Insurances
Name 3 types of insurance
Medicare, Medicaid, TRICARE, Private Insurance (for example, HNE, BCBS) and will accept COBRA
What are two facts about Medicare
Usually 65+ yrs. of age or SSDI, there are 4 parts, part A is inpatient, part b is outpatient, part d is meds, federal insurance, etc...
What is the purpose of the maximum out-of-pocket cost?
The purpose of the maximum out-of-pocket cost is to limit the amount a patient pays before insurance covers the remainder of the bills.
Name one type of of codes in this chapter
ICD-10
CPT
HCPCS
What constitutes a billing error?
Typographical errors, coding mistakes, or incorrect information submitted.
What is COBRA?
Allows workers who lose group health insurance to purchase the same coverage privately for a certain amount of time
Name 3 facts on Medicaid
Aided insurance based on income, coverage individuals with certain disabilities, usually free or low cost to have, covers all ages if they qualify, differs by state, funded by federal and state, etc...
What is the difference between a benefit and a claim
Benefit is service or item that is covered by insurance
A claim is a submission for payment of a service or item
Who developed ICD-10 codes?
CMS (federal government)
Name five items/things needed on all submitted claims
Patient’s name, demographic info, Subscriber’s info (full name, DOB, and employer on claims for spouse/dependents), Provider’s NPI number, Patient’s diagnosis, Date of service, Treatment provided, Procedures performed, Location of service, Provider’s charges
What federal insurance is for pregnant women and children
CHIP
How many parts of Medicare and what are they called
Part A, Part B, Part C, Part D
What is a co-pay?
A co-pay is the fixed amount of money a patient owes for a medical visit, service, or medication
Who maintains ICD-10 codes?
CDC
Joe is having a scan done:
Allowable amount is $120. Copay is $20. Insurance covers 80% after the copay. What is the total amount the patient will pay for their scan.
$40 is what the patient paid/pays
$120-$20= 100
$80 is 80% of the $100
Therefore, $20 (20% patient pays) and the co-pay was paid by patient ($20) = TOTAL PAID: $40
True or False: Under the ACA, there are certain services insurers must provide with no copayment/coinsurance, such as surgeries.
False - Such as preventative care
True or False: Someone can have Medicare and Medicaid
True
What is a deductible?
A deductible is the amount of money a patient must pay before insurance will cover an expense.
What are two purposes for ICD-10 codes?
Unification of billing
Identify diagnoses and inpatient procedures for insurance purposes
Established to track morbidity and mortality
Used so that disease trends can be tracked around the world
Provides information to guide healthcare decisions on a global scale
Explain what an NPI is and how is it used?
A 10-digit number unique to each healthcare provider used in the filing of insurance claims. All PCP’s or providers have an NPI.
(National Provider Identifier)
Name three types of medically necessary services that are required to be covered by insurance policies
Preventive care and routine vaccinations
Ambulatory care
Emergency care
Inpatient care
Diagnostic services
What does Medicare's ACO stand for or what is it? (Either answer will earn the points)
Medicare’s Accountable Care Organization (ACO) Coordinate care (and continuum of care) and provider high-quality care at a lower cost.
Explain the difference between: error, abuse, and fraud in regards to insurance billing and coding by this chapter
Error - Honest mistake, typo, etc...
Abuse - Using wrong code or info to gain financially, or "upcharging" "upcoding"
Fraud - Billing for services not provided, billing for equipment not used or provider, etc...
Who are two different people who can select a new ICD-10 code when a rejected claim or rejected pre-auth form is returned.
Provider, an MA who verified the correct ICD-10 code in the physician's note, an admission nurse in some settings based on communication with a provider.
What parts of Medicare cover 1) Inpatient stays and 2) Medications
Inpatient - Part A (acute)
Medications - Part D (drugs)