits
A list of covered services that an insurance policy covers is called
Covered services
Are medical procedures and treatments included as benifits in a health plan
Copayment
Is a small fixed fee paid by the policyholder/patient at the time of each office visit
Payer
is the third party in the medical insurance relationship who carries some of the risk of paying for services on the behalf of the beneficiaries
Payers
are private or goverment organizations that insure or pay for health care on behalf of beneficiaries
the patient’s diagnosis and procedures received are logically linked
Medically necessary means
Medically necessary
means treatmentes that are appropriate and rendered in accordance with generally accepted standards of medical practice
Ethics
are the standards of behavior requiring truthfulness, honesty, and integrity
Ethics
Are standards of conduct based on moral principles
Job-related illnesses and injuries
Workers’ compensation covers people with
Their employer
People with ijob-related illnesses or injuries are covered under workers’ compensaton insurance through
Gathering basic demographic and insurance information about patients
Preregistraton involves
Part of the patient checkout process
Patient payments such as copayments are
actions that help to ensure the provider receives maximum appropriate payment
Revenue cycle management (rcm) in volves
Health information technolgy is
computer hardware and software information systems that record, store, and manage patient information
Practice management programs ( PMPS) are
specialized accounting software programs used in many medical offices
bill insurance companies and patients
Practice management programs (PMPs) are used to
computer lifelong health care record for an individual
an electrionc health record (EHR) is a
65
Medicare covers people over the age of
Illness
Health plans offer finanical protection in the case of
receives the service
A copayment is due when the patient
$70
if a policyholder owes coinsurance of 30 percent and the charges are $100, what is the amount the insurance policy will pay
Patient
Who pays for the excluded services
increased payments to providers
in the United States, rising medical costs are due to
cost-containment practice
an example of ___ is requiring patients to choose from a specific group of physicians
nonemergency hospitalization
Manged care plans often require preauthorizaton for
Health care claims
Policyholders receive insurance benefits when which of the following is filed
consumer-driven health plan
is a type of managed care plan in witch a high-deductible low-permium insurance plan is combined with a pretax savings plan
denied clamis
inaccurate health care claims result in
The managed care organization
fees are set by ____ under a managed care plan
copayment
copay is the shortened version of witch term
physicians
in a fee-for-service plan, benefits are based on the fees charged for services by
procedures
the services and treatments given by a licensed medical professional are called
etiquette
correct behavior in the medical office is called
tricare
the goverment sponsored insurance program for the families of military personnel is called
update them
what should patients returning to a medical office periodically be asked to do with their patient information forms
Health savings account
is the second element of a CPHP that is used to pay medical bills before the deductible has been met
both front and back
what side(s) of the patients insurance identification card does a medical assistant usually scan or photocopey
medical billing cycle
the process that results in timely payment for medical services is called
medicaid
is for individuals with lower incomes who cannot afford medical care is cosponsored by the federal and state governments
CHAMPVA
is the healtyh plan for the dependents of veterans with permanent service-related disabilities
CHAMPVA
is the health plan that covers surviving spouses and dependent childern of veterans who died from service-related disabilities
preferred providers organization
is a type of manged care health plan in witch a network of providers under contract with a managed care organization agree to perform services for plan members at discounted fees
health maintenance organization
is a type of manged care system in which providers are paid fixed rates at regular intervals to provide necessary contracted services to patients who are plan members
Health maintenance organization
HMO is the abbreviation for
preferred provider organization
PPO is the abbreviation for
Chief complaint
is the illness or condition that is the reason a patient needs to see the physician
certification
recognition of a superior level of skill by an official organization is called
statement
shows services provided to a patient,total payments made, total charges, adjustments, and balance due
e-claims
are claims that are prepared and sent electronically
electronic health record and practice management program
PM/EHR is a software program that combines
coding
is the process of translating a description of a diagnosis or procedure into standardized code
adjudication
is when a claim goes through a series of steps that are designed to determine wheather the claim should be paid
routine cancer screening
whitch one of the following is considered preventive medical services
third-party payer
is a private or goverment organization that insures or pays for health care on the behalf of beneficiaries
account receivable
are monies that are owed to the practice
accounts payable
are a medical practices operating expenses