Final Exam Review (2nd Half) Flashcards
What is a contract between a policy holder and an insurance company to reimburse a percentage of the cost of the covered’s medical expenses?
Medical insurance
What is a policy designed to reimburse the cost of preventative and corrective medical care?
Health insurance
What covers only the cost of athletic accidents (and typically serves as a supplemental insurance after injuries go through primary insurance)?
Athletic accident insurance
What is meant to provide funding for lifelong or severe injuries? Is this usually accompanied by a high or low deductible?
Catastrophic insurance (high deductible)
What is insurance designed to protect against future loss of earning due to disablement or dismemberment?
Disability insurance
What are exclusions?
Situations that are not covered by policy
What are riders?
Additions to a policy to cover things that are not normally covered by the policy
What is your premium?
The cost of your insurance policy (what you pay each month)
What type of procedures will typically not be covered and often be denied?
Experimental therapy
What does UCR stand for? What is it?
Usual, customary, and reasonable; it is a flexible fee system that was started by Medicare…it’s what the insurance company will pay for a particular service based on what the 90% percentile fee for that geographic location
What are the three options an employer has when designing a medical insurance system?
Self-insurance, primary coverage, or secondary coverage
What is self-insurance?
An institution or business determines that they will pay less for medical expenses then they would pay for insurance premiums
What is primary coverage?
A type of health, medical, or accident insurance that beings to pay for covered expenses immediately after a deductible has been paid
What is secondary coverage?
A type of health, medical, or accident insurance that begins to pay for covered expenses only after all other sources of insurance have been exhausted
What is a third-party?
A medical vendor with no binding interest in a particular insurance contract
What constitutes third-party reimbursement?
The process by which medical vendors receive reimbursement from insurance companies for services provided to policyholders
What is another name for a fee-for-service plan?
An indemnity plan
What is a fee-for-service plan?
A type of traditional insurance whereby patients are free to seek medical services from any provider. The plan covers the cost of the covered procedure to their reported level and any cost over this amount is the patient’s responsibility (or secondary insurance’s responsibility)
What are examples of managed-care models?
HMOs, PPOs, EPOs, POSs, Medicare, Medicaid, CHAMPUS, and BWC (worker’s comp)
WHat are HMOs?
Health maintanence org. that requires policy holders to use only approved medical vendors. Their primary physician acts as a gatekeeper to speciality care. The vendor and the insurance have a pre-aproved rate for services
What are PPOs?
Preferred provider organization…they give patients a broader choice of providers as compared to HMOs, and give incentives (aka discounts) to using in-network providers
What are POSs?
Point of service…uses the primmary care physician as the gatekeeper to services, similar to PPOs
True or false:
The patient has to give the medical provider a signed release to be able to give the necessary information to their insurance provider.
True…the insurance company needs to have proof to help issue reimbursement
What is a common cause of driving up health care costs and makes insurance companies cautious of processing claims?
Fraud
What is fraud?
The criminal misrepresentation for the purpose of financial gain (for example, false entering or documenting medical info–date of injury, treatment, ; unfair billing, etc.)
What is used for diagnostic coding for insurance purposes?
ICD-10 codes…International Classification of Diseases. This is a 6 digit code
For an ICD-10-CM code, what does the first number/letter constitute? What about the second number? 3rd? The last 3?
1st= injury type 2nd= site of injury 3rd= more detail about problem 4-6th= diagnosis specific (Ex= M25.561--right knee pain_
What is used for procedural coding?
CPT (current procedural terminology) codes…a 5 digit code with no periods
What does rehabilitation procedural codes begin with?
97
What is defined as the act of formally communicating with an insurance company or other third-party payer to seek payment for services rendered to an injured patient?
Claims processing
What is a summary prepared by the insurance company and sent to the policy holder that documents how the insurance policy covered the charges associated with a claim?
EOB (explanation of benefits)
What is positional power? What does it include as types?
The power vested in people by virtue of the roles they play in an organization…coercive, connection, reward, and legitimate
What is personal power? What does it include as types?
The potential to influence others by virtue of personal characteristics and personality attributes…informmational, referent, and expert
What type of power is key in AT?
Referent
What is counterpower?
The potential to influence the behavior of a superior
What is legitimacy?
The aspect of power that gives the leader right to make a request and provides the obligation of the subordinate/follower to comply
What is the zone of difference?
A hypothetical boundary of legitimacy outside of which requests or orders will be met with mere compliance or refusal
What is a subset of power that involves influencing the behavior and attitudes of others to achieve intended outcomes?
Leadership
What does management involve?
Planning, decision making, and coordinating the activities
What are the five elements of management?
Planning, organizing, command, coordination, and control
What does a disseminator do?
Requires the leader to communicate with members of the group
What is a written expression of an organization’s philosophy, purposes, and characteristics?
A mission statement
What is a concise statement that describes the ideal state to which an organization aspires?
A vision statement
What are the four elements of a vision statement?
Name of service provider, description of services, identification of target clients, and quality declaration
Who uses strategic planning? Who uses operational planning?
Strategic- leaders
Operational- managers
What is the WOTS UP analysis?
Weaknesses, opportunities, threats, and strengths that underline planning…this helps reveal important sources of opportunities and threats for the program
What is a type of plan that expresses an organization’s intended behavior relative to a specific program subfunction?
Policy
What is a collection of incremental and mutually dependent steps designed to direct the most important tasks of an organization?
Processes
What are a type of operational plan that provides specific directions for members of an organization to follow?
Procedures
What are the actions that take place in response to administrative problems?
Practices
What does PERT stand for? What is it?
Program evaluation and review technique…it’s a method of graphically depicting the time line for and interrelationships of different stages of a program
What are Gannt charts?
Takes tasks and maps them on a chart with a time table/calendar
What is the agreement-trust matrix?
A model that identifies and types the most important people in developing support for a plan
Allies (high trust & agreement)
Bedfellows (low trust, high agreement)
Opponents (high trust, low agreement)
Adversaries (low trust & agreement)
Who are allies?
People who exhibit a high level of support for a plan
Who are opponents?
People who support a program but dispute the implementation of a plan related to that program (NOT AN ENEMY)
Who are bedfellows?
People who support a plan but have a history of untrustworthy behavior
Who are adversaries?
People who are unsupportive of both a program and plan related to the program
What are the 7 principles of meetings?
1-Organize the meeting 2-Divide into three parts (announcements, decisions, discussions) 3-Control meeting behavior 4-Avoid new business 5-Avoid reports 6-Look to the future 7-Make high-quality decisions
