Medical billing and coding Questions
with expert curated solutions
( GUARANTEED SUCCESS )
Medical Insurance - answer Financial plan (the payer) that covers
the cost of hospital and medical care
Policyholder - answer Person who buys an insurance plan; the
insured, subscriber, or guarantor
Health Plan - answer Individual or group plan that provides or
pays for the cost of medical care
Benefits - answer What a health plan pays for services covered in
an insurance policy; listed in the schedule of benefits.
Medical Necessity - answer Reasonable services of provider
(doctor or facility) consistent with professional medical standards.
Covered Services - answer Determined as being medically
necessary and both reasonable and consistent with the standards
for the diagnosis or treatment of injury or illness.
Non-covered Services - answer Medical procedures not covered in
a plans benefits.
,Individual Health Plan (I H P) - answer contract between individual
and the plan
known as direct pay.
Group Health Plan (G H P) - answer contract between an employer
or organization and the plan,
the group members are insured as "subscribers".
Disability Insurance - answer Replaces income lost because the
insured cannot work
Workers' Compensation Insurance - answer Provides benefits for
an insured injured on the job
Indemnity Insurance - answer Payment method is fee-for-service
based on the contract's schedule of benefits,fee is paid AFTER the
patient receives services from the physician.
Managed care - answer A system that combines the financing and
the delivery of appropriate, cost-effective health care services to
its members.
Premium - answer Periodic payment the patient is required to
make to keep the policy in effect.
Deductible - answer Amount that the insured pays on covered
services before benefits begin.
,Coinsurance - answer Percentage of each claim that the insured
pays; states the health plan's percentage of the charge, followed
by the insured's percentage.
Health Maintenance Organizations (HMOs) - answer A manged
health care system in which providers agree to offer healthcare to
the organization's members for fixed periodic payments from the
plan.
capitation Method - answer a fixed prepayment made to the
medical provider for all necessary contracted services provided to
each patient who is a plan member no matter how much medical
care is received during the determined time period.
Per member per month, (PMPM) - answer (per member per
month): The "capitated rate" Capitation this amount is paid to the
health care provider based on the schedule of benefits, no matter
how much medical care is received during the determined time
period.
Point of Service Plan (PPO) - answer Combines features of both
HMOs and PPOs Also called an "open access HMO "Allows
members to see providers in or out of HMO's network Members
pay more for out-of-network providers.
Preferred Provider Organizations (PPO) - answer A managed care
organization structured as a network of health care providers who
agree to perform services for plan members at discounted fees;
usually, plan members can receive services from non-network
, providers for a higher charge. PPOs control the cost of health care
by:
Directing patients' choices of providers
Controlling use of services
Requiring preauthorization for services
Requiring Cost-sharing
Consumer-Driven Health
Plans (CDHP) - answer Combine two elements:
A health plan, usually a PPO, that has a high deductible (such as
$1,000) and low premiums
A special "savings account" that is used to pay medical bills
before the deductible has been met
Cost containment plan based on consumerism:
Idea that patients who pay for health care services become more
careful consumers.
Private Payers - answer Have contracts with businesses to provide
benefits for their employees...better rates
self-funded health plans - answer The organization "insures itself"
a company creates its own insurance plan for its employees,
rather than using a carrier; the plan assumes payment risk,
contracts with physicians, and pays for claims from its funds.
with expert curated solutions
( GUARANTEED SUCCESS )
Medical Insurance - answer Financial plan (the payer) that covers
the cost of hospital and medical care
Policyholder - answer Person who buys an insurance plan; the
insured, subscriber, or guarantor
Health Plan - answer Individual or group plan that provides or
pays for the cost of medical care
Benefits - answer What a health plan pays for services covered in
an insurance policy; listed in the schedule of benefits.
Medical Necessity - answer Reasonable services of provider
(doctor or facility) consistent with professional medical standards.
Covered Services - answer Determined as being medically
necessary and both reasonable and consistent with the standards
for the diagnosis or treatment of injury or illness.
Non-covered Services - answer Medical procedures not covered in
a plans benefits.
,Individual Health Plan (I H P) - answer contract between individual
and the plan
known as direct pay.
Group Health Plan (G H P) - answer contract between an employer
or organization and the plan,
the group members are insured as "subscribers".
Disability Insurance - answer Replaces income lost because the
insured cannot work
Workers' Compensation Insurance - answer Provides benefits for
an insured injured on the job
Indemnity Insurance - answer Payment method is fee-for-service
based on the contract's schedule of benefits,fee is paid AFTER the
patient receives services from the physician.
Managed care - answer A system that combines the financing and
the delivery of appropriate, cost-effective health care services to
its members.
Premium - answer Periodic payment the patient is required to
make to keep the policy in effect.
Deductible - answer Amount that the insured pays on covered
services before benefits begin.
,Coinsurance - answer Percentage of each claim that the insured
pays; states the health plan's percentage of the charge, followed
by the insured's percentage.
Health Maintenance Organizations (HMOs) - answer A manged
health care system in which providers agree to offer healthcare to
the organization's members for fixed periodic payments from the
plan.
capitation Method - answer a fixed prepayment made to the
medical provider for all necessary contracted services provided to
each patient who is a plan member no matter how much medical
care is received during the determined time period.
Per member per month, (PMPM) - answer (per member per
month): The "capitated rate" Capitation this amount is paid to the
health care provider based on the schedule of benefits, no matter
how much medical care is received during the determined time
period.
Point of Service Plan (PPO) - answer Combines features of both
HMOs and PPOs Also called an "open access HMO "Allows
members to see providers in or out of HMO's network Members
pay more for out-of-network providers.
Preferred Provider Organizations (PPO) - answer A managed care
organization structured as a network of health care providers who
agree to perform services for plan members at discounted fees;
usually, plan members can receive services from non-network
, providers for a higher charge. PPOs control the cost of health care
by:
Directing patients' choices of providers
Controlling use of services
Requiring preauthorization for services
Requiring Cost-sharing
Consumer-Driven Health
Plans (CDHP) - answer Combine two elements:
A health plan, usually a PPO, that has a high deductible (such as
$1,000) and low premiums
A special "savings account" that is used to pay medical bills
before the deductible has been met
Cost containment plan based on consumerism:
Idea that patients who pay for health care services become more
careful consumers.
Private Payers - answer Have contracts with businesses to provide
benefits for their employees...better rates
self-funded health plans - answer The organization "insures itself"
a company creates its own insurance plan for its employees,
rather than using a carrier; the plan assumes payment risk,
contracts with physicians, and pays for claims from its funds.
