Pharmacy Business: Module 4 Review

Question 1

Systematic reviews and evaluations of records and other data to determine the quality of services or products provided.

Answer 1

audits

Question 2

A person designated by an insurance policy to receive benefits or funds.

Answer 2

Beneficiary

Question 3

A comprehensive health care program in which the Office of Veterans’ Affairs (VA) shares the cost of covered health care services and supplies with eligible beneficiaries.

Answer 3

CHAMPVA

Question 4

An arrangement in which the insured must pay either a fixed amount or a percentage of the cost of medical services covered by the insurer.

Answer 4

coinsurance

Question 5

A legally enforceable agreement.

Answer 5

contract

Question 6

A process in which two or more insurance companies apportion each one’s share of responsibility of payment of a claim for health care services provided to an insured client.

Answer 6

coordination of benefits

Question 7

A cost-sharing requirement of most insurance policies, under which it is the responsibility of the insured to make a payment of a specified amount (e.g., $20) at the time of treatment or purchase of a prescription. Some policies have both a copayment and coinsurance clause.

Answer 7

copayment

Question 8

A rejection of a medication refill due to an amount that has exceeded the preapproved supply for a specific period of days.

Answer 8

days supply exceeded

Question 9

A specific amount of money that must be paid yearly before the policy benefits begin (e.g., $50, $100, $300, or $500). The higher the deductible, the lower the cost of the policy; and the lower the deductible, the higher the cost of the policy.

Answer 9

Deductible

Question 10

The spouse and children of the insured who are also covered under the terms of the policy.

Answer 10

depndents

Question 11

An evaluation of a pharmacy or related facility that does not involve an auditor being sent out to the location; it is less intensive than a field audit.

Answer 11

desk audits

Question 12

The determination of the exact coverage to which the insured is entitled. The pharmacy technician may be responsible for checking on a customer’s or patient’s eligibility of coverage. This can be done over the telephone, via a voice-automated system, using computer software, over the Internet, or by checking an eligibility list for a managed care plan.

Answer 12

eligibility

Question 13

An intensive, systematic investigation of a pharmacy or other facility’s operational practices, procedures, records, inventory, and accounting.

Answer 13

filed audits

Question 14

A type of contract purchased by individuals or employers that provides reimbursement for specified medical and related expenses.

Answer 14

health insurance

Question 15

A government-funded health cost assistance program that pays for health services and pharmacy expenses for enrolled U.S. citizens who cannot afford to pay for their own health care. It also covers those who are blind, disabled, orphaned, or underage parents.

Answer 15

Medicaid

Question 16

A government-funded program that pays for health coverage for people over age 65, and certain other persons.

Answer 16

medicare

Question 17

A type of health plan providing coverage within Part C of Medicare; it pays for managed health care based on a monthly fee rather than on the basis of billing a fee for each service provided.

Answer 17

medicare advantage plan

Question 18

Payment by the insurer or by the patient of more than the amount due.

Answer 18

overpayment

Question 19

An individual numeric code that identifies a specific patient, used in pharmacies and other health care facilities.

Answer 19

patient identification number

Question 20

An individual numeric code that identifies a specific patient, used in pharmacies and other health care facilities.

Answer 20

patient identification number

Question 21

A rejection of a medication refill in which the amount requested exceeds the amount allowed by insurance plan.

Answer 21

plan limitations exceeded

Question 22

The exclusion of specific medical conditions or procedures from reimbursement under a health insurance policy. Some types of exclusions are acquired immunodeficiency syndrome (AIDS), attempted suicide, cancer, losses due to injury on the job, and pregnancy.

Answer 22

policy limitation

Question 23

Prior authorization; many private insurance companies and prepaid health plans have certain requirements that must be met before they will approve diagnostic testing, hospital admissions, inpatient or outpatient surgical procedures, other specific procedures, and specific treatment or medications. For example, most outpatient intravenous therapies require a prior approval authorization.

Answer 23

preauthorization

Question 24

The cost of the coverage provided by an insurance policy; this may vary greatly depending on the age and health of the individual and the type of insurance protection. The premium may be paid in full or in part by the employer and/or the employee.

Answer 24

premium

Question 25

A rejection of a medication refill in which the refill has been requested too soon after a previous refill was requested.

Answer 25

refill too soon

Question 26

The individual or organization protected in case of loss under the terms of an insurance policy. The subscriber is known as an insured, member, policyholder, or recipient. In group insurance, the employer is known as the insured and the employees are the risks.

Answer 26

subscriber

Question 27

An organization or corporation that pays medical claims for patients; third-party payers reimburse providers directly, with patients making only any required copayments.

Answer 27

third-party payer

Question 28

The amount of time from the date of service to the date (deadline) a claim can be filed with the insurance company. Each insurance program has specific time limits that must be adhered to or the insured party will not be able to collect from the insurance company.

Answer 28

time limit

Question 29

A health care program serving active duty service members, members of the National Guard (including reserve members), retirees, their families, survivors, and selected former spouses worldwide.

Answer 29

TRICARE

Question 30

The period of time that an individual must wait to become eligible for insurance coverage (e.g., 30 days), before coverage commences or for a specific benefit (e.g., an employee must wait 9 months before seeking maternity benefits); also known as an elimination period.

Answer 30

waiting period

Question 31

By 2025, total healthcare expenditures are expected to reach $_____ trillion.

Answer 31

5.6

Question 32

Pharmacy technicians must understand how to correctly _____ prescription insurance.

Answer 32

bill

Question 33

Correct billing helps ensure payment, protects against audits, and affords accurate patient _____.

Answer 33

copays

Question 34

A _____ plan insures a group under one policy issued to their employer.

Answer 34

group

Question 35

Group plans usually offer lower _____ than individual plans.

Answer 35

premiums

Question 36

A prepaid health plan charges a fixed fee and pays providers via _____.

Answer 36

capitation

Question 37

An individual insurance plan is also called _____ insurance.

Answer 37

personal

Question 38

A third-party payer is not a party to the original _____.

Answer 38

contract

Question 39

Most health insurers work with _____ to process prescription claims.

Answer 39

pharmacy. benefit managers

Question 40

Examples of private insurance include HMOs, Blue Cross-Blue Shield, and _____.

Answer 40

kaiser foundation

Question 41

_____ laws protect workers from lost wages and medical costs from on-the-job injuries.

Answer 41

workers compensation

Question 42

BCBS is a federation of local insurers providing care to _____.

Answer 42

subscribers

Question 43

BCBS covers hospital, outpatient, and _____ care services.

Answer 43

home

Question 44

BCBS may pay the _____ if the provider is out-of-network.

Answer 44

subscriber

Question 45

The Kaiser Foundation is a type of prepaid group practice _____.

Answer 45

HMO

Question 46

Kaiser owns medical facilities and directly employs _____.

Answer 46

→ providers

Question 47

Injured workers under workers' comp pay no _____ or coinsurance.

Answer 47

deductible

Question 48

Managed care programs aim to keep costs down by negotiating _____ fees.

Answer 48

fixed

Question 49

An IPA is a _____ panel HMO contracting with independent physicians.

Answer 49

closed

Question 50

IPA doctors may be paid via capitation or _____-for-service.

Answer 50

fee

Question 51

PPO patients get the highest benefits from _____ providers.

Answer 51

preffered

Question 52

PPO enrollees can see specialists without _____.

Answer 52

preauthorization

Question 53

Government health plans include Medicare, Medicaid, TRICARE, and _____.

Answer 53

CHAMPVA

Question 54

Medicare is the largest medical benefits program in the _____. →

Answer 54

United States

Question 55

Medicare offers benefits in all _____ states.

Answer 55

50

Question 56

Medicare covers those 65+, or younger people who are blind, widowed, or _____.

Answer 56

disabled

Question 57

Medicare Part A covers hospital, nursing, and _____ care.

Answer 57

hospice

Question 58

Medicare Part B includes outpatient care, physician services, and _____ equipment.

Answer 58

durable medical

Question 59

Claims for Part B are submitted via the _____ form.

Answer 59

CMS 1500

Question 60

Medicare Part C is also known as Medicare _____.

Answer 60

advantage

Question 61

Medicare Part D gives greater access to _____ in a retail setting.

Answer 61

medications

Question 62

Medicaid is designed for low-income individuals and the _____.

Answer 62

disabled

Question 63

Managed Medicaid uses per-member, per-month _____ rates.

Answer 63

capitation

Question 64

TRICARE Prime is an HMO plan, while TRICARE Standard is _____.

Answer 64

fee for service

Question 65

CHAMPVA is for families of veterans with permanent, service-connected _____.

Answer 65

disabilities

Question 66

An insurance policy is a legally _____ agreement.

Answer 66

enforcable

Question 67

Patient profiles must be kept up to date for correct _____.

Answer 67

billing

Question 68

Drug costs are based on AWP and patient _____.

Answer 68

copays

Question 69

Non-formulary drugs may require a _____ authorization.

Answer 69

prior

Question 70

Medicare and Medicaid use TAR, which stands for _____.

Answer 70

Treatment Authorization Request

Question 71

Claims are processed through a system called _____.

Answer 71

adjudication

Question 72

Person codes indicate the patient is not the _____.

Answer 72

member

Question 73

A _____ too soon rejection occurs when a refill is attempted early.

Answer 73

refill

Question 74

Billing more than one payer is called coordination of _____.

Answer 74

benefits

Question 75

immunization claims require diagnosis codes and _____ fees.

Answer 75

administration

Question 76

DMEPOS includes walkers, test strips, and _____ supplies.

Answer 76

wound care

Question 77

DMEPOS stands for Durable Medical Equipment, Prosthetics, Orthotics, and _____.

Answer 77

supplies

Question 78

Hospital medications are billed using diagnosis _____ groups (DRGs).

Answer 78

related

Question 79

MTM services include CMR, TMR, and _____ consultations.

Answer 79

adherence

Question 80

J-codes are used in the _____ Procedure Coding System.

Answer 80

healthcare common

Question 81

Billing units are not related to package _____.

Answer 81

size

Question 82

An _____ is when an insurer or patient pays more than the amount due.

Answer 82

overpayment

Question 83

Claims are reviewed both automatically and _____.

Answer 83

manually

Question 84

A PMP is used to track accounts _____.

Answer 84

receivable

Question 85

Payers usually have 30–60 days to _____ claims.

Answer 85

adjudicate

Question 86

Desk audits are done electronically, while field audits involve a pharmacy _____.

Answer 86

visit

Question 87

A staff member should be assigned to the _____.

Answer 87

auditor

Question 88

Large financial losses may occur from audit ____

Answer 88

non compliance

Question 89

Dispensed quantity exceeds _____ quantity.

Answer 89

authroized

Question 90

Inappropriate _____ code can result in audit flags.

Answer 90

dispense as written

Question 91

Audits may flag inconsistent days _____ or missing prescriptions.

Answer 91

supply

Question 92

Audits may flag inconsistent days _____ or missing prescriptions.

Answer 92

insurer

Question 93

An insurance claim includes the patient, prescriber, pharmacy, and _____.

Answer 93

medications

Question 94

HMOs were created to control costs and manage patient _____.

Answer 94

care

Question 95

n HMOs, patients select a PCP from a _____.

Answer 95

medical group

Question 96

Which of the following parts of Medicare covers drug prescriptions?

Answer 96

Medicare Part D

Question 97

A(n) ____________________ is a specific amount of money that must be paid each year before the policy benefits begin.

Answer 97

Deductible

Question 98

All of the following conditions are “exclusions” on insurance policies, except: cancer. heart attack. pregnancy. attempted suicide.

Answer 98

heart attack

Question 99

T or F If a patient has both Medicare and Medicaid, charges must be filed with Medicare first, and Medicaid is the secondary payer.

Answer 99

True

Question 100

With workers’ compensation, it is the injured worker’s responsibility to:

Answer 100

notify the employer promptly of an injury.

Question 101

Patients who can receive medical benefits under Medicare include:

Answer 101

citizens 65 years of age and older.

Question 102

TRICARE replaced which government program?

Answer 102

CHAMPUS

Question 103

Government-sponsored health plans include all of the following, except:

Answer 103

Kaiser Foundation Health Plan.

Question 104

Which of the following is an example of fraud?

Answer 104

Altering a patient’s chart to increase the amount reimbursed

Question 105

What is true about Health Maintenance Organizations (HMOs)?

Answer 105

Members of an HMO select a primary care physician (PCP) from a group.

Question 106

Medicare Part B covers:

Answer 106

Outpatient services

Question 107

For patients who have an HMO, what option will allow them to utilize an out-of-network provider?

Answer 107

Point-of-service option

Question 108

Most outpatient IV therapies require a:

Answer 108

preauthorization

Question 109

What is true regarding a Preferred Provider Organization (PPO)?

Answer 109

Enrollees can see a specialist without prior authorization from a primary care physician

Question 110

Medicaid is:

Answer 110

secondary carrier when the patient has Medicare.

Question 111

Which of the following is true about Blue Cross and Blue Shield?

Answer 111

It offers prepaid health services.

Question 112

TRICARE is a health care benefit program for all of the following, except:

Answer 112

families of veterans with service-related disabilities.

Question 113

True or False Medicare Part D is offered to all Medicare recipients to cover the costs of their medications.

Answer 113

True

Question 114

Medicare Part B covers:

Answer 114

Medicare Part B covers:

Question 115

insurance policy that is a legally enforceable agreement

Answer 115

contract

Question 116

spouse and children of the insured person who are also covered under terms of the policy

Answer 116

dependents

Question 117

determination of the exact coverage to which the insured person is entitled

Answer 117

eligibility

Question 118

insurance policy’s coinsurance or cost-sharing requirement in which the insured must make a payment of a specified amount at the time of treatment or purchase of a prescription

Answer 118

co-payment

Question 119

cost of the coverage that the insurance policy contains

Answer 119

premmium

Question 120

payment by the insurer or by the patient of more than the amount due

Answer 120

overpayment

Question 121

insured or a member, policyholder, or recipient

Answer 121

subscriber

Question 122

person designated by an insurance policy to receive benefits or funds

Answer 122

beneficiary

Question 123

specific amount of money that must be paid yearly before the policy benefits begin

Answer 123

deductible

Question 124

arrangement in which the insured must pay a percentage of the cost of medical services covered by the insurer

Answer 124

coinsurance

Question 125

All claims processing involving pharmacies is now done ____________________.

Answer 125

electronically

Question 126

Which of the following is a third-party health plan that is funded by the federal government?

Answer 126

TRICARE

Question 127

Medicare Part B coverage:

Answer 127

is optional

Question 128

Medicare plus Choice plan is also known as:

Answer 128

Medicare Part C

Question 129

Medicare Part A covers hospitals, nursing facilities, home health care, ____________________, and inpatient care.

Answer 129

hospice