Chapter16 Study Guide
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 plan
If Mr. Jones's insurance haws 0 deductible and a $50 surgery copay and then pays 80% of the charges, how much will his policy pay on his bill of $4,359
$3047.20
If Mr. Jones's insurance has a $500 deductible and a $50 surgery copay, how much will his insurance pay on his bill of $4359
$3809
What individuals are covered under Medicare
23 yr old recipient of AFDC
What are disadvantages of managed care
Access to specialized care and referrals can be limited more paperwork physicians choices in the treatment of patients can be limited
The MA should always verify what prior to the patients appointment
All of the above
The maximum amount of money third-party pays will pay for a specific procedure or service is called
Allowable amount
What expenses would be paid by Medicare Part B
Ambulatory care, including primary care and specialists
The amount payable by an insurance company for monetary loss to an individual insured by that company, under each coverage is called
Benefits
Which of the following plans require healthcare providers to become participating providers
Both A and B
Veterans of the US Armed Forces may be covered by
CHAMPVA
A payment method in which providers are paid for each individual enroll plan, regardless of whether the person sees the provider that month is called a _______ plan
Capitation
which part of Medicare covers prescription drugs
D
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
Deductable
Medigap policies cover which of the following
Difference between major medical reimbursement and patient financial responsibilities
What are advantages of managed health care
Healthcare costs are usually contained Established fee schedules are used Authorized services are usually paid for Out of pocket is usually less
Health insurance benefits are determined by
Indemnity schedules Service benefits Relative value study
What HMO model consists of physicians with separately owned practices who formally into a group but continue to practice in their own offices
Independent practice association
The federal and state sponsored health insurance program for the medically indigent is
Medicaid
What Medicare plans does the patient have to pay a premium for primary and specialists services
Part B
The physician who enters into a contract with an insurance company and agrees to certain rules and regulation is called a _______ provider
Participating
The amount of money paid to keep an insurance policy in force is the
Premium
Most of todays health insurance policies cover what
Preventative care and procedures deemed medically necessary
Which type of referral is usually processed immediately
STAT
What referral can be approved online when it is submitted through the providers web portal to the utilization review department
STAT referral
What pays the hospital surgical room fees
Hospital
The "cafeteria style" plan allows employers to choose the benefits they want for their respective employees
True
A type of insurance that protects workers from loss wages after an industrial accident that happened on the job is what
Workers Compensation
A physician can choose whether to accept Medicaid patients
True
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 cosmetic surgeries, that are not considered medically necessary.
False
What is reviewed by the utilization review committee
Fees for services provided
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 (true/false)
First - True Second - 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
What managed care plans require preauthorization for medical services such as surgery
HMO and PPO
What MCO typically has/have the lowest monthly premiums with lower patients financial responsibility
HMO's
Organizations that fund their own insurance programs offer their employees
Self-funded plans
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
Health insurance designed for military dependents and retired military personnel is called
TRICARE
Entities that make payment on an obligation or debt but not parties of the contract that created the debt are called
Third party payers
Nearly all of the physicians income is derived from the insurance payments received for services rendered
True
TRICARE is a form of government insurance for veterans of the US Armed Forces
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
utilization review