Lesson 2: The Fundamentals of Health Insurance

Which Act is responsible for setting certain minimum standards for employer-provided health plans?

ERISA

The ___________________ protects the Federal Government from being overcharged or sold substandard goods or services and imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government.

False Claims Act (FCA)

An organization that offers health insurance at a fixed monthly premium with little or no deductible and works through a primary care provider is called a(n):

health maintenance organization

The Affordable Care Act was designed to what? Choose all that apply.

increase health insurance quality increase health insurance affordability lower the uninsured rate reduce the cost of healthcare

Fee for service plans are also known as what?

indemnity

The owner of the health insurance policy.

insured

Jen and her husband just had a baby. Jen is laid off from her job, her husband works part time and they do not have insurance coverage. Who should you provide Jen and her husband contact information for?

medicaid

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

medicaid

A health program for people age 65 and older under social security is called:

medicare

________________ means that the doctor or facility providing your care does not have a contract with your health insurance company.

out of network

A person who is covered under a group insurance policy

subscriber

One who belongs to a group insurance plan is called:

subscriber

______________is any organization, public or private, that pays or insures health or medical expenses on behalf of the insured.

third party payer

Billing for an appointment that a patient did not keep is an example of medical fraud.

true

Billing for unnecessary medical services is an example of fraud and abuse.

true

CHAMPVA offers coverage for the families of veterans who are deceased.

true

Dependents can be spouses and children.

true

Fraud is the intentional falsification of information or deception.

true

If a patient is injured in the process of a false claim, as per HIPAA, the conviction and prison term can be doubled up to 20 years.

true

Insurance fraud is the only case in which an individual may be denied coverage by an insurance company.

true

Most Americans with private health insurance receive it through an employer-sponsored program.

true

One of the advantages of Managed care plans is lower healthcare cost.

true

Open enrollment is when a person can adjust their health plan.

true

Overcharging for a medical service is an example of abuse.

true

Part D of Medicare covers prescription drug services.

true

Private insurance is regulated by both state and federal laws.

true

Privately funded health plans are state-licensed insurance organizations.

true

Suspected fraud and abuse in healthcare can be reported by calling the OIG hotline.

true

The anti-kickback statute makes the following example a crime: A provider receives cash or below fair market value rent for medical office space in exchange for referrals.

true

The first health maintenance organization in the United States was believed to have been formed in 1929.

true

When working under managed care plan, physicians agree to accept fees that are predetermined by the plan.

true

What is not an advantage of a managed care organization?

unlimited care

What factors contributed to the to the growth of commercial health insurance?

All of the above

Which Medicare service plan provides outpatient insurance?

B

The Healthcare Fraud Prevention and Enforcement Action Team (HEAT) consists of the following organizations. Choose all that apply:

DOJ OIG HHS

Organizations wishing to receive Hill-Burton funds, must be participants in which programs? Choose all that apply.

Medicare Medicaid

This type of insurance offers a network of providers and the choice to see providers outside of the network for a bit more money.

PPOs

Stan has a deductible of $500 before his insurance pays 100%. Upon calling to check how much of the deductible has been met, the insurance representative informs you that he has only met $100. The services for his visit equal $750. How much is Stan responsible for at the time of service?

$400

In a hospital setting, a doctor, who participates in Medicare, performs a $450.00 service for a patient. The patient has met her deductible for the current year. The Medicare allowable charge for the service is $500.00. Medicare will pay:

$450.00

A patient's insurance company states that she has a coinsurance of 90/10 of covered services. When they receive their notice from the insurance carrier, it stated that the charges for their last office visit were not allowed. Therefore, the patient would be responsible for how much of the payment?

100%

__________________ states that healthcare fraud and abuse is a federal criminal offense that can have significant penalties attached to it.

HIPAA

The person who receives benefits or insurance coverage.

beneficiary

When a patient has health insurance, the percentage of covered services that are the responsibility of the patient to pay is known as:

coinsurance

_______________is a process applied by individuals who have two or more existing policies to ensure that their beneficiaries do not receive more than the combined maximum payout for the plans.

coordination of benefits

A type of insurance whereby the insured pays a specific amount per unit of service and the insurer pays the rest of the cost is called:

copayment

An amount the insured must pay before policy benefits begin is called:

deductible

Blue Cross was born out of a merging of various physician groups who were, at the time, offering prepaid plans to their patients.

false

Medicare is a privately funded insurance plan.

false

Premiums are only paid yearly.

false

The beneficiary is the person who is paying for the health insurance plan.

false

The deliberate and frequent act of using a more complex code for a procedure on forms submitted to an insurance company so that a higher level of reimbursement will be made to the doctor, may result in a case being brought against the medical facility for:

fraud

The _____________is the person responsible for the medical bill.

guarantor

The person responsible for the medical bill.

guarantor

A previous injury, disease or physical condition that existed before the health insurance policy was issued is called:

preexisting condition

Amount a person pays their insurance company for health coverage each month or year.

premium

Payment made periodically to keep an insurance policy in force is called:

premium

A person or institution that gives medical care is a(n):

provider

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

workers' compensation