Plan types
PPO-Preferred Provide organization is the only plan that pays the least out of pocket?
True
Coinsurance
Coinsurance is a set percentage of service costs that you will be expected to pay once you have met your annual deductible. When your annual deductible is met, your insurance provider pays for their portion of the full cost of the service and you pay the coinsurance, or remaining percentage.
Which tab would we view a patient's membership status?
Subscription Membership.
How can a patient use their credits?
If a patient has credits on their account, they are automatically applied to their visit cost when booking their next appointment.
List the PPO benefits
-Offers both in and out of network coverage
-Deductibles, co-insurance and copays
-Pay less out of pocket
Copay
Copayments or copays, are pre-set dollar amounts you are expected to pay for office visits, procedures or prescription drugs under your insurance plan. Once the copay has been met, typically, the insurance company pays all remaining costs.
True or False
All members need to go through the free 30-day trial first before they subscribe?
false
Members can sign up without going through the trial.
What is API used for?
To store a patient's medical information.
Who has the ability to enroll:
All new and returning patients
What is the health savings account for on the high deductible health plan?
-To offset the cost of the deductible
Deductible
A deductible is the amount you pay out of your pocket before your insurance starts to pay its share of the costs. It does not include your employee per pay contributions. The deductible runs from January 1 through December 31 each year. Once you have met that dollar amount, you have met the requirements for the plan year.
The easiest forms of PHI to verify are?
Name 4.......
First and last name, date of birth, email address, phone number.
True of False
"Shift" tab in API is used to check a patient's schedule?
False
It's for the provider's schedule
What questions TPYES would we use to ask probing questions?
5 Ws and 1 H.
What?
When?
Why?
Where?
Who?
How?
-EPO does not have OON coverage?
TRUE/FALSE and substantiate
TRUE except if it's an emergency
Allowed Amount
The maximum amount a plan will pay for a covered health service. May also be called "eligible expense," "payment allowance," or "negotiated rate."
What Insurance Plans Do We Accept? (In network)
Name any 4.....
Anthem Blue Cross
Blue Cross Blue Shield (any state)
Humana (not with Medicare)
Aetna
Medicare*
Cigna (Starting May 2024)
Medi-Cal (some plans)
What do we use the "Cost Estimator" tab for?
To run a patient's insurance to find out their estimated cost.
Patients are able to utilize VPC service without an active subscription?
Substantiate......
Yes, they will have limited services like not being able to book an appointment on the app instead they would need to call in.
True or False
POS-Point Of Service plan does not require a referral?
False
-May require a referral
Balance Billing
When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30.
When Should Credits not Be Issued?
Mention 2......
Patient is experiencing medication side effects.
Patient has already had an appointment and received treatment, but is still not feeling better.
Patient is needing an alternative medication due to issues like the original prescription being out of stock at the pharmacy or not covered by insurance.
Patient had labs done and needs a follow-up to discuss the results even if a follow-up is requested by the ordering physician.
Patient has a new concern that was not brought up in their previous visit.
Patient booked an appointment that was subsequently cancelled or missed by the provider. Whenever this happens, the patient is automatically refunded the amount paid at the time of booking, therefore credits cannot be issued for them to reschedule and they will need to pay their visit cost again for the new appointment. (if you are unsure please reach out for assistance)
True or False
"Lab orders" and 'Lab results" tabs in API house the same information?
False
Lab Orders
Update lab location and payment method, and download or resend lab requisitions.
Lab Results
Verify if we have received and matched lab results for an existing lab order.
When Should Credits Be Issued?
Mention 2......
A medical or prescription error was made in the patient's original visit
Patient is experiencing financial hardship but there are labs that must be reviewed face-to-face
AccoladeCare patients that are not able to be located under the 'Employees' tab
Insured PrEP patients that have a cost estimate over $0
A vPC provider, nurse, or shift lead has requested we issue credits to a patient
Pregnancy or breastfeeding medication interactions if an established patient calls in with questions regarding pregnancy or breastfeeding medication interactions
Service Failure
Quality Issues -