Chapters 1-4

Question 0

POS

Answer 0

Point of Service:

Question 1

PPO

Answer 1

Preferred Provider Organization: members can choose their own doctors and facilities.

Question 2

Subscriber

Answer 2

person who prepays the fee for insurance coverage.

Question 3

What are the two type of insurance contracts?

Answer 3

Service Benefit Contracts
and
Indemnity Benefit Contracts

Question 4

Plans that have participating physicians.

Answer 4

Service Benefit Contracts

Question 5

An insurance contract that covers the actual expenses for providing a service. This type of contract sometimes allows the physician to bill the subscriber for any amount not covered by the insurance company.

Answer 5

Indemnity Benefit Contract

Question 6

What are the three level of payments for participating physicians?

Answer 6

1. Usual, customary and reasonable
2. Customary maximum
3. Fixed Fee Schedule

Question 7

The amount a physician would normally charge the majority of patients, the fee most physicians in the geographic area charge, and the amount determined to be appropriate for the service or procedure.

Answer 7

Usual, customary and reasonable

Question 8

The fee charged by most physicians in the community.

Answer 8

Customary maximum

Question 9

the maximum fee allowed by the insurance company for a specific medical service or procedure.

Answer 9

Fixed Fee Schedule

Question 10

EOB

Answer 10

Explanation of Benefits

Question 11

The prepaid health plan in which individuals receive medical services from participating physicians.

Answer 11

Health Maintenance Organization (HMO)

Question 12

A health care plan that allows members to choose their own doctors and treatment facilities, but benefit from choosing a participating physician in this plan and also receive less benefits from nonparticipating physicians.

Answer 12

Preferred Provider Organization (PPO)

Question 13

A health care plan that consists of participating physicians and hospitals who offer discounted healthcare for plan participants. At non participating facilities, the patients benefits are decreased.

Answer 13

Point of Service Plans (POS)

Question 14

The amount at which the co-payment drops.

Answer 14

threshold limit

Question 15

A health care plan physicians own to negotiate individual contracts with employers, insurance companies and other entities in order to provide healthcare coverage.

Answer 15

Physician Provider Groups (PPGs)

Question 16

A bill in 2003 allowing a way for individuals to make yearly contributions to an account toward medical expenses on a tax-free basis.

Answer 16

Health Savings Account (HSA)

p. 4-11 gives other restrictions on who can have an HSA

Question 17

A plan requiring a deductible of $1,200 for an individual or $2,400 for a family in order to set up a HSA.

Answer 17

High Deductible Health Plan (HDHP)

Question 18

The approval of the managed care provider for certain procedures.

Answer 18

Preauthorization

Question 19

Consists of physicians who evaluate the physicians in managed care situations to make sure their patients are receiving proper care.

Answer 19

Peer Review Organization
aka
Professional Review Organizations

Question 20

This program safeguards against unnecessary and inappropriate medical care.

Answer 20

Utilization Review Program

Question 21

A participating physicians reimbursement is based on how many patients the physician sees rather than which services the physician performs.

Answer 21

Capitation

Question 22

The limitation on the number of visits to specialists a patient may make or the number of special treatments, such as physical therapy.

Answer 22

Visitation Limits

Question 23

A card that contains vital information for each managed care program used by patients of the doctors you work with. Information should include your contact, co-payment info, preauthorization requirements and a list of participating facilities.

Answer 23

Managed Care Quick Reference Card