Week 2 Study Guide
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
What is not reviewed by a utilization review committee?
Individual cases to ensure medical care services are medically necessary
The federal- and state-sponsored health insurance program for the medically indigent is called?
Medicaid
Medigap polices cover what?
Medigap policies cover the difference between Medicare reimbursement and patient financial responsibilities.
Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?
Part B
What expenses would be paid by Medicare Part B?
Physician's office visits
Most of today's health insurance policies cover what?
Preventive care
What referral can be approved online when it is submitted through the provider's Web portal to the utilization review department?
STAT referral
Which type of referral is usually processed immediately?
STAT referral
What HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network?
Staff model
Dependents of military personnel are covered by which of the following government-sponsored health insurance plans?
TRICARE
The maximum amount of money third-party payers will pay for a specific procedure or service is called the
allowable amount.
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.
TRICARE is a form of government insurance for veterans of the U.S. armed forces. True or false?
false
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
group policy.
The physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ______ provider.
participating
The amount of money paid to keep an insurance policy in force is the
premium.
Organizations that fund their own insurance programs offer their employees
self-funded plans.
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.
The "cafeteria-style" plan allows employers to choose the benefits they want for their respective employees. True or false?
true
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.
A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called
workers' compensation.
If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay and then pays 80% of the charges, how much will his policy pay on his bill of $4,359?
$3047.20 $3,809 ´ 0.8 = $3,047.20.
Who would not normally be eligible for Medicare?
A 23-year-old recipient of AFDC
What plans require healthcare providers to become participating providers?
All government-sponsored health plans & Most privately sponsored health plans
What managed care plans require preauthorization for medical services such as surgery?
All managed care plans, including HMOs, PPOs, and EPOs
Which part of Medicare covers prescription drug services?
D
The medical assistant should always verify which of the following prior to the patient's appointment?
Eligibility Benefits and exclusions Effective date of insurance
The TRICARE option that is similar to a preferred provider network is TRICARE
Extra.
Health insurance typically covers services and procedures considered medically necessary. Most insurance policies also cover "elective" procedures, such as certain cosmetic surgeries, that are not considered medically necessary. True or false?
False
What MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility?
HMOs
what pays the hospital surgical room fee?
Hospital
Health insurance benefits are determined by?
Indemnity schedules service benefit plans relative value studies
Nearly all of the physician's income is derived from the insurance payments received for services rendered. True or false?
True
A physician can choose whether to accept Medicaid patients. True or false?
True.