Chapter 12 B&C FINAL

Which type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own offices?

Independent practice association

Which is NOT true about the Affordable Care Act?

It provides the patient loss income due to wages due to an injury

Which of the following expenses would be paid by Medicare Part B?

Physician's office visits

Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department?

STAT referral

This is the healthcare program for the Department of Defense.

TRICARE

The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage is called the

benefits

A payment method in which providers are paid for each individual enrolled in a plan, regardless of whether the person sees the provider that month, is called a ______ plan.

capitation

The amount of money the policyholder pays per claim or per accident toward the total amount of an insured loss before the company will pay on the claim is known as the

deductible

Which of the following plans require healthcare providers to become participating providers?

government and privately sponsored plans

Which of the following pays the hospital surgical room fee?

hospital

Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?

part B

The amount of money paid to keep an insurance policy in force is the

premium

Most of today's health insurance policies cover which of the following?

preventative care and procedures deemed medically necessary

Organizations that fund their own insurance programs offer their employees

self-funded plans

Which of the following HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network?

staff model

Entities that make payment on an obligation or debt but are not parties of the contract that created the debt are called

third party payers

A review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called a(n)

utilization review

Which of the following individuals would not normally be eligible for Medicare?

A 23-year-old recipient of AFDC

Which of the following is not an advantage of managed care?

Access to specialized care and referrals is limited.

Which of the following are not reviewed by a utilization review committee?

Fees for services provided

Which of the following managed care plans require preauthorization for medical services such as surgery?

HMO, PPO, EPO

Employee-sponsored group policies usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected. However, these employee-sponsored group health insurance plans offer limited benefits, and healthcare access is limited to healthcare providers that are contracted with them.

The first statement is true; the second is false.