Chp 13

Question 1

group of physicians, hospitals, and other providers who have joined together to provide coordinated care to their patients.

Answer 1

Accountable care organizations
(ACO)

Question 2

provides uninsured Americans with affordable health coverage. This law gave new rights, benefits, and protections regarding health insurance to all Americans. Some of the important features of the law include coverage for required preventative and wellness services.

Answer 2

Affordable Care Act
(ACA)

Question 3

transfer of the patient’s legal right to collect third-party benefits for medical expenses to the provider of the services.

Answer 3

Assignment of benefits

Question 4

billing the patient for the balance or difference between the physician’s charges and the Medicare-approved charges; prohibited by most managed care contracts.

Answer 4

Balance billing

Question 5

commonly used by benefit plans and claims administratiors to coordinate the benefits of dependent children covered byh two plans.

p.313

Answer 5

Birthday rule

Question 6

managed care plan that pays a certain amount to a provider over a specific time for caring for the patients in the plan regardless of what or how many services are performed.

Answer 6

Capitation

Question 7

a company that assumes the risk of an insurance company.

Answer 7

Carrier

Question 8

requests to an insurance company for reimbursement of costs.

Answer 8

Claims

Question 9

an individual who manages the thir-party reimbursement policies for a medical practice.

Answer 9

Claims administrator

Question 10

the agreed-upon amount paid to the provider by a policyholder, also called “copayment.”

Answer 10

Coinsurance

Question 11

the method of designating the order in which multiple carriers pay benefits to avoid duplication of payment.

Answer 11

Coordination of benefits

Question 12

that part of an insured service the patient must pay (copay).

Answer 12

Copayments

Question 13

claim that crosses over automatically from one coverage to another for payment.

Answer 13

Crossover claim

Question 14

a specific amount paid by the policyholder before the carrier begins paying.

Answer 14

Deductible

Question 15

spouse, children, and sometimes other individuals designated by the insured who are covered under a health care plan.

Answer 15

Dependent

Question 16

categories used to determine hospital and physician reimbursement for Medicare patients’ inpatient services.

Answer 16

Diagnosis-related groups
(DRGs)

Question 17

the determination of an insured’s right to receive benefits from a third-party payer based on such criteria as payment of premiums and date of start of coverage.

Answer 17

Eligibility

Question 18

a person hired to perform given duties in return for financial compensation.

Answer 18

Employee

Question 19

a statement that accompanies a payment from an insurance carrier and outlines which duties and services are being paid.

Answer 19

Explanation of Benefits
(EOB)

Question 20

an established set of fees charged for specfic services and paid by the patient or insurance carrier.

Answer 20

Fee-for-service

Question 21

a list of pre-established fee allowances set for specific sercvices and procedures performed by a provider.

Answer 21

Fee schedule

Question 22

a policyholder who is a member of a group and covered by the group’s insurance carrier.

Answer 22

Group member

Question 23

a benefit offered by some employers that allows employees to save money through payroll deduction to accouts that can only be used for medical care.

Answer 23

Health care savings account
(HSA)

Question 24

a policy that promises to pay some or all of a customer’s medical bills.

Answer 24

Health insurance

Question 25

several independently practicing physicians contracted with HMO to provide services to HMO members.

Answer 25

Independent practice association
(IPA)

Question 26

an individual who owns a policy that promises to pay some or all of his or her medical bills.

Answer 26

Insured

Question 27

the practice of third party payers to control costs by requiring physicians to adhere to specific rules as a condition of payment.

Answer 27

Managed care

Question 28

social security-established health insurance for low-income or indigent persons of all ages.

Answer 28

Medicaid

Question 29

social security - established health insurance for older adults.

Answer 29

Medicare

Question 30

the 10-digit identification number assigned to all health care providers as part of the HIPAA Administration Simplification Standard.

Answer 30

National Provider Identifier
(NPI)

Question 31

payment for health care services that are the responsibility of the patient or guarantor.

Answer 31

Out-of-pocket

Question 32

a model of health care delivery in which the PCP coordinates the care for patients and refers patients to other providers for medical care as needed.

Answer 32

Patient-Centered Medical Homes
(PCMH)

Question 33

organization of a group of physicians and specialists that conducts a review of a disputed case and makes a final recommendation.

Answer 33

Peer review organization

Question 34

a coalition of physicians and a hospital contracting with large employers, insurance carriers, and other benefits groups to provide discounted health services.

Answer 34

Physician hospital organization
(PHO)

Question 35

the highest amount paid by a third-party payer for any given service.

Answer 35

Plan maximum

Question 36

a medical condition that existed before an individual’s health insurance policy became effecdtive.

Answer 36

Preexisting condition

Question 37

an organization whose purpose is to contract with providers and then lease this network of contracted providers to health care plans.

Answer 37

Preferred provider organization
(PPO)

Question 38

a notice from the Medicare Administrative Contractor showing payments and adjustments made on Medicare claims with explanations for reimbursement decisions. RAs submitted electronically are known as ERAs.

Answer 38

Remittance advice
(RA)

Question 39

a value scaled designed to decrease Medicare Part B costs and establish national standards for coding and payment.

Answer 39

Resource-based relatvie value scale
(RBRVS)

Question 40

administrator who processes claims for the sponsor of self-funded benefit planning.

Answer 40

Third-party administrator
(TPA)

Question 41

the basis of a physician’s fee schedule, the usual and customary cost of the same service or procedure in a similar geographic area and under the same or similar circumstances.

Answer 41

Usual, customary, and reasonable
(UCR)

Question 42

an analysis of individual cases by a committee to make sure services and procedures are being billed to a third-party payer, are medically necessary, and to ensure compliance with its rules and regulations regarding reimbursement.

Answer 42

Utilization review
(UR)

Question 43

approved documentation prior to referrals to specialists and other facilities.

Answer 43

Precertification