Chapter 15

Question 1

a form of patient care review by healthcare professionals who do not provide the care but are employed by health insurance companies

Answer 1

utilization management/ utilization review

Question 2

Two types of insurance

Answer 2

government and private

Question 3

a designated person who receives funds from an insurance plan

Answer 3

beneficiary

Question 4

a payment arrangement for healthcare providers in which providers receive a per person/per month payment regardless of how often the provider sees the patient

Answer 4

capitation

Question 5

a formal request for payment from an insurance company for services provided

Answer 5

claim

Question 6

a list of fixed fees for services

Answer 6

fee schedule

Question 7

the primary care provider who is in charge of a patient’s treatment. Additional treatments must be approved by this person

Answer 7

gatekeeper

Question 8

poor, needy, impoverished

Answer 8

indigent

Question 9

a written agreement between two parties in which one agrees to pay the other if certain specified circumstances occur

Answer 9

policy

Question 10

a process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services

Answer 10

preauthorization

Question 11

the amount paid or to be paid by the policy holder for coverage under the contract

Answer 11

premium

Question 12

an approved list of physicians, hospitals and other providers

Answer 12

provider network

Question 13

an order from a PCP for a patient to see a specialist or to get certain medical services

Answer 13

referral

Question 14

used to determine how much providers should be paid for services provided. The geographic region is also taken into account. It is used by Medicare and many other health insurance companies.

Answer 14

resource based relative value system (RBRVS)

Question 15

an organization that processes claims and provides administrative services for another organization. Often used by self-funded plans

Answer 15

third-party administrator (TPA)

Question 16

The person responsible for the payment of the premium is referred to as the _____.

Answer 16

subscriber

Question 17

Cost-sharing includes the following three things:

Answer 17

deductible, co-insurance, and copayment

Question 18

a set dollar amount that the policyholder must pay before the insurance company starts to pay for services.

Answer 18

deductible

Question 19

The higher the deductible, the lower the _______.

Answer 19

premium

Question 20

After the deductible has been met, the policyholder may need to pay a certain percentage of the bill, and the insurance company pays the rest. Atypical split is 80/20- the insurance company pays 80% and the policyholder pays 20%. What is this called?

Answer 20

co-insurance

Question 21

Aset dollar amount that the policy holder must pay for each visit.

Answer 21

copayment

Question 22

_________ services are those that are proper and needed for the diagnosis or treatment of the medical condition.

Answer 22

medically necessary

Question 23

________ are procedures that are not deemed necessary, such as a facelift.

Answer 23

elective procedures

Question 24

Most insurance policies do not cover ____ _____.

Answer 24

elective procedures

Question 25

The fee schedule for medicare part B is determined using the RBRVS. This system consists of 3 parts:

Answer 25

provider work, charge-based professional liability expenses, charge-based overhead

Question 26

____ is the govt program that provides medical care for the indigent.

Answer 26

Medicaid

Question 27

_____ is a federal health insurance program that provides coverage for individuals over the age of 65, disabled people, and those with ESRD (end stage renal disease)

Answer 27

Medicare

Question 28

what would be a covered service of Medicare part A?

Answer 28

inpatient hospital care

Question 29

What would be a covered service under medicare part B?

Answer 29

outpatient hosptial care, durable medical equipment

Question 30

What is covered under medicare part D?

Answer 30

prescription drugs

Question 31

Which part of Medicare REQUIRES a monthly premium?

Answer 31

Part B

Question 32

______ is currently the world's largest insurance program.

Answer 32

Medicare

Question 33

Medicare refers to those covered as _____.

Answer 33

beneficiaries

Question 34

RBRVS

Answer 34

resource-based relative value scale

Question 35

Supplemental health insurance plans are known as ______ policies.

Answer 35

Medigap

Question 36

Mandatory medicaid benefits include:

Answer 36

family planning services, nurse midwife services, transportation to medical care

Question 37

a comprehensive healthcare program for uniformed service members and retirees and their families.

Answer 37

TRICARE

Question 38

a health benefits program that provides coverage for the families of veterans who were permanently disabled or killed in line of duty.

Answer 38

CHAMPVA

Question 39

CHAMPVA

Answer 39

civilian health and medical program of the veterans administration

Question 40

________ are contracted with the insurance plan and have agreed to accept the contracted fee schedule as payment in full.

Answer 40

participating providers

Question 41

What does QMB stand for

Answer 41

Qualified Medicare Beneficiaries

Question 42

Many large companies or organizations have enough employees that they can fund their own insurance programs. This is called ______

Answer 42

A self-funded plan

Question 43

A ______ plan is one that is not offered by an employer or group. This can cover just one person or a family. These policies can be purchased through a health insurance exchange or directly through an insurance company. Premiums are usually higher with these

Answer 43

Individual health insurance

Question 44

When providers become participating providers, they agree to the insurance plan’s ____ and will not collect more than that amount.

Answer 44

Fee schedule

Question 45

When setting up a fee schedule, a healthcare provider considers three factors:

Answer 45

Time Expertise Services

Question 46

The _______ is the maximum dollar amount the insurance will pay for a service or procedure.

Answer 46

Allowable charge

Question 47

There are basically two different models of health insurance today:

Answer 47

Traditional health insurance Managed care organizations

Question 48

__________ pay for all or a share of the cost of covered services, regardless of which provider or hospital is used. ________ provide the most flexibility for the patient but are also the costliest option.

Answer 48

Traditional health insurance plans

Question 49

Benefits are usually paid to the insured, unless that person has authorized payment to be made directly to the provider. This is referred to as the _______.

Answer 49

Assignment of benefits

Question 50

______ are health insurance companies whose goal is to provide quality, cost effective care to their members.

Answer 50

Managed care organizations (MCOs)

Question 51

MCOs

Answer 51

Managed care organizations

Question 52

Many MCOs require the patient to choose a ____ who coordinates the patient’s care. MCOs also require ____ for their patients to be seen by a specialist, thus limiting patient access to more expensive care.

Answer 52

PCP, referral

Question 53

Models of managed care organizations include:

Answer 53

HMO, PPO, EPO

Question 54

HMO

Answer 54

Health maintenance organization

Question 55

Of HMOs, PPO, and EPO, which is the least flexible?

Answer 55

HMOs

Question 56

Under HMOs, patients are not required to pay a ____ or co-insurance, but are required to select a _______. This plan will not pay for services that are not included in its ______.

Answer 56

Deductible, PCP, provider network

Question 57

PPO

Answer 57

Preferred provider organization

Question 58

Under a PPO plan, patients do not need a ____, and they typically have more control over healthcare choices. If the patient chooses to see a provider not in the PPO network, the patients ____, ____, and ____ will be higher.

Answer 58

Referral, deductible, co-insurance, copayments