Term
| _________ impacts coding & reimbursement for other insurance |
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Definition
| Center for Medicare and Medicaid Services (CMS) |
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Term
| Does medicare cover hearing aids? |
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Definition
| No, however, supplemental medicare programs may. |
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Term
| Example of a supplemental medicare program? |
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Definition
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Term
Medicare-Federal Program Covers Those Who Are...
-are ___ & older
-are under 65 with certain ___
-have ___-___ ___ disease |
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Definition
| 65; disabilities; end-stage renal |
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Term
Medicare:
-Formed in ___ via changes to the Social Security Act
-___ drug coverage |
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Definition
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Term
| What kind of insurance is part A of Medicare? |
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Definition
| Hospital insurance. Covers hospital stays, skills nursing facilities, hospice care, some home health |
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Term
Medicare:
Payment for audiology services in a hospital setting is include in the “___ payment” under Part A |
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Definition
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Term
| What kind of insurance is part B of Medicare? |
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Definition
| Medical insurance. Most patients pay a monthly premium. Pays for services & supplies that are medically necessary |
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Term
| needed for the diagnosis or treatment of your medical condition, meet[s] the standards of good medical practice in the local area, and is not mainly for the convenience of you or your doctor |
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Definition
| Medicare's definition of medically necessary |
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Term
| What does Part C of Medicare cover? |
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Definition
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Term
| Type of plan offered by private companies that contract with Medicare to provide all Part A & B services; Many plans covered prescriptions, hearing aids, hearing tests |
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Definition
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Term
| What does part D of Medicare cover? |
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Definition
| Prescription drug coverage |
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Term
| Combined federal-state program for the indigent population |
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Definition
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Term
Medicaid:
-Formed in ___ via changes to the Social Security Act
-Oklahoma Medicaid is called “___” administered by the Ok Health Care Authority (OHCA)
-Covers health care services at ___ ___ for those who
meet guidelines |
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Definition
| 1965; SoonerCare; no cost |
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Term
| Medicaid coverage for hearing aids varies by ___ |
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Definition
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Term
| Federal-state program that providers health insurance to low-income children |
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Definition
| Children's Health Insurance Program (CHIP) |
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Term
Commercial Payers:
patients have to choose PCP & get referrals; patients pay all/most costs to see out-of-network providers (unless emergency) |
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Definition
| health maintenance organization (HMO) |
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Term
Commercial Payers:
has preferred providers, do not need PCP or referral; less cost if patients choose “in-network” providers; audiologists have to be participating providers (e.g. sign contract) |
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Definition
| Preferred provider organization (PPO) |
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Term
Commercial Payers:
groups of providers who have an agreement with an insurer to provide care to subscribers: hybrid HMO/PPO (more flexible than HMO, less costly than PPO) |
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Definition
| Exclusive Provider Network (EPO) |
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Term
Commercial Payers:
type of managed care plan, has elements of an HMO & PPO; limited choice for less cost |
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Definition
| Point of Service plan (POS) |
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Term
| What are the 5 major insurance carriers? |
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Definition
-Aetna
-Cigna
-Humana
-United Healthcare
-WellPoint, Inc. (Blue Cross) |
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Term
| Summarize three contracting considerations (there are more than three) |
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Definition
-Is “balance billing” allowed? (e.g. audiologist bills patients for any amounts not covered by insurance)
-Is it a “discount plan”? If so, what is the discount amount for hearing aids?
-What specific services are covered? |
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Term
| Name two things audiologists can watch for in contracts with insurance companies (there are more than two) |
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Definition
-Watch for vague language
-Contracts that allow unilateral changes (e.g. only the insurance company can make changes) |
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Term
| 10 digit number that is required for all individual & organizational healthcare providers |
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Definition
| National Provider Identification Number |
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Term
| Form of insurance that give benefits to workers injured on the job |
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Definition
| Worker compensation programs |
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Term
| Offers Medical Benefits Package to all enrolled veterans |
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Definition
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Term
| Became a law in 2010 and requires plans to cover essential health benefits |
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Definition
| Affordable Care Act (ACA) |
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Term
| Use CPT code ___ for an unlisted procedure |
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Definition
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Term
CPT Codes:
-Category I: procedure or service that reflects current state of the ___ ___
-Example? |
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Definition
| art practice; 92557 Basic Comp Audio |
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Term
International Classification of Diseases-10th Revision (ICD-10):
-__ digits; includes decimal point
-H: hearing loss. Example?
-Q: congenital malformations, deformation, chromosomal abnormalities. Example?
-R: symptoms, signs & abnormal clinical & lab findings. Example?
-T: injury, poisoning, certain other consequences of external causes. Example?
-Z: factors influencing health status. Example? |
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Definition
-5
-bilateral CHL
-congenital absence of (ear) auricle
-Dizziness and giddiness
-foreign body in right ear
-encounter for hearing examination following failed hearing screening |
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Term
| Prosthetic and durable medical equipment codes. Example? |
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Definition
| HCPCS codes. Hearing aid V5261 |
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Term
| the total amount an insurance carrier will reimburse for a covered a service or test |
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Definition
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Term
| the total amount an insurance carrier will reimburse for a covered a service or test |
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Definition
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Term
| when a patient or providers tries to convince an insurance carrier to pay for services/tests after they decided not to cover costs |
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Definition
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Term
| When a patient's health plan requires them to get permission from the insurance company before receiving services |
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Definition
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Term
| person who receives benefits and/or coverage (may not be the person who pays for the plan) |
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Definition
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Term
| a fixed payment that a patient makes to a health insurance company or provider to recoup costs for services (different than a deductible or co-pay) |
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Definition
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Term
| federal organization that manages & administers health care coverage via Medicare and Medicaid |
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Definition
| Centers for Medicare and Medicaid Services (CMS) |
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Term
| a paper medical claim form to submit claims; some insurance companies require this form |
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Definition
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Term
| process to translate tests & diagnoses, included on claim forms |
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Definition
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Term
| a federal program that lets a person who no longer has a job to keep his/her health insurance for up to 18 months (longer if workers is disabled) |
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Definition
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Term
| The amount a patient must pay a provider before they receive any treatment/service (separate from deductibles) |
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Definition
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Term
| Amount a patient pays before an insurance company starts their coverage; these range in price |
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Definition
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Term
| medical tools that can be reused; examples: wheelchairs, stretchers, canes, crutches |
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Definition
| Durable medical equipment (DME) |
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Term
| A person covered by a health insurance plan |
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Definition
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Term
| document attached to a processed medical claim that explains the services covered (or not covered) |
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Definition
| Explanation of benefits (EOB) |
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Term
| type of insurance in which providers are paid for every service they do; patients with this plan typically can choose any hospitals/physicians; plans have higher deductibles & co-pays |
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Definition
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Term
| document that shows the fees associated with each medical service indicated by a CPT code |
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Definition
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Term
| additions to CPT codes that explain changes to routine treatments or tests |
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Definition
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Term
| when a provider refuses to accept Medicare payments as a sufficient amount for the services rendered to a patient |
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Definition
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Term
| a document used by health care staff and providers to write down information about patients receiving care (may have demographic information, codes, insurance information; coding specialists use information to file claims) |
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Definition
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Term
| a secondary policy that covers health care costs after coverage from the primary insurance |
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Definition
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Term
| fraudulent practice of ascribing more than one code to a service or procedure on a superbill or claim form when only one is needed |
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Definition
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Term
| discrepancy between a providers’ fee and the amount that insurance pays for the services/products (that the patient is not responsible for); for billing purposes this amount is described as “not covered” amounts |
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Definition
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