Chapter 15 Flashcards
a form of patient care review by healthcare professionals who do not provide the care but are employed by health insurance companies
utilization management/ utilization review
Two types of insurance
government and private
a designated person who receives funds from an insurance plan
beneficiary
a payment arrangement for healthcare providers in which providers receive a per person/per month payment regardless of how often the provider sees the patient
capitation
a formal request for payment from an insurance company for services provided
claim
a list of fixed fees for services
fee schedule
the primary care provider who is in charge of a patient’s treatment. Additional treatments must be approved by this person
gatekeeper
poor, needy, impoverished
indigent
a written agreement between two parties in which one agrees to pay the other if certain specified circumstances occur
policy
a process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services
preauthorization
the amount paid or to be paid by the policy holder for coverage under the contract
premium
an approved list of physicians, hospitals and other providers
provider network
an order from a PCP for a patient to see a specialist or to get certain medical services
referral
used to determine how much providers should be paid for services provided. The geographic region is also taken into account. It is used by Medicare and many other health insurance companies.
resource based relative value system (RBRVS)
an organization that processes claims and provides administrative services for another organization. Often used by self-funded plans
third-party administrator (TPA)
The person responsible for the payment of the premium is referred to as the _____.
subscriber
Cost-sharing includes the following three things:
deductible, co-insurance, and copayment
a set dollar amount that the policyholder must pay before the insurance company starts to pay for services.
deductible
The higher the deductible, the lower the _______.
premium
After the deductible has been met, the policyholder may need to pay a certain percentage of the bill, and the insurance company pays the rest. Atypical split is 80/20- the insurance company pays 80% and the policyholder pays 20%. What is this called?
co-insurance
Aset dollar amount that the policy holder must pay for each visit.
copayment
_________ services are those that are proper and needed for the diagnosis or treatment of the medical condition.
medically necessary
________ are procedures that are not deemed necessary, such as a facelift.
elective procedures
Most insurance policies do not cover ____ _____.
elective procedures
The fee schedule for medicare part B is determined using the RBRVS. This system consists of 3 parts:
provider work, charge-based professional liability expenses, charge-based overhead
____ is the govt program that provides medical care for the indigent.
Medicaid
_____ is a federal health insurance program that provides coverage for individuals over the age of 65, disabled people, and those with ESRD (end stage renal disease)
Medicare
what would be a covered service of Medicare part A?
inpatient hospital care
What would be a covered service under medicare part B?
outpatient hosptial care, durable medical equipment
What is covered under medicare part D?
prescription drugs
Which part of Medicare REQUIRES a monthly premium?
Part B
______ is currently the world’s largest insurance program.
Medicare
Medicare refers to those covered as _____.
beneficiaries
RBRVS
resource-based relative value scale
Supplemental health insurance plans are known as ______ policies.
Medigap
Mandatory medicaid benefits include:
family planning services, nurse midwife services, transportation to medical care
a comprehensive healthcare program for uniformed service members and retirees and their families.
TRICARE
a health benefits program that provides coverage for the families of veterans who were permanently disabled or killed in line of duty.
CHAMPVA
CHAMPVA
civilian health and medical program of the veterans administration
________ are contracted with the insurance plan and have agreed to accept the contracted fee schedule as payment in full.
participating providers
What does QMB stand for
Qualified Medicare Beneficiaries
Many large companies or organizations have enough employees that they can fund their own insurance programs. This is called ______
A self-funded plan
A ______ plan is one that is not offered by an employer or group. This can cover just one person or a family. These policies can be purchased through a health insurance exchange or directly through an insurance company. Premiums are usually higher with these
Individual health insurance
When providers become participating providers, they agree to the insurance plan’s ____ and will not collect more than that amount.
Fee schedule
When setting up a fee schedule, a healthcare provider considers three factors:
Time
Expertise
Services
The _______ is the maximum dollar amount the insurance will pay for a service or procedure.
Allowable charge
There are basically two different models of health insurance today:
Traditional health insurance
Managed care organizations
__________ pay for all or a share of the cost of covered services, regardless of which provider or hospital is used.
________ provide the most flexibility for the patient but are also the costliest option.
Traditional health insurance plans
Benefits are usually paid to the insured, unless that person has authorized payment to be made directly to the provider. This is referred to as the _______.
Assignment of benefits
______ are health insurance companies whose goal is to provide quality, cost effective care to their members.
Managed care organizations (MCOs)
MCOs
Managed care organizations
Many MCOs require the patient to choose a ____ who coordinates the patient’s care. MCOs also require ____ for their patients to be seen by a specialist, thus limiting patient access to more expensive care.
PCP, referral
Models of managed care organizations include:
HMO, PPO, EPO
HMO
Health maintenance organization
Of HMOs, PPO, and EPO, which is the least flexible?
HMOs
Under HMOs, patients are not required to pay a ____ or co-insurance, but are required to select a _______. This plan will not pay for services that are not included in its ______.
Deductible, PCP, provider network
PPO
Preferred provider organization
Under a PPO plan, patients do not need a ____, and they typically have more control over healthcare choices.
If the patient chooses to see a provider not in the PPO network, the patients ____, ____, and ____ will be higher.
Referral, deductible, co-insurance, copayments
