Knowledge Evaluation - Medical Billing Trainer

Define the following term.Co-insurance:

• A fixed dollar amount paid for a covered service by a beneficiary (guarantor). Amount that a member of a health plan has to pay for specific health services, such as visits to a physician.

• A type of cost sharing where the beneficiary and insurance provider share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, for Medicare physicians' services, the beneficiary pays co-insurance of 20 percent of allowed charges.

• The amount the patient pays for medical care before insurance covers the balance

• A form of payment made by the insurance company in advance of medical services received; the prepayment by the insurance carrier of a fixed amount, usually monthly, to a physician (PCP) to cover services for a member of a particular plan (HMO).

Define the following term.Capitation:

• A type of cost sharing where the beneficiary and insurance provider share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, for Medicare physicians' services, the beneficiary pays co-insurance of 20 percent of allowed charges.

• Total amount a member of a health plan has to pay for services before that person's plan begins to cover the costs of care.

• A fixed dollar amount paid for a covered service by a beneficiary (guarantor). Amount that a member of a health plan has to pay for specific health services, such as visits to a physician.

• A form of payment made by the insurance company in advance of medical services received; the prepayment by the insurance carrier of a fixed amount, usually monthly, to a physician (PCP) to cover services for a member of a particular plan (HMO).

Define the following term.Ancillary Providers:

• Services over and above physician services, including laboratory, radiology, home health and skilled nursing facilities.

• Surgery done in the physician’s office or at a surgical center, and not requiring an overnight stay.

• A process under which Medicare/insurance carrier pays its share of the allowed charge directly to the physician or supplier. Medicare will do this only if the physician accepts Medicare's allowed charge as payment in full.

• How physician's services are identified and defined.

Define the following term.Carve-out Policy:

• The method by which a patient’s health care service claims are review before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.

• A contracted agreement between an insurance company and another company/healthcare provider which provides special services to its members, such as prescription drugs, pediatric vaccinations, or cancer treatment.

• Free or reduced-fee care provided due to financial situation of patients. Legally, the charge(s) must be entered on the patient ledger as the Usual & Customary charge(s); then can be adjusted or written off.

• The process which allows you to process a group of entries, versus one entry at a time.

Explain the usage of ICD-9 codes.

Explain the usage of CTP-4 codes.

Provide a brief explaination of the Claims Revenue Cycle.

Explain the difference between an in-network and an out-of-network provider.

Explain the function/benefit of using the services  a claims clearinghouse.