Chapter 2: Providers

Question 1

Blue Cross and Blue Shield

Answer 1

• Healthcare organization

- Each subscriber pays a set fee in order to receive services

Question 2

What is a PPO?

Answer 2

Preferred Provider Organization

• Contract with Employers, insurers, or third party organizations to provide services at a reduced fee
• A PPO subscriber can still receive care from a provider out of network but it will cost more

Question 3

Medicare

Answer 3

• Government insurance program
• for ages 65 and older
• Social security provides information and encourages enrollment

Question 4

Medicaid

Answer 4

Title XIX

• To help needy persons regardless of age
• Financed by both state and federal gov.

Question 5

State Workers Compensation Program

Answer 5

• To compensate employees for lost wages and medical expenses due to occupational accidents
• Misconduct is not covered

Question 6

Self-Insurance

Answer 6

• Employer funds and pays for member claims and benefits
• The employers premiums are directed into a trust from which the plans benefits and claims are paid
• Trust are also called 501(c)(9)

Question 7

Partially self-insured plan

Answer 7

An employee may share the risk of covering claims by buying stop-loss insurance coverage from an insurance company

Question 8

MET

Answer 8

Multiple Employer Trusts
- Method of marketing group benefits to employers who have a small number of employees

• Can provide a single type of insurance or a wide range of coverages
• Employer must subscribe to trust first before using METs

Question 9

MEWA

Answer 9

Multiple Employee Welfare Arrangements

• Consists of small employers who have joined to provide health benefits for their employees
• Tax-exempt entities
• Employees must have an employment related common bond

Question 10

Name some types if Health Insuring Corporations

Answer 10

• Physicians
• outpatient hospital and medical
• Urgent care
• Lab services
• Radiological services

Question 11

Prepayment Plan

Answer 11

A Health Insurance Corp. (HIC) Operate in a prepayment basis which then entitles the insured to a wide range of services

Question 12

Managed care

Answer 12

Organized method of providing health care services and involves a third party in the planning, approval and monitoring of a subscriber

Question 13

Gatekeeper Concept

Answer 13

• Requires subscribers to choose a primary care physician from a list

Question 14

Prior Authorization

Answer 14

• Ensure that treatment is medically necessary according to doctor
• Cost control measure

Question 15

Capitation

Answer 15

The amount received by a primary care physician from the health insurance corporation (HIC)

• Based on members per month physician has received

Question 16

Service Area

Answer 16

Geographical are of the state the HIC is licensed to operate

Question 17

Evidence of Coverage

Answer 17

Coverage and services provided and the rights of the subscriber

Question 18

What three cases can an HIC release subscriber information?

Answer 18

• Consent of subscriber is given
• A court order
• Litigation between the enrollee and the HIC

Question 19

Open Enrollment for HICs

Answer 19

• Open enrollment for at least 30 days

Question 20

Cancelation of coverage under these five rules:

Answer 20

1. Fails to pay fixed periodic premiums
2. Engaged in fraud or forgery
3. Engaged in material misrepresentation
4. Engaged in unauthorized use of an ID card
5. Unable to maintain or establish a physician/patient relationship

Question 21

Coverage of Newborn Children

Answer 21

Coverage for 31 days after birth then parent must notify HIC to continue coverage after 31 days

Question 22

Healthcare Maintenance Organization (HMO)

Answer 22

• Group enrollment system
• Prepaid services to take preventative measures in their health
• More costly procedures can be avoided this way

Question 23

Four parts of Medicare

Answer 23

Part A: Pay inpatient hospital care, home health, nursing/hospice (100 days)

Part B: Pays for doctors services and other services not covered by hospital insurance (optional) 80% coverage. Jan 1 to March 31 enrollment perid

Part C: Services offered approved HMOs or PPOs. Must be Enrolled in both A and B

Part D: access to private prescription drug plans

Question 24

HIC

Answer 24

Health Insurance Corporation

• Operates on a reimbursement basis
• Works with primary care physicians
• Medical, dental, feet…. (not outpatient medical)

Question 25

A health care provider claim can be settled with what kind of payment method?

Answer 25

Fee-for-service payment method