Major medical insurance was developed to cover the costs of catastrophic expenses from illness or injury. Medicaid (A) was created to help those who are on aid for families with dependent children and supplemental security income. Medicare (B) was created to give all seniors access to health care. Primary care (C) is given by a general practitioner. In an HMO, all care is coordinated through the patient’s primary care physician. Private insurance (D) is when a person pays for insurance on his own and not through an employer.
Preferred providers are physicians and other health care professionals who contract with the insurance carrier to provide patient care. Managed care organizations (MCOs) (B) offer health insurance programs that ensure cost-effective services by employing case managers or primary care providers to keep costs down. Assigning of benefits (C) is signing over of benefits by the beneficiary to another party. Primary care physicians (D) serve as the key point of care for their patients. Primary care physicians may be responsible for any or all referrals to other specialty practices. Exclusive provider organizations (EPOs) (E) often require the provider to work exclusively for the EPO organization.
Capitation is the use of the members enrolled in a plan to determine salary of the physician; the physician is paid a fixed fee for each member no matter how many times that member is seen by the physician. Basic insurance (A) is medical insurance that covers most physician fees, hospital expenses, and surgical fees according to the terms of the policy. The patient is usually responsible for a deductible. A health maintenance organization (HMO) (B) is the type of managed care operation that is typically set up as a for-profit corporation with salaried employees. A catchment (D) is a 40-mile radius of a military base where medical care is available to military dependents. Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) (E) covers the spouse and unmarried dependent children of a veteran with permanent total disability from service-related injury and the surviving spouse and children of veterans who died of a service-related disability.
TRICARE is the insurance that covers the dependents of active-duty personnel, retired personnel, dependents of retired personnel, and dependents of personnel who died while on duty. Civilian Health and Medical Program of the Department of Veterans Affairs or CHAMPVA (A), covers the spouse and unmarried dependent children of a veteran with permanent total disability from service-related injury and the surviving spouse and children of veterans who died of a service-related disability. Supplemental Security Income or SSI (C) is a federally funded program that assists single women who are pregnant and whose income is at or below the national poverty level, and people who for many reasons due to physical, emotional, or mental difficulties are unable to work. An exclusive provider organization or EPO (D) is a type of insurance. It usually requires that the physician work for the EPO organization. Health maintenance organization or HMO (E) is a type of managed care facility. It is very different from the traditional insurance.
When an on-the-job accident or illness results in injury and/or disability, workers’ compensation insurance (A) pays the medical bills. In most states, the employer pays a premium to an insurance carrier for a policy. Private insurance (B) is when a person pays for insurance on his own and not through an employer. TRICARE (C) is the insurance that covers the dependents of active-duty personnel, retired personnel, dependents of retired personnel, and dependents of personnel who died while on duty. Medicaid (D) was created to help those who are on aid for families with dependent children and supplemental security income. Medicare (E) was created to give all seniors access to health care.
An EOB is an Explanation of Benefits. This patient-facing document does not include coding updates. The insurance company provides the EOB to the patient under the patient’s name (D) following a claim by a provider. The EOB includes the amount of deductible (C) the patient has met and has yet to meet before additional coverage is included. It also demonstrates how much the insurance company allowed (A) and how much was paid, as well as any additional obligations the patient has for payment (E). If the provider has entered an agreement with the insurance company, the provider is obligated to accept the paid amount and not bill for the higher amount, excluding any deductible that may be required to be paid. The EOB would also note any exclusions and explain why a particular claim was not covered.
Medicare is a federally funded health insurance program under the Social Security Act. Preschool children would not qualify for Medicare but may qualify for Medicaid, another federal program that works in conjunction with the individual states. Medicare covers all the other categories of people listed. In addition, patients with amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease) may qualify for Medicare after a waiting period.
ICD coding is important for efficient and proper reimbursement for services rendered and is also used for statistical purposes. Z-codes record a patient encounter for something other than disease or injury; they can be used as primary or secondary codes in billing and include health information such as exposure to a contagious disease like tuberculosis, even if the patient is not currently sick. E&M codes (A) are evaluation and management billing codes that are derived from reading the medical record and determining the services provided, the medical necessity and appropriateness of the services, and the location of services. E-codes (B) are supplemental codes that identify the external cause of an injury or poisoning. Volume I codes (D) are those found in the ICD book, which contains the tabular list of diseases and is numerically coded. Volume II codes (E) are an alphabetical listing of diseases and disorders.
The root capit means “head,” and capitation means that payment is per head or per patient. This type of a provider/insurance agreement pays the practitioner per patient, usually on a monthly basis, whether the patient is seen multiple times or not at all. Fixed coverage plans (B) are sold by insurance companies to patients; they are designed to provide the patient with a fixed amount of payment each time they see a provider. Fixed coverage plans are becoming less common because they tend not to meet minimal essential coverage needs. Total coverage (C) is a plan that covers all aspects of a patient’s care. This type of coverage is unusual today given the rising cost of health care; often a copayment or coinsurance is required. Universal coverage (D) is usually offered to all citizens of the same country with the goal of assuring all citizens receive health care. Utilization review (E) is a periodic evaluation to determine if billing and other insurance components are being administered correctly.
Patients have a right to know how much they will have to pay out of pocket for a particular procedure or service; predetermination is a means of providing that information to the patient. If an elective procedure is planned, the patient may then choose to establish a payment plan with the provider prior to services being performed. Coinsurance (A) is a percentage of the fee that the patient may be required to pay for the procedure. Preauthorization (B) is the process of getting permission from the patient’s insurance company for procedures, tests, and other medical services. Precertification (C) is often used for hospitalization admissions to determine the maximum length of stay allowed for a particular procedure. Reimbursement (E) is repayment for the patient’s out-of-pocket expenses after expenses have been incurred.