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Medical billing and coding questions and answers rated A+ 2024/2025
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Medical billing and coding questions and answers rated A+ 2024/2025
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Medical billing and codingMedical Insurance - ANSFinancial plan (the payer) that covers the fee of health facility and
hospital therapy
Policyholder - ANSPerson who buys an insurance plan; the insured, subscriber, or guarantor
Health Plan - ANSIndividual or organization plan that offers or can pay for the fee of hospital
treatment
Benefits - ANSWhat a health plan can pay for services blanketed in an insurance coverage;
listed inside the time table of benefits.
Medical Necessity - ANSReasonable services of issuer (medical doctor or facility) regular with
expert scientific requirements.
Covered Services - ANSDetermined as being medically vital and each affordable and steady
with the requirements for the diagnosis or remedy of damage or contamination.
Non-protected Services - ANSMedical methods not protected in a plans benefits.
Individual Health Plan (I H P) - ANScontract between individual and the plan
referred to as direct pay.
Group Health Plan (G H P) - ANScontract between an employer or company and the plan,
the group members are insured as "subscribers".
Disability Insurance - ANSReplaces profits lost due to the fact the insured cannot work
Workers' Compensation Insurance - ANSProvides advantages for an insured injured at the task
Indemnity Insurance - ANSPayment method is charge-for-carrier based totally on the contract's
schedule of advantages,rate is paid AFTER the patient gets services from the physician.
Managed care - ANSA gadget that combines the financing and the delivery of suitable,
fee-powerful fitness care services to its participants.
Premium - ANSPeriodic payment the affected person is required to make to maintain the policy
in effect.
Deductible - ANSAmount that the insured can pay on covered offerings before advantages start.
,Coinsurance - ANSPercentage of every claim that the insured will pay; states the fitness plan's
percentage of the price, observed through the insured's percentage.
Health Maintenance Organizations (HMOs) - ANSA manged fitness care gadget in which
vendors comply with provide healthcare to the business enterprise's members for fixed periodic
payments from the plan.
Capitation Method - ANSa fixed prepayment made to the clinical company for all important
reduced in size offerings furnished to each affected person who is a plan member irrespective of
how a whole lot hospital treatment is obtained throughout the decided term.
Per member in step with month, (PMPM) - ANS(in keeping with member per month): The
"capitated rate" Capitation this quantity is paid to the health care company primarily based on
the time table of advantages, regardless of how a whole lot medical care is received throughout
the decided term.
Point of Service Plan (PPO) - ANSCombines capabilities of both HMOs and PPOs Also known
as an "open get entry to HMO "Allows individuals to see vendors in or out of HMO's network
Members pay greater for out-of-network providers.
Preferred Provider Organizations (PPO) - ANSA controlled care corporation established as a
community of fitness care carriers who agree to perform offerings for plan members at
discounted costs; generally, plan participants can acquire offerings from non-community
providers for a better rate. PPOs control the price of fitness care by way of:
Directing patients' picks of companies
Controlling use of services
Requiring preauthorization for services
Requiring Cost-sharing
Consumer-Driven Health
Plans (CDHP) - ANSCombine factors:
A health plan, generally a PPO, that has a high deductible (together with $1,000) and low
charges
A special "financial savings account" this is used to pay medical bills before the deductible has
been met
Cost containment plan based totally on consumerism:
Idea that patients who pay for fitness care offerings emerge as extra cautious purchasers.
Private Payers - ANSHave contracts with companies to offer advantages for their
personnel...Better quotes
self-funded fitness plans - ANSThe business enterprise "insures itself"
, a organization creates its personal insurance plan for its employees, instead of the usage of a
service; the plan assumes price risk, contracts with physicians, and will pay for claims from its
price range.
Medicare - ANSCoverage for those age sixty five and older, people with certain disabilities, and
those with permanent kidney failure.
Medicaid - ANSCoverage for low-profits people who can not manage to pay for hospital
treatment
TRICARE - ANS(was CHAMPUS): Coverage for active-obligation military employees, their
spouses, children, and different dependents; additionally retired military personnel and their
dependents, as well as family individuals of deceased lively-responsibility personnel
CHAMPVA - ANSCoverage for veterans with permanent carrier-related disabilities and their
dependents.
Payer Adjudication - ANSPayers overview claims by way of following the adjudication process
Puts the claim thru a series of steps designed to decide whether it ought to be paid or now not
The payer's choice is defined on a file sent returned to the company with the payment.
Ethics - ANSValues, Standards of conduct shared via those inside the scientific career.
Etiquette - ANSManners, Describes proper protocol and behavior in a clinical practice.
CMA - ANSCertified Medical Assistant
RMA - ANSregistered scientific assistant
Fee for Service - ANSschedule of prices set for offerings completed by carriers and paid with
the aid of the patient
Medical Billing cycle - ANS10 steps-preregister sufferers, establish fin responsibility, take a look
at in, test out, overview coding compliance, take a look at billing compliance, put together and
transmit claims, monitor payer adjudication, generate patient statements, comply with up bills
and collections.
Medical Chart - ANSPaper chart pointing out, All affected person touch related to hospital
treatment, workplace visits, conversations, and correspondence. Contents - CC - Chief criticism;
PMH - beyond medical records; FH - circle of relatives records; PI - gift illness; SH - social
history; OH -occupational records (ex. Pa - mortician - chemical substances); PE - bodily
examination (assessment of the status of every frame device); diagnostic and laboratory take a
look at effects; session reviews; past clinical facts; correspondence; companies notes;
termination summary.
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