Week 4 Assignment Worksheet-Sarah Orr
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Fortis College *
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MOA 110
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History
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Feb 20, 2024
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MOA115 Medical Records and Insurance Week 4 Assignment –
Insurance Concepts Part 1 –
Managed Care Procedures and Third-Party Billing Guidelines Chapter 12 Health Insurance Essentials 1.
Define fee schedule and list types of fee schedules. ________________________________________________________________________ ________________________________________________________________________ 2.
Define utilization management and describe the role of a utilization review committee. ________________________________________________________________________ ________________________________________________________________________ 3.
Define a third-party payer and list major third-party payers in medical insurance. ________________________________________________________________________ ________________________________________________________________________ Part 2
–
Study Guide Questions
A. Health Insurance Plans 1.
Match the following terms and definitions: _____ Medicaid _____ Medicare _____ Medigap a. A federally funded health insurance program for those older than 65 years or disabled individuals younger than 65 years b. A term sometimes applied to private insurance products that supplement Medicare insurance benefits c. A health insurance program that is funded by both the federal and state governments for the medically indigent 2.
List two different populations who qualify for Medicare. ________________________________________________________________________ ________________________________________________________________________ 3.
The RBRVS includes the following three parts: a.
__________________________________________________________________ b.
__________________________________________________________________ c.
__________________________________________________________________ 4.
The intermediary and administrator who coordinates patients and providers and processes claims for self-funded plans is called a(n) _______________________. 5.
Prescription drugs are covered by Medicare _______________________. 6.
List four different populations who qualify for Medicaid. a.
__________________________________________________________________ 9GWGM 5WW
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MOA115 Medical Records and Insurance Week 4 Assignment –
Insurance Concepts b.
__________________________________________________________________ c.
__________________________________________________________________ d.
__________________________________________________________________ 7.
Active duty military personnel, family members of active duty personnel, and military retirees and their eligible family members younger than age 65 are covered by _______________________. 8.
The health benefits program run by the Department of Veterans Affairs (VA) that helps eligible beneficiaries pay the cost of specific healthcare services and supplies is the (give acronym) _______________________. 9.
List the services covered by workers’ compensation plans
________________________________________________________________________ ________________________________________________________________________ 10.
Private health insurance plans are obtained from two sources. List those sources. ________________________________________________________________________
________________________________________________________________________ B. Health Insurance Models 1.
Traditional health insurance plans are also referred to as _______________________ plans. 2.
For each of the following managed care plans, describe the deductible, coinsurance, and copayment requirements: a.
Health maintenance organization (HMO): __________________________________________________________________
__________________________________________________________________ b.
Preferred provider organization (PPO): __________________________________________________________________
__________________________________________________________________ c.
Exclusive provider organization (EPO): __________________________________________________________________
__________________________________________________________________ 3.
A(n) _____________________________ is a review of individual cases by a committee to make sure ser-vices are medically necessary and to study how providers use medical care resources. 4.
Describe the managed care requirements for a patient referral. ________________________________________________________________________
________________________________________________________________________
MOA115 Medical Records and Insurance Week 4 Assignment –
Insurance Concepts C. Participating Provider Contracts 1.
A(n) _____________________________ is a healthcare provider who enters into a contract with a specific insurance company or program and agrees to accept the contracted fee schedule. 2.
The _____________________________ is the maximum that third-party payers will pay for a procedure or service. D. The Medical Assistant’s Role 1.
One of the medical assistant’s responsibilities is verifying eligibility. Describe the processes available for the verification of eligibility for services. ________________________________________________________________________
________________________________________________________________________ 2.
Describe how the patient’s insurance eligibility is confirmed. ________________________________________________________________________
________________________________________________________________________ 3.
What items should the medical assistant gather when using the paper method to obtain a precertification for a service or procedure? ________________________________________________________________________
________________________________________________________________________ 4.
Describe the processes for precertification using the paper method. What does the medical assistant need to do? ________________________________________________________________________
________________________________________________________________________ ________________________________________________________________________
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