Book terms

Question 1

adverse selection

Answer 1

buyers and sellers of an insurance product do not have the same information available.

Question 2

adjusted community rating

Answer 2

insurance charges of a particular group are based on demographics

Question 3

balance bill

Answer 3

difference between the amount the provider charges and the amount the payer pays is billed to the patient

Question 4

beneficiary

Answer 4

a patient that is entitled to the benefits of Medicare

Question 5

benefit period

Answer 5

the time that a beneficiary that enters into a skilled nursing facility and ends after 60 consecutive days of no care in a skilled nursing facility

Question 6

benefits

Answer 6

services provided by an insurance plan

Question 7

capitation

Answer 7

provider is paid a set monthly fee per enrollee

Question 8

carriers

Answer 8

payers or insurance providers

Question 9

categorical programs

Answer 9

programs that are designed for a certain category of people (medicare, medicaid, VA)

Question 10

case mix

Answer 10

severity of conditions requiring clinical intervention

Question 11

charge

Answer 11

a fee set by the provider

Question 12

claim

Answer 12

itemized statement of services and costs from a health care provider submitted to a payer

Question 13

copay

Answer 13

flat amount the insured must pay each time health services are rendered

Question 14

community rating

Answer 14

spreads risk among members of a large population

Question 15

consumer driven health plan

Answer 15

high deductible health plans that combine a savings option

Question 16

cost-plus

Answer 16

contract where vendors are paid for providing a service plus an additional sum

Question 17

cost-shifting

Answer 17

used to make up for revenue short falls

Question 18

churning

Answer 18

people gain and lose health insurance periodically

Question 19

coinsurance

Answer 19

copay for Medicare

Question 20

deductible

Answer 20

amount you must pay before you receive any benefits from the insurance company

Question 21

entitlement

Answer 21

Part A is an entitlement program because people pay into it their entire lives

Question 22

experience rating

Answer 22

based on a groups medical claim experience

Question 23

fee schedule

Answer 23

complete listing of fees used by Medicare to pay doctors or other providers

Question 24

fiscal intermediaries

Answer 24

private company contracted by Medicare to pay bills for Part A and B

Question 25

group insurance

Answer 25

provides health plans to a group, usually for company employees

Question 26

insurance

Answer 26

protection against risk

Question 27

insured

Answer 27

anyone covered by health insurance

Question 28

insurer

Answer 28

insuring agency that assumes risk

Question 29

means-tested-program

Answer 29

eligibility depends on financial resources

Question 30

medical loss ratio

Answer 30

percentage of premium revenue spent on medical expenses

Question 31

Medigap

Answer 31

private health insurance that can be purchased only by those enrolled in the original Medicare

Question 32

moral hazard

Answer 32

high utilization of health care services when services are covered by insurance

Question 33

national health expenditure

Answer 33

amount the nation spends for all health services and suppliers

Question 34

outliers

Answer 34

additional payments are made for cases that involve long expensive stays in the hospital

Question 35

pay-for-performance

Answer 35

payment model that offers financial incentives to physicians

Question 36

personal health expenditure

Answer 36

component of national health expenditure and compromised of the total spending for goods and services related to patient care

Question 37

plan

Answer 37

form that private health insurance is obtained

Question 38

play-or-pay

Answer 38

employers must provide health insurance to employees or pay a fine

Question 39

preexisting condition

Answer 39

physical or mental condition that existed before the effective date of the insurance policy

Question 40

premium

Answer 40

insurers charge for insurance coverage

Question 41

prospective reimbursement

Answer 41

method of payment that established criteria are used to determine the amount of reimbursement

Question 42

rate

Answer 42

price for a healthcare service generally set by a 3rd party payer

Question 43

reinsurance

Answer 43

self insured employers purchase to protect themselves against potential risk

Question 44

relative value units

Answer 44

measures based on time, skill, and intensity it takes to provide a service

Question 45

retrospective reimbursement

Answer 45

setting of reimbursement rates based on costs actually incurred

Question 46

risk

Answer 46

possibility of a substantial financial loss from an event of that’s probability is small

Question 47

risk rating

Answer 47

high risk individuals pay more than average premium price, low risk individuals pay less than average price

Question 48

risk selection

Answer 48

healthy people disproportionately enrolled into a health plan

Question 49

self-insured plan

Answer 49

large companies act as insurer by collecting premiums and paying claims

Question 50

third-party-administrator

Answer 50

organization that collects premiums, pays claims and providers administrative services

Question 51

third party payers

Answer 51

not provider or recipient of medical services; insurance companies, managed care organizations, government

Question 52

underwriting

Answer 52

techniques used by insurer to evaluate, select, classify and rate risk.