Ch 4: Review Test

Question 1

The traditional healthcare delivery system relies heavily on what type of reimbursement model?

Answer 1

Fee-for-service (indemnity)

Question 2

If an insurer negotiates to pay a healthcare provider $300 per year for 1000 people enrolled in a plan, the healthcare reimbursement model would be what?

Answer 2

Indemnity

Question 3

What three things can a patient do if they have an indemnity policy?

Answer 3

• Can choose any provider they want
• Can change physicians at any time
• Pay a monthly “premium”

Question 4

Under an FFS plan, the value of a provider’s service is based on specific historical data, referred to as what?

Answer 4

The usual, customary, and reasonable (UCR) fee

Question 5

What is the universal form used to submit claims to third-party payers?

Answer 5

CMS-1500

Question 6

Under the ____ system, a formula established by CMS assigns a value to every medical procedure to calculate Medicare’s fee schedule allowance

Answer 6

RBRVS

Question 7

The percentage (typically 20%) a patient is required to pay out of pocket toward the cost of healthcare when a health insurance claim is filed is called what?

Answer 7

Coinsurance

Question 8

Minimum coverage requirements for all plans in the Health Insurance Marketplace are referred to as what?

Answer 8

Essential health benefits

Question 9

Under a(n) ____ plan, patients are told which healthcare providers they can see and their medications and treatments are monitored, thus ensuring enrollees that their costs will remain as low as possible

Answer 9

Managed care

Question 10

What is the federal health insurance program the provides healthcare benefits to individuals age 65 or older and individuals younger than 65 with certain disabilities?

Answer 10

Medicare

Question 11

What is the name of the federal entitlement program that covers certain categories of low-income individuals and certain disabled individuals?

Answer 11

Medicaid

Question 12

What type of insurance pays workers who are injured or disabled on the job or who experience job-related illnesses?

Answer 12

Workers’ compensation

Question 13

What type of plan is available to self-employed individuals and works in conjunction with special low-cost, high-deductible health insurance?

Answer 13

Health savings account (HSA)

Question 14

What is a network of doctors and hospitals that share responsibility for managing the healthcare needs of a minimum of 500 Medicare beneficiaries for at least 3 years called?

Answer 14

Accountable Care Organization

Question 15

What three organizations are instrumental in recognizing and assessing healthcare plans and certifying the quality of the care they provide?

Answer 15

• The Joint Commission
• National Committee for Quality Assurance
• Consumer Coalition for Quality Health Care