Insurance and Reimbursement Flashcards
6 cards from real RMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Insurance and Reimbursement flashcards as text
Which federal program provides health insurance primarily to individuals age 65 and older?
Answer: Medicare
Medicare is a federal health insurance program that primarily serves people aged 65 and older, as well as certain younger individuals with disabilities or end-stage renal disease.
What is a copayment in health insurance?
Answer: A fixed amount paid by the patient at the time of a healthcare visit
A copayment (copay) is a fixed, predetermined amount that the patient pays at the time of a medical service, regardless of the total cost of the service.
What is the primary difference between HMO and PPO health plans?
Answer: HMOs require referrals to see specialists; PPOs generally allow direct access
HMOs (Health Maintenance Organizations) require patients to choose a primary care physician and obtain referrals for specialist care, while PPOs (Preferred Provider Organizations) allow patients to see specialists without referrals.
What does 'coordination of benefits' mean when a patient has two insurance plans?
Answer: Rules that determine which insurance plan pays first when a patient has dual coverage
Coordination of benefits (COB) is a set of rules that determine the order in which multiple insurance plans pay when a patient is covered by more than one plan, ensuring total payments do not exceed the total charges.
Which of the following best describes a deductible in health insurance?
Answer: The amount a patient must pay out-of-pocket before insurance begins covering costs
A deductible is the amount a patient must pay for covered health services before their insurance plan begins to pay, typically calculated on an annual basis.
A patient's insurance claim is denied due to 'lack of medical necessity.' What does this mean?
Answer: The insurer determined the service was not clinically justified for the diagnosis
A denial for lack of medical necessity means the insurance company determined that the service provided was not clinically justified or appropriate for the patient's diagnosis or condition.