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MAA > Chapter 15 > Flashcards

Chapter 15 Flashcards

1
Q

a form of patient care review by healthcare professionals who do not provide the care but are employed by health insurance companies

A

utilization management/ utilization review

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2
Q

Two types of insurance

A

government and private

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3
Q

a designated person who receives funds from an insurance plan

A

beneficiary

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4
Q

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

A

capitation

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5
Q

a formal request for payment from an insurance company for services provided

A

claim

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6
Q

a list of fixed fees for services

A

fee schedule

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7
Q

the primary care provider who is in charge of a patient’s treatment. Additional treatments must be approved by this person

A

gatekeeper

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8
Q

poor, needy, impoverished

A

indigent

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9
Q

a written agreement between two parties in which one agrees to pay the other if certain specified circumstances occur

A

policy

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10
Q

a process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services

A

preauthorization

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11
Q

the amount paid or to be paid by the policy holder for coverage under the contract

A

premium

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12
Q

an approved list of physicians, hospitals and other providers

A

provider network

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13
Q

an order from a PCP for a patient to see a specialist or to get certain medical services

A

referral

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14
Q

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.

A

resource based relative value system (RBRVS)

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15
Q

an organization that processes claims and provides administrative services for another organization. Often used by self-funded plans

A

third-party administrator (TPA)

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16
Q

The person responsible for the payment of the premium is referred to as the _____.

A

subscriber

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17
Q

Cost-sharing includes the following three things:

A

deductible, co-insurance, and copayment

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18
Q

a set dollar amount that the policyholder must pay before the insurance company starts to pay for services.

A

deductible

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19
Q

The higher the deductible, the lower the _______.

A

premium

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20
Q

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?

A

co-insurance

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21
Q

Aset dollar amount that the policy holder must pay for each visit.

A

copayment

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22
Q

_________ services are those that are proper and needed for the diagnosis or treatment of the medical condition.

A

medically necessary

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23
Q

________ are procedures that are not deemed necessary, such as a facelift.

A

elective procedures

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24
Q

Most insurance policies do not cover ____ _____.

A

elective procedures

25
Q

The fee schedule for medicare part B is determined using the RBRVS. This system consists of 3 parts:

A

provider work, charge-based professional liability expenses, charge-based overhead

26
Q

____ is the govt program that provides medical care for the indigent.

A

Medicaid

27
Q

_____ 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)

A

Medicare

28
Q

what would be a covered service of Medicare part A?

A

inpatient hospital care

29
Q

What would be a covered service under medicare part B?

A

outpatient hosptial care, durable medical equipment

30
Q

What is covered under medicare part D?

A

prescription drugs

31
Q

Which part of Medicare REQUIRES a monthly premium?

A

Part B

32
Q

______ is currently the world’s largest insurance program.

A

Medicare

33
Q

Medicare refers to those covered as _____.

A

beneficiaries

34
Q

RBRVS

A

resource-based relative value scale

35
Q

Supplemental health insurance plans are known as ______ policies.

A

Medigap

36
Q

Mandatory medicaid benefits include:

A

family planning services, nurse midwife services, transportation to medical care

37
Q

a comprehensive healthcare program for uniformed service members and retirees and their families.

A

TRICARE

38
Q

a health benefits program that provides coverage for the families of veterans who were permanently disabled or killed in line of duty.

A

CHAMPVA

39
Q

CHAMPVA

A

civilian health and medical program of the veterans administration

40
Q

________ are contracted with the insurance plan and have agreed to accept the contracted fee schedule as payment in full.

A

participating providers

41
Q

What does QMB stand for

A

Qualified Medicare Beneficiaries

42
Q

Many large companies or organizations have enough employees that they can fund their own insurance programs. This is called ______

A

A self-funded plan

43
Q

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

A

Individual health insurance

44
Q

When providers become participating providers, they agree to the insurance plan’s ____ and will not collect more than that amount.

A

Fee schedule

45
Q

When setting up a fee schedule, a healthcare provider considers three factors:

A

Time
Expertise
Services

46
Q

The _______ is the maximum dollar amount the insurance will pay for a service or procedure.

A

Allowable charge

47
Q

There are basically two different models of health insurance today:

A

Traditional health insurance
Managed care organizations

48
Q

__________ 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.

A

Traditional health insurance plans

49
Q

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 _______.

A

Assignment of benefits

50
Q

______ are health insurance companies whose goal is to provide quality, cost effective care to their members.

A

Managed care organizations (MCOs)

51
Q

MCOs

A

Managed care organizations

52
Q

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.

A

PCP, referral

53
Q

Models of managed care organizations include:

A

HMO, PPO, EPO

54
Q

HMO

A

Health maintenance organization

55
Q

Of HMOs, PPO, and EPO, which is the least flexible?

A

HMOs

56
Q

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 ______.

A

Deductible, PCP, provider network

57
Q

PPO

A

Preferred provider organization

58
Q

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.

A

Referral, deductible, co-insurance, copayments

MAA (23 decks)

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