insurance theory review

Usual customary reasonable fees

Define UCR FEES

Sum of money that is paid at time of medical services

Define copayment

Whether patient insurance coverage is in effect/ eligible for payment

Define eligibility.

Special provision/ group that may be added to policy to expand / limit benefits otherwise payable

Define rider

True

EOB is a statement sent by the insurance company to the patient stating an MD is requesting payment and why

Third party payers

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

true

the purpose of health insurance is to help individuals and families offset the costs of medical care.

A 23 year old recipient of AFDC

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

Workers compensation

A type of insurance that protects workers from loss wages after an industrial accident that happened on the job is called

65+, disabled

Age to be eligible for Medicare

20

Approximately _____% of people in the United States have no health insurance coverage

True

Before Medicare was established only 50% of the nation elderly had health insurance

3809

If Mr jones insurance has a $500 deductible and a $50 surgery co-pay how much will his insurance pay on his bills of $4359?

Participating provider/ enters contract with specific insurance program

If a doctor is considered PAR this means he/she is

3047.20

If mr jones insurance has insurance has a $500 deductible a $50 surgery co-pay and then pays 80% of the charges how much will his policy pays on his bill of 4359?

Special risk insurance

Insurance that protects a person in the event of a certain type of accident such as an automobile or plane crash is called

False

MSA stands for medicine standard act of 1971

True

Medicare part A will pay for home healthcare

Self insured plans

Organizations that fund their own insurance programs offer their employees

Primary care physicians

PCP stands for

True

The carrier assumes the risk of the insurance policy

Medicaid

The federal and state sponsored health insurance program for the medically indigent is called

False

The guarantor is always the patient

Allowed charge

The maximum amount of money third party payers will pay for a specific procedure or service is called the

Participating

The physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a _______ provider

Beneficiary

They individual entitled to receive benefits from an insurance policy or program is called the

CHAMPVA

Veterans of the usa armed forces may be covered by

Current procedural terminology

What does CPT stand for

International classification of diseases

What does ICD stands for?

1965

What year was Medicare established

Physicians office visits

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

All of the above

Which of the following is a type of insurance verification method

Authorized services usually are covered

Which of the following is not a disadvantage of managed care?

Access to specialized care and referrals is limited

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

D

Which part of Medicare covers prescription drug services

Independent practice association

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?

Major medical

Which type of protection formerly called catastrophic insurance provides coverage for especially large medical bills resulting from a prolonged illness

STAT

Which type of referrals is usually processed immediately?

true

a physician can choose whether to accept medical patients.

false

health insurance typically covers services and procedure considered medically necessary. Most insurance policies also cover elective procedures, such as certain cosmetic surgeries that are not considered necessary

False

2002 was the year Medicare part D was added

Remittance advice

A documents that explains what expense were paid after submission to Medicaid and sent to the physicians office is called an

Capitation

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

Group coverage

A policy that covers a number of people under a single master contract issued to the employer or to an association with which they are affiliated and that is not self funded is usually called

Utilization review

A review of individual cases by a committee to make sure that serves are medically necessary and to show how providers use medical care resources is called

False

A term used in managed care for an approved referral is a rider

True

A third party payor is a person other then the patient, spouse or parent who is responsible for Paying all or part of patient's medical costs

Deductible/ Co-payment

Give 2 examples of cost of coverage

Health insurance portability accountability acts

HIPPA stands

True

HMO means health maintenance organization

All of the above

Health insurance benefits are determined by

TRICARE

Health insurance designed for military dependents and retired military personnel is

Third Party Administrator

TPA STANDS FOR

Extra

The TRICARE option that is similar to a preferred provider network is TRICARE

Premium

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

Deductible

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