Week 4 Assignment Worksheet
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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.
a listof fixed fees for services
3.
insurance fees and patient fees are two types.
a list of fixed fees for services insurance fees and patient fees are two types.
2.
Define utilization management and describe the role of a utilization review committee.
a decision making process used by managed care organizations to manage healthcarecosts
3.
Define a third-party payer and list major third-party payers in medical insurance.
an organization that processes claims and provides administrative services for another organization insurance companies governmental payers
Part 2– Study Guide Questions
A. Health Insurance Plans
1.
Match the following terms and definitions:
b
Medicaid
a
Medicare
c
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.
person who are 65 or older or people who are disabled
3.
The RBRVS includes the following three parts:
a.
Total physician work
b.
Practice expenses
MOA115 Medical Records and Insurance
Week 4 Assignment – Insurance Concepts
c.
Malpractice expenses
4.
The intermediary and administrator who coordinates patients and providers and
processes claims for self-funded plans is called a(n) third party administato
.
5.
Prescription drugs are covered by Medicare part d
.
6.
List four different populations who qualify for Medicaid.
a.
low income familie
MOA115 Medical Records and Insurance
Week 4 Assignment – Insurance Concepts
b.
qualified pregnant women
c.
individuals who are medically indigent
d.
individuals who receive SSI
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
TRiCARE
.
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) CHAMPVA
.
9.
List the services covered by workers’ compensation plans.
services rendered by physicians, reasonable surgical and medical services, hospital treatment,services and supplies, prescriptions and orthepethic appliances
10. Private health insurance plans are obtained from two sources. List those sources.
group poicy and self-funded
B. Health Insurance Models
1.
Traditional health insurance plans are also referred to as managed health plans plans.
2.
For each of the following managed care plans, describe the deductible, coinsurance, and copayment requirements:
a.
Health maintenance organization (HMO):
usually no deductible or co-insurance, copayments required for office visits andprescriptions
b.
Preferred provider organization (PPO):
lower deductible and co-insurance if an in-network provider is used. copayment required for office visits
and prescriptions
c.
Exclusive provider organization (EPO):
usually no deductible or co-unsurance, copayment required for office visits and prescriptions
3.
A(n) utilization review
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.
a pre-authorization needs to be obtained before hand
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MOA115 Medical Records and Insurance
Week 4 Assignment – Insurance Concepts
C. Participating Provider Contracts
1.
A(n) participating provider
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 allowable change
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.
when you are scheduling an appt, health insurance info,should be collected, the patient then can decide if they want to schedule, the MA should verify the effective date, and comfirm patient will be covered.
2.
Describe how the patient’s insurance eligibility is confirmed.
through the online in insurance WEB portaL
3.
What items should the medical assistant gather when using the paper method to obtain
a precertification for a service or procedure?
patient health record, prior authorization request form, copy of patient health insurance ID card and a pen of course
4.
Describe the processes for precertification using the paper method. What does the
medical assistant need to do?
the MA must gather all the stuff they need surch as listen on question 3, then they must complete the precertification/ prior authorization from using a pen