Chapter 16 Admin
benefits
The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage is called the
Medicaid
The federal- and state-sponsored health insurance program for the medically indigent is called
CHAMPVA
Veterans of the U.S. armed forces may be covered by
Staff model
Which of the following HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network?
HMOs
Which of the following MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility?
Fees for services provided
Which of the following are not reviewed by a utilization review committee?
Physician's office visits
Which of the following expenses would be paid by Medicare Part B?
A 23-year-old recipient of AFDC
Which of the following individuals would not normally be eligible for Medicare?
Authorized services usually are covered
Which of the following is not a disadvantage of managed care?
D
Which part of Medicare covers prescription drug services?
capitation
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.
True
A physician can choose whether to accept Medicaid patients.
group policy
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 services are medically necessary and to study how providers use medical care resources is called a(n)
workers' compensation
A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called
TRICARE
Dependents of military personnel are covered by which of the following government-sponsored health insurance plans?
Difference between Medicare reimbursement and patient financial responsibilities
Medigap polices cover which of the following?
Preventive care Procedures deemed medically necessary
Most of today's health insurance policies cover which of the following?
True
Nearly all of the physician's income is derived from the insurance payments received for services rendered.
self-funded plans
Organizations that fund their own insurance programs offer their employees
$2,809
If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay, how much will his insurance pay on his bill of $4,359?
Part B Correct
Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?
Access to specialized care and referrals is limited
Which of the following is not an advantage of managed care?
HMOs B. PPOs C. EPOs D. Both A and B E. All of the above Correct
Which of the following managed care plans require preauthorization for medical services such as surgery?
All government-sponsored health plans Most privately sponsored health plans
Which of the following plans require healthcare providers to become participating providers?
STAT referral
Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department?
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?
STAT
Which type of referral is usually processed immediately?
$3047.20
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?
Hospital
Which of the following pays the hospital surgical room fee?
False
TRICARE is a form of government insurance for veterans of the U.S. armed forces.
indemnity schedules. service benefit plans. relative value studies. ( All of the above )
Health insurance benefits are determined by
TRICARE
Health insurance designed for military dependents and retired military personnel is called
False
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
The "cafeteria-style" plan allows employers to choose the benefits they want for their respective employees.
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
The first statement is true; the second is false
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.
third-party payers
Entities that make payment on an obligation or debt but are not parties of the contract that created the debt are called
allowable amount
The maximum amount of money third-party payers will pay for a specific procedure or service is called the
Eligibility Benefits and exclusions Effective date of insurance
The medical assistant should always verify which of the following prior to the patient's appointment?
participating
The physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ______ provider.
