Chapter 14

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

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

Medicaid

Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department?

STAT referral

Health insurance benefits are determined by

all of the above

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

allowable amount

TRICARE is a form of government insurance for only veterans of the U.S. armed forces.

False

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

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

A 23-year-old recipient of AFDC

Which part of Medicare covers prescription drug services?

D

Which of the following pays the hospital surgical room fee?

D. Hospital

Medigap polices cover which of the following?

Difference between Medicare reimbursement and patient financial responsibilities

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.

False

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

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

Access to specialized care and referrals is limited.

The medical assistant should always verify which of the following prior to the patient's appointment?

All of the above

Which of the following managed care plans require preauthorization for medical services such as surgery?

All of the above

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

Authorized services usually are covered.

Which of the following plans require healthcare providers to become participating providers?

Both A and B

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

Participating

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

Physician's office visits

Which type of referral is usually processed immediately?

STAT

A physician can choose whether to accept Medicaid patients.

True

Which of the following are not reviewed by a utilization review committee?

Fees for services provided

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

Which of the following MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility?

HMO's

Which of the following 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

Veterans of the U.S. armed forces may be covered by

TRICARE

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

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

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

workers' compensation.