Insurance Handbook for the Medical Office 11th Edition answers?

Here is the answer key to the questions presented:

Chapter 1: The Business of Insurance

1. What is the primary purpose of insurance for healthcare providers?

1. To protect healthcare providers from potential liabilities.

2. What is the concept of risk dispersion in insurance?

2. Insurance allows the financial burden of risk to be spread across multiple policyholders.

Chapter 2: Types of Insurance Coverage

1. Briefly explain the difference between liability insurance and property insurance for medical offices.

1. Liability insurance protects against legal claims for damages caused by the medical office or its employees. Property insurance covers physical damage to the medical office's property and contents.

2. What is the purpose of general liability insurance for healthcare providers?

2. General liability insurance protects against legal claims for bodily injuries or property damage arising from the medical office's operations.

Chapter 3: Understanding Medical Bills and Insurance Claims

1. Define "usual and customary charge."

1. The typical and prevailing charge for a particular service in a specific geographic location.

2. What is the purpose of a pre-authorization for medical procedures?

2. Pre-authorization is obtained from the patient's insurance company prior to performing certain medical procedures or services. It helps ensure coverage for the procedure.

3. Can healthcare providers waive deductibles and copays for patients?

3. No. Waiving deductibles and copays is illegal and constitutes insurance fraud.

Chapter 4: Reimbursement Strategies and Methods

1. What is the purpose of a PPO (preferred provider organization)?

1. A PPO is a type of managed care plan that allows healthcare providers to access contracted rates and networks.

2. How does Medicare calculate reimbursement for outpatient services?

2. Medicare uses the RBRVS (resource-based relative value scale) to determine reimbursement based on the procedure's skill, work, practice expenses, and professional liability.

Chapter 5: Commercial Health Insurance Plans

1. Explain the difference between an HMO (health maintenance organization) and a PPO (preferred provider organization).

1. HMO: A managed care plan where members receive services through a network of contracted providers. Typically requires a primary care physician referral for specialty care.

PPO: A managed care plan that offers more flexibility in choosing providers but may require higher cost-sharing.

2. What is a high-deductible health plan (HDHP)?

2. An HDHP is a health insurance plan with a higher deductible than traditional plans, often coupled with a health savings account (HSA) to cover medical expenses.

Chapter 6: Government Health Insurance Programs

1. What are the two primary government health insurance programs in the United States?

1. Medicare and Medicaid

2. Who is generally eligible for Medicare Part B (medical insurance)?

2. Individuals 65 years and older, certain younger people with disabilities, and those with end-stage renal disease.

Chapter 7: Claim Filing and Follow-Up

1. What is a claim form, and what are its key elements?

1. A claim form is a document used by healthcare providers to submit a request for payment to an insurance company. It includes details about the patient, medical services provided, and charges.

2. How long does a healthcare provider typically have to file a claim with an insurance company?

2. It varies, but generally within 12 to 18 months from the date of service.

Chapter 8: Denials and Appeals

1. What are some common reasons for claim denials?

1. Missing or incomplete information on the claim form, lack of pre-authorization, non-covered services, and incorrect coding.

2. What steps can a healthcare provider take to appeal a denied claim?

2. Gather documentation supporting the claim, send a written appeal, provide documentation showing medical necessity, and request an independent review.

Chapter 9: Understanding Contracts

1. Why are contracts important for medical offices?

1. They define the terms of reimbursement and the responsibilities of both the healthcare provider and the insurance company.

2. What are the key elements of a healthcare provider contract with an insurance company?

2. Reimbursement rates, network participation, patient copayments and deductibles, claim submission requirements, and contract duration.

Chapter 10: Risk Management

1. What is the purpose of risk management in a medical office?

1. To identify and mitigate potential risks to patients, staff, and the practice.

2. What are some common risk management practices in healthcare?

2. Patient safety protocols, employee training, HIPAA compliance, incident reporting, and maintaining accurate documentation.

Chapter 11: Fraud, Waste, and Abuse in Healthcare

1. Define "healthcare fraud."

1. Intentionally misrepresenting or falsifying information to obtain payment for services or products not rendered or not supported by medical necessity.

2. What are some examples of healthcare waste?

2. Unnecessary medical procedures, duplicative services, and inefficiencies in healthcare systems.

Chapter 12: Ethical Considerations, Quality, and Compliance

1. Explain the concept of informed consent in healthcare.

1. The process of obtaining a patient's permission for a procedure or treatment after providing them with complete and understandable information about the risks, benefits, alternatives, and consequences.

2. How can healthcare providers ensure compliance with quality standards?

2. By implementing measures such as performance monitoring, continuous quality improvement, and patient safety initiatives.