Chapter 2 - Review Flashcards
What is the largest health program in the United States?
Blue Cross/Blue Shield
Medicare
Medicaid
Tricare
Medicare
Which of the following services is not covered under Medicare Part B?
Cardiovascular disease screening
Diabetes self management
Nutrition therapy services
Home health services
Home health services
Health Savings Account (HSA) is _ to employees?
Tax free income
Taxed income
A monthly contribution only made by employers
Only for medical coverage
Tax free income
Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient and are reimbursed by _
Capitation
Fee-for-service
Reimbursement account
Patient payments
Capitation
A Medicare patient 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 homeowners insurance only - Medicare will not pay anything
-Bill Medicare then homeowners insurance as secondary
-File to both at the same time and see which pays more
-Bill the homeowners insurance first then Medicare secondary if it is not paid within 120 days
Bill the homeowners first, then Medicare secondary if it is not paid within 120 days
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?
Utilization review
Coverage restrictions
Arbitration
Non emergency weekend admission restrictions
Utilization review & Non emergency weekend admission restrictions
A 2019 Medicare deductible and co insurance amount for outpatient services on Part B is _
-$185 per calendar year and 20% of the approved amount
-$185 per calendar year and 20% of the billed amount
-$185 per hospitalization and 20% of the approved amount
-$185 per calendar year
$185 per calendar year and 20% of the approved amount
A group contracts with a third party administrator to manage paperwork. This group pays for the operation of the insurance plan and the costs of administration. What type of plan does this represent?
Fully insured employer group
Self funded ERISA
Association Group
Management Service Organization
Self funded ERISA
Which of the following statements is true regarding the key provisions of coverage under the Affordable Care Act?
-Children under 21 may be eligible to be covered under their parents plan if they are in college
-There are 30 covered preventive services for women
-Patients have the right to appeal a health plans decision to deny payment for a claim or termination of health coverage
-Lifetime limits are not banned on any health plans issued
Patients have the right to appeal a health plans decision to deny payment for a claim or termination of health coverage
Which type of HMO contracts with multiple specialty groups, individual practice groups, and individual physicians?
Group model HMO
Mixed model HMO
Network model HMO
Hybrid Model HMO
Network model HMO
A new physician comes into the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans?
Credentialing
Privileging
Contract negotiations
Board certification
Credentialing
A patient needs to see a specialist for a cardiac condition. She references her insurance handbook for a list of network providers that belong to that specialty. She may choose any physician she wishes and does not need a referral from her internist to see the specialist. If she chooses an out-of-network physician, she will have to pay a higher co-insurance amount to see them. What type of insurance does this patient have?
HMO
PPO
Medicare
Medicaid
PPO
NPI is an abbreviation for a unique number that is required by HIPAA. What does NPI stand for?
National Physician Identifier
National Provider Insurance
National Provider Identifier
National Participating Identifier
National Provider Identifier
Medicaid plans provide for low income families. Which statement regarding Medicaid is not correct?
-CMS reviews all state plans to make sure they offer federal regulations
-Individual states establish their own rates based on the multiple criteria
-All Medicaid plans offer HMO options
-States have the option to charge copays and deductibles
All Medicaid plans offer HMO options
Which Medicaid services are eligible for reimbursement for an individual that is not a citizen or does not have eligible immigration status?
No services are covered
All services are covered
Emergency services
Outpatient services only
Emergency services
A patient presents for an immunization. When the patient pays his bill, he asks for a receipt so that he may turn it in to meet his spend down. What type of coverage does this patient have?
Medicare
Commercial insurance
Medicaid
Tricare
Medicaid
Dr Williams is enrolled in a capitation plan. For his list of covered lives, he received a check for $100,000. During the year, the cost of treating the covered lives was $125,000. Which statement below is true?
-Dr Williams will receive payment for the overage cost of $25,000 from the insurance carrier
-Dr Williams has a loss of $25,000 on the capitated contract of the year
-Dr Williams can file claims for all services provided under the capitated plans and will be paid fee for service because his cost was more than the contracted payment
-Dr Williams will be reimbursed an additional $125,000 for his services
Dr Williams has a loss of $25,000 on the capitated contract for the year
A Medicare patient is seen in the Internist’s office for a check up. The office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10% above the Medicare fee schedule amount. What type of Medicare provider is this physician?
Non-limiting
Opt-out
Participating
Non-participating
Non-participating
