Exam 3: Health Care Information

Question 1

complementary medicine

Answer 1

practices and products of non-mainstream origin

Question 2

integrative health

Answer 2

incorporate complementary approaches into the mainstream health care

Question 3

alternative medicine

Answer 3

using a non-mainstream approach in place of conventional medicine

Question 4

premium

Answer 4

what you pay monthly for insurance

Question 5

Co-pay

Answer 5

what you have to pay each time you visit a health care provider’s office or fill a prescription

Question 6

Deductible

Answer 6

The amount you have to pay before insurance begins to cover costs

Question 7

co-insurance

Answer 7

the percentage you have to pay once the deductible has been met

Question 8

maximum amount out-of pocket costs

Answer 8

after you reach this level, any additional health care for this calendar year is free

Question 9

Three key aspects of insurance reimbursement

Answer 9

1) Coverage - the service covered by the insurance plan 2) reimbursement amount - how much will the insurance pay for it 3) Documentation/coding - Has the appropriate documentation and coding been completed?

Question 10

What drives the services that insurance companies will pay for?

Answer 10

Medicare: services that medicare pays for or reimburses is modeled off of medicare.

Question 11

Diagnosis-related groups

Answer 11

(simply pricing and reimbursement) Groups of patients with the same diagnosis have common demographic, diagnostic and therapeutic attributes that determine their resource needs
Sets a rate that Medicare will reimburse
Any additional expense is paid by the hospital
Example-appendectomy-$5500-18,000

Question 12

CPT codes

Answer 12

Current Procedural Terminology 1) Established by the Centers for Medicare and Medicaid services 2) Identify medical care interventions 3) Specific for health profession 4) If there isn’t a code you can’t ask for insurance reimbursement

Question 13

ICD-10 Codes

Answer 13

International Statistical Classification of Diseases and Related Health Problems

1) Medical classification list
2) Contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease

Question 14

CPT vs ICD-10

Answer 14

CPT - identifies “what you did” ICD -10 “ The diagnosis that identifies why you did what you did”

Question 15

NPI

Answer 15

National Provider identifier : Identifies health care providers in the U.S used by the CMS

Question 16

EIN

Answer 16

Employer identification number: used by employers for the purpose of paying taxes.

Question 17

Superbill

Answer 17

receipt to submit to insurance companies; CMS 1500 claim form most commonly used superbill

Question 18

Medicare

Answer 18

People over the age of 65; under the age of 65 with disabilities, and at any age for individuals with end-stage renal disease

Question 19

FICA

Answer 19

Federal Insurance Contribution Act; Employer and employee contribute equally (self-employed have to pay for both)

Question 20

Medicare Part A

Answer 20

Hospital insurance ; 1) Inpatient care hospital or rehabilitation 2) Skilled nursing facility (maximum of 100 days coverage) 3) Hospice Care 4) Home Health 5) Premium Free

Question 21

Medicare Part B

Answer 21

Medical; 1) Premium paid each month directly to insurance company 2) Doctors’ Services 3) Preventive Services 4) Outpatient Hospital Visits 5) Emergency Room Visits 6) Durable Medical Equipment
7) Other services and supplies

Question 22

Medicare Part D

Answer 22

Prescription; Prescription drugs only, Brand drugs and generic, No over-the-counter drugs

Question 23

Medicaid

Answer 23

Income based, health care payed for by state and federal government, covers more than 60% of all long-term care residents

Question 24

Identify the accreditation sought by the majority of hospitals and health care facilities in the U.S. What is the main goal of this accrediting body

Answer 24

1) The joint commission 2) goal is to ensure that people get the safest, high quality, best-value health care across all hospitals

Question 25

Primary Care

Answer 25

First point of consultation (Family practitioners)

Question 26

Secondary health

Answer 26

Curative, not preventative (medical specialists)

Question 27

Tertiary

Answer 27

Highly specialized; 1) Personnel and facilities for advanced medical investigation and treatment
ex: intensive care unit, burn unit, bone marrow transplant

Question 28

Quaternary care

Answer 28

highly specialized and not widely available; Research, experimental medicine, and some types of uncommon diagnostic or surgical procedures

Question 29

Levels of Trauma Care

Answer 29

Basic (Level: IV) ; Level I ( comprehensive trauma)

Question 30

restorative care

Answer 30

1) Brain injury, spinal cord injury, stroke, orthopedic, or neurological illnesses/injuries 2)Reach as high a functional level as possible

Question 31

Not-for-profit hospitals

Answer 31

view as charities by IRS do not pay federal income, state or property taxes, tend to provide more uncompensated care