FINANCIAL MANAGEMENT

Question 1

traditional indemnity insurance policies

Answer 1

coverage on a fee-for-service basis, in this method of reimbursement, the insurer pays the provider a fee based on the cost of service

Question 2

employer-sponsored plans

Answer 2

offer group coverage, while individuals who buy insurance on their own receive individual coverage (which may extend to family members as well). The patient is usually responsibe for paying a deductible and a coinsurance amount.

Question 3

basic insurance

Answer 3

covers a specific dollar amount for physicians’ fees, hospital care, surgery, and anesthesia

Question 4

major medical insurance

Answer 4

covers some of the costs of catastrophic expenses from illness or injury

Question 5

traditional insurance

Answer 5

Blue Cross/Blue Shield indemnity policies

Question 6

Blue Cross

Answer 6

covers hospitalization, radiology, and other basic coverage under the health plan

Question 7

Blue Shield

Answer 7

covers the major medical portion and physician fees

Question 8

capitated plan

Answer 8

a managed care group makes a fixed per capita payment periodically to a medical service provider (such as a physician) in return for medical care provided to enrolled individuals

Question 9

MCO

Answer 9

managed care organizations

Question 10

managed care system

Answer 10

the insurers require that policyholders seek medical attention only from preferred providers

Question 11

preferred providers

Answer 11

physicians and other health care professions who contract with the insurance carrier to provide patient care at a discounted rate

Question 12

HMO

Answer 12

health maintenance organizations

Question 13

6 primary MCO models

Answer 13

1. integrated delivery systems
2. health maintenance organizations
3. exclusive provider organizations
4. preferred provider organizations
5. physician-hospital organization
6. utilization review organizations

Question 14

integrated delivery systems

Answer 14

groups of affiliated provider sites that operate under single ownership to offer full and/or specialty services to the subscribers

Question 15

HMO’s

Answer 15

health maintenance organization

cover large groups of people for a monthly premium and a small copayment from the patient each time of service

Question 16

closed-panel HMO

Answer 16

when the HMO employs the physicians

Question 17

open-panel HMO

Answer 17

establish a network of preferred providers who agree to a capitated contract fee schedule

Question 18

EPO

Answer 18

exclusive provider organization

plan delivers in-network-only benefits through the national Blue Card PPO network

Question 19

PPO

Answer 19

preferred provider organization

a network of physicians and hospitals that have contacted together with insurance companies to provide health care at a discounted fee

Question 20

PHO

Answer 20

physician-hospital organization

a hospital and selected physicians may form a business arrangement

Question 21

utilization review organizations

Answer 21

also known as third-party administrators, that supervise funds set aside to cover medical expenses to employees under self-insured plans

Question 22

Medicare program

Answer 22

the federal government funds the health insurance coverage for the aged and disabled in the United States and was initiated by an act of Congress in 1965

Question 23

CMS

Answer 23

Centers for Medicare and Medicaid Services

Question 24

Medicare coverage Part A

Answer 24

covers hospital care, skilled nursing home care, and home health care

Question 25

Medicare coverage Part B

Answer 25

covers outpatient care, physician services, certain home health services, durable medical equipment, and some health services not covered under Part A

Question 26

AGI

Answer 26

adjusted gross income

Question 27

UCR

Answer 27

usual, customary, and reasonable

Question 28

“usual”

Answer 28

refers to the fee that the specific physician charges most of his patients for the same treatment

Question 29

“customary”

Answer 29

based on the average charge for a specific procedure by all the physicians practicing the same specialty in a specific geographical location

Question 30

“reasonable”

Answer 30

refers to the midrange of fees charged for this type of procedure or visit

Question 31

Medicaid program

Answer 31

another form of government-funded health insurance for people who are unable to work due to illness or life circumstances, that is funded by both the federal and state government. Eligibility for coverage is based on income, employment status, and state-specific requirements

Question 32

TRICARE

Answer 32

covers dependents of active-duty personnel, retired personnel, and dependents of personnel who died on active duty

Question 33

CHAMPVA

Answer 33

The Civilian Health and Medical Program of the Department of Vertans Affairs

covers spouses and unmarried dependent children of verans with permanent total disabilities from service-related injuries and the surviving spouses and children of veterans who died of service-related disabilities.

Question 34

catchment

Answer 34

military dependents are eligible to receive care within a 40-mile radius from a military base

Question 35

workers’ compensation

Answer 35

when an on-the-job accident or illness results in injury and/or disability, workers’ compensation insurance pays the medical bills and a significant portion of the lost wages if the patient was covered by a workers’ compensation policy

Question 36

self-insured plans

Answer 36

special accounts are established and rather than paying premiums to an insurance carrier, the entity makes payments into the plan

Question 37

RVUs

Answer 37

relative value units

identify a range of charges for varying degrees of common office procedures and activities

Question 38

RBRVs

Answer 38

resource based relative value scale

these scales help rank a variety of laboratory tests and medical products relative to the intensity of labor and goods used to produce them

Question 39

DRGs

Answer 39

diagnostic-related groups

in this system, the government, under the Medicare program, pays a flat fee to the hospital based on a patient’s diagnosis, age, and presence of comorbidities. Payment is then made to the hospital, regardless of the actual costs incurred in the episode of illness

Question 40

bookkeeping

Answer 40

the actual daily recording of the accounts or transactions of the business

Question 41

accounts receivable

Answer 41

the money owed to the office by third-party payers or patients

Question 42

accounts payable

Answer 42

amounts of money due for goods and services provided to the practice office

(ex. payroll, rent, utilities, housekeeping)

Question 43

adjustments

Answer 43

entries made to change the patient’s balance, but they do not represent charges or payments

Question 44

The Truth-in-Lending Act (Consumer Credit Protection Act of 1968)

Answer 44

was established to protect consumers by requiring that providers of installment credit state the charges clearly in writing and express the interest as an annual rate

Question 45

monthly billing

Answer 45

all accounts are billed at the same time each month

Question 46

cycle billing

Answer 46

all accounts are divided alphabetically into groups, with each group billed at a different time

Question 47

coding

Answer 47

the process of converting descriptions of diseases, injuries, and procedures into numerical designations

Question 48

CPT

Answer 48

Current Procedural Terminology

Question 49

AMA

Answer 49

American Medical Association

Question 50

WHO

Answer 50

World Health Organization

Question 51

episode of care

Answer 51

care for a certain condition or care over a specified time period

Question 52

The Affordable Care Act

Answer 52

designed to reform the health care system by providing affordable insurance coverage and access to quality health care for all Americans while curbing or controlling the cost of health care spending; designed to eliminate discrimination in delivering services and charging for those services