Chapter 2 Flashcards
What type of plan allows an insurer to administer straight indemnity insurance, an HMO, or a PPO insurance plans to its members?
Triple option Plan
A Medicare PT presents after slipping and falling in a neighbor’s walkway. The neighbor has contacted his homeowner’s insurance and they are accepting liability and have initiated a claim. How should the visit be billed?
Bill the homeowner’s first, then Medicare secondary if it is not paid within 120 days
What is a disadvantage of giving care to a PT in a capitated managed care situation?
Having a large population of high-risk PTs
Medicare has 4 parts-which part is responsible for paying hospital claims?
Medicare Part A
Rational:
-Part A: pays Hospital claims
-Part B: pays for outpatient services
-Part C: pays for Commercial Advantage Plans
-Part D: Pays for prescriptions
Health care organization has 2 hospitals, 20 clinics, and 3 urgent care centers that belongs to a ACO program. They have been in the shared savings program for two years and are now eligible to more large payments to a population-based model as they have been successful in keeping costs down and have met all the CMS benchmarks set for them. What type of ACO is this?
Pioneer ACO Model
Rational: Is an ACO that allows for higher level of shared savings payment model the first two years of the program and, in year three, if they have shown a specific level of savings, they will be eligible to move a large portion of their payment model.
-Advanced payment modelACO is for smaller ACOs that allows them ability to participate by offering upfront fixed payments; upfront, variable payments based on the number of historically-assigned beneficiaries; or monthly payments of varying amounts depending on the size of the ACO based on its historically-assigned beneficiaries.
Health SAvings Account (HSA) is what?
Tax-free income
A PT presents for an immunization. When the PT pays his bill, he asks for a receipt so that may turn it in to meet his spenddown. What type of coverage does this PT have?
Medicaid
Rationale: Spenddown program under Medicaid is for people that earn too high an income or have too many assets to qualify for regular Medicaid. A spenddown is similar to a deductible.
Which of the following statements is true regarding the key provisions of coverage under the Affordable Care Act (ACA)?
PTs have the right to appeal a health plan’s decision to deny payment for a claim or termination of health coverage
Rationale: Children under the age of 26 may be eligible to be covered under their parent’s health plan, lifetime limits on most benefits are banned, and there are 22 covered preventative services for women.
What are some of the ways that managed care organizations (MCOs) offer provisions that provide insurers with ways to manage the cost, use, and quality of healthcare services received by a member?
I: Utilization review
IV: Non-emergency weekend admission restrictions
Rationale: Managed care organizations offer managed care provisions that provide insurers with ways to manage costs including: Utilization review, non-emergency weekend admission restrictions, pre-admission certification, pre-admission testing, and second surgical options.
A PT is scheduled in your office for Botox Injections. She has not met her deductible and states that she is going to use money from her Healthcare Reimbursement Account (HRA) to pay for it, is this possible?
No, cosmetic procedures are ineligible
What components make up the Medicare Physician Fee Schedule?
Relative value units for physician work, practice expense, and professional liability insurance; the Geographical Cost Index; and the conversion factor.
Which of the following services is NOT covered under Medicare Part B?
Home Health Services
Which is an insurance plan that provides a gatekeeper to manage the PT’s healthcare?
HMO
Physician-Hospital Organization (PHO), Management Service Organization (MSO) and Integrated Provider Organization (IPO) are examples of what type of healthcare models?
Integrated Delivery System
Rationale: Integrated Delivery Systems are a network of providers and facilities that work together to offer to offer joint healthcare services to its members.
A new PT is seen for a visit with a participating commercial carrier. The contracted fee for this carrier is $153.35. The PT has a 20% co-pay after after a $1000 deductible. Of which $500 has been met. How much will the PT owe?
$153.35
