chapter 8

Question 1

third-party payer

Answer 1

private or government organization that insures or pays for health care on behalf of beneficiaries

Question 2

preferred provider organization (PPO)

Answer 2

managed care network of health care providers who agree to perform services for plan members at discount fees

Question 3

Health maintenance organization (HMO)

Answer 3

health care system in witch providers offer health care to members for fixed periodic payments.

Question 4

Primary care physician (PCP)

Answer 4

physician in a managed care organization who directs all aspects of a patients care

Question 5

point-of-service (POS) plan

Answer 5

managed care plan that permits patients care plan that permits patients to receive medical services from nonnetowrk providers

Question 6

consumer-driven (directed) health plans (CDHP)

Answer 6

medical insurance that a high- deductible health plan with one or more tax- preferred savings accounts that the patients

Question 7

High- deductible health plan (HDHP)

Answer 7

health plan that combines high- deductible insurance and a funding option to pay for patients out-of-pocket expenses up to the deductible

Question 8

Health reimbursement account (HRA)

Answer 8

consumer-driven health plan funding option where an employer sets aside an annual amount for health care costs

Question 9

Health saving accounts (HSA)

Answer 9

consumer- driven health plan funding option under which funds are set aside to pay for certain health care cost

Question 10

Flexible saving account (FSA)

Answer 10

consumer-driven health plan funding option that has employer that has employer and employee and employee contributions

Question 11

Group health plan (GHP)

Answer 11

plan of an employer or employee organization to provide health care to employees, former employees, and/ or their families

Question 12

federal employees health benefits (FEHB)

Answer 12

Health care program that covers federal employees

Question 13

Self- insured health plans

Answer 13

health insurance plans paid for directly by the organization, which sets up a funds which to pay

Question 14

self-insured health plans

Answer 14

a law providing incentives and protection for copies with employee health and pension plans

Question 15

Individual health plans (IHP)

Answer 15

medical insurance plan purchased by an individual

Question 16

Blue cross and blue shield association (BCBS)

Answer 16

licensing agency of blue cross and blue shield plans

Question 17

medicare

Answer 17

federal health insurance program for people sixty-five or older and some people with disabilities

Question 18

medicare part A hospital insurance (HI)

Answer 18

program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care

Question 19

Medicare Part B, supplementary medical insurance (SMI)

Answer 19

program that pays for physician services, outpatients, hospital services, durable medical equipment, and other services and supplies

Question 20

original medicare plans

Answer 20

medicare fee-for-service plan

Question 21

Medigap

Answer 21

plan offered by a private insurance carrier to supplement insurance carrier to supplement medicare coverage

Question 22

medicare part C, medicare advantage

Answer 22

managed care health plans under the medicare program

Question 23

Medicare Part D

Answer 23

Medicare prescription drug reimbursement plans

Question 24

Medicaid

Answer 24

federal and state assistance program that pays for health care services for people who cannot afford them

Question 25

Medi-Medi beneficiary

Answer 25

person eligible for both medicare and medicaid

Question 26

Dual-eligible

Answer 26

medicare- medicaid beneficiary

Question 27

TRICARE

Answer 27

government health program serving dependents of active- duty service members, military retirees and their family some former spouses and survivors of deceased military members

Question 28

Civilian health and medical program of the department of veterans affairs (CHAMPVA)

Answer 28

Health care plans for families of veterans with 100 percent service- related disability and the surviving spouse and children of veterans who die from service related disabillityl

Question 29

Workers compensation insurance

Answer 29

states of federal plan that covers medical care and other benefits for employees when suffer accidental injury or become ill as a result of employment

Question 30

disability compensation programs

Answer 30

programs that provide partial reimbursement for lost income when a disability prevents an individual from working

Question 31

fee schedule

Answer 31

document that specifies the amount the provider bills for services

Question 32

usual fees

Answer 32

normal fees charged by a perovider

Question 33

usual, customary and reasonable (UCR)

Answer 33

fees set by comparing usual fees, customary fees and reasonable fees

Question 34

relative value scale (RVS)

Answer 34

system of assigning unit values to medical services based on their required skill and time

Question 35

resource- base relative value scale (RBRVS)

Answer 35

relative value scale for establishing medicare charges

Question 36

Medicare physician fee schedule (MPFS)

Answer 36

RBRVS0 based allowed fees that are the basis for medicare reimbursements

Question 37

Allowed charge

Answer 37

Maximum charged a plans pays for services or procedure

Question 38

Balance billing

Answer 38

collecting the difference between a providers usual fee and a payers lower allowed charged

Question 39

write off

Answer 39

to deduct an amount from a patients account

Question 40

Discounted fee-for- services

Answer 40

payment schedule for services based on a reduced percentage of usual charged

Question 41

Capitation (CAP) rate

Answer 41

periodic prepayment to a provider for specified services to each plan member