Chapter 6

Question 1

DME

Answer 1

durable medical equipment

Question 2

FSA

Answer 2

flexible spending agreement

Question 3

FI

Answer 3

fiscal intermediary

Question 4

MS

Answer 4

masters (HIM)

Question 5

ICD-9-CM

Answer 5

international classification disease 9th edition clinically modified (US)

Question 6

CPT

Answer 6

current procedural terminology - coding system for physician service developed by the AMA

Question 7

MDC

Answer 7

major diagnostic category

Question 8

WC

Answer 8

worker’s compensation

Question 9

EOB

Answer 9

eligibility of benefits

Question 10

VA

Answer 10

veterans association

Question 11

RAC

Answer 11

recovery audit contractor

Question 12

MHSS

Answer 12

mental health service survey

Question 13

CMS

Answer 13

center for medicare and medicaid services

Question 14

BCBS

Answer 14

blue cross blue shield

Question 15

COB

Answer 15

coordination of benefits

Question 16

HAC

Answer 16

hospital acquired condition

Question 17

UCR

Answer 17

usual, customary & reasonable, insurers limited free-for-service reimbursement to a reasonable amount

Question 18

POA

Answer 18

present on admission

Question 19

TPA

Answer 19

third party administrator

Question 20

PHP

Answer 20

physician’s health plan

Question 21

FFS

Answer 21

fee-for-service

Question 22

DRG

Answer 22

diagnostic related group, system that classifies hospital cases into one of 467 groups

Question 23

APC

Answer 23

ambulatory payment classification

Question 24

enrollment period

Answer 24

period in which an employee may select their insurance from employer, once a year

Question 25

beneficiary

Answer 25

one who is eligible to receive or is receiving benefits from an insurance policy or a managed care program

Question 26

payers

Answer 26

third party payers (insurance companies, MCO, BCBS, gov't), other two parties are the patient and the provider

Question 27

group insurance

Answer 27

anticipates that a substantial # of people in the group will purchase insurance through a sponsor, cost of insurance (risk) is spread out

Question 28

claim

Answer 28

to receive payment for services rendered, PROVIDERS must file a claim with the 3rd party payer

Question 29

adjudication

Answer 29

argue w/ the provider (or insurance company)

Question 30

remittance or reimbursement

Answer 30

determination of rates, how much providers should be paid

Question 31

copay

Answer 31

amount insured must pay each time health services are received

Question 32

coinsurance

Answer 32

copay that is calculated by a proportion of medical costs incurred (80/20% after deductible is reached)

Question 33

deductible

Answer 33

amount a beneficiary must first pay before any benefits are payable by the plan, must be paid on an annual basis, insurance only pays once deductible is exceeded

Question 34

patient billing

Answer 34

fee schedule (index of charges)

Question 35

fee for service

Answer 35

reimbursement method, fee is met by services provided by the physician

Question 36

per diem

Answer 36

daily rates for in patient stays in hospitals (reimbursement rate) (per patient day PPD)

Question 37

capitation

Answer 37

mechanism of reimbursing provided by MCO, provider is paid a set monthly fee per enrollee, paid regardless of how often medical services are provided

Question 38

CMS

Answer 38

centers for medicare and medicaid services, runs them

Question 39

medicare part A

Answer 39

hospital, in patient insurance

Question 40

PPS

Answer 40

prospective payment system

Question 41

medicare part B

Answer 41

supplementary medical insurance

Question 42

medicare part C

Answer 42

medicare advantage (ABD)

Question 43

medicare part D

Answer 43

prescription drug coverage

Question 44

medicaid

Answer 44

finances health care services for the poor, any age group, public welfare issues

Question 45

medicare

Answer 45

finances medicare for groups of people (1) 65+, (2) disabled who entitled to social security, (3) people who have end stage renal disease

Question 46

TRICARE

Answer 46

health care for military

Question 47

indian health service (IHS)

Answer 47

federal program, comprehensive care to native americans living on reservations and in rural areas, operates in own hospitals and centers

Question 48

SCHIP (now CHIP)

Answer 48

children's health insurance program, noted income threshold, states typically cover children (up to 19) in families with incomes up to 200% of federal poverty level

Question 49

program of all-inclusive care for elderly (PACE)

Answer 49

provides community based care for persons aged 55+ who otherwise qualify for placement in a nursing facility

Question 50

worker's compensation (WC)

Answer 50

employer is financially liable for the full cost of work related injuries and illnesses regardless of who is at fault

Question 51

retrospective reimbursement method

Answer 51

cost-plus, per diem, reimbursement based on historical records of providers, not really used extensively anymore related to length to length of stay, services rendered, and cost of providing services, provides inflated costs

Question 52

coordinator of benefits

Answer 52

members of group who are covered by more than one healthcare plan, the coordinator must determine which plan is primary

Question 53

guarantor

Answer 53

person held accountable for the patient's bills

Question 54

subscriber

Answer 54

person who elects to enroll of participate in managed care or purchase health care insurance

Question 55

assignment of benefits

Answer 55

an arrangement by which a patient requests that their health benefit payments be made directly to a designated person/facility (physician/hospital)