Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Healthcare Ecosystems - D391 > health careiinsuarance and reimbursment > Flashcards

health careiinsuarance and reimbursment Flashcards

1
Q

What is the primary purpose of healthcare insurance?

A

To provide financial protection against high medical costs.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

True or False: All healthcare insurance plans cover the same services.

A

False

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Fill in the blank: The process of determining the amount of money an insurance company will pay for a claim is called _____.

A

reimbursement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is a premium in healthcare insurance?

A

The amount paid for an insurance policy, typically on a monthly basis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What does a deductible refer to in healthcare insurance?

A

The amount a policyholder must pay out-of-pocket before insurance coverage begins.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are copayments?

A

Fixed amounts paid by the insured for specific services at the time of care.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the difference between in-network and out-of-network providers?

A

In-network providers have agreements with the insurance company, while out-of-network providers do not.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is a health maintenance organization (HMO)?

A

A type of health insurance plan that requires members to use a network of doctors and hospitals.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

True or False: PPO stands for Preferred Provider Organization.

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the significance of prior authorization in healthcare insurance?

A

It is required approval from the insurance company before a service is provided to ensure coverage.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What does the term ‘out-of-pocket maximum’ refer to?

A

The maximum amount a policyholder has to pay for covered services in a policy period.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Fill in the blank: The Affordable Care Act aimed to increase ____ in healthcare insurance.

A

access

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What does ‘coordination of benefits’ mean?

A

The process of determining the order in which multiple insurance policies will pay for a claim.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is a formulary in the context of healthcare insurance?

A

A list of medications that are covered by a particular insurance plan.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

True or False: Medicare is a federal program that provides health coverage primarily for individuals over 65.

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is Medicaid?

A

A state and federal program that provides health coverage for low-income individuals and families.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the role of a claims adjuster?

A

To investigate and evaluate insurance claims to determine the insurer’s liability.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What does ‘network’ refer to in healthcare insurance?

A

A group of healthcare providers that have contracted with an insurance company.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Fill in the blank: The term ____ refers to the percentage of costs the insured pays after the deductible has been met.

A

coinsurance

20
Q

What is a waiting period in healthcare insurance?

A

The time period during which coverage is not available after enrollment.

21
Q

True or False: Preventive services are typically covered at no cost under many insurance plans.

A

True

22
Q

What is a balance bill?

A

A bill sent to the patient for the difference between what the provider charges and what the insurance pays.

23
Q

What does ‘medical necessity’ mean?

A

Services or treatments that are appropriate and necessary for a patient’s condition.

24
Q

What is the purpose of an Explanation of Benefits (EOB)?

A

To provide details about what services were billed, what the insurance paid, and what the patient owes.

25
Q

What is ‘risk management’ in healthcare?

A

The process of identifying, assessing, and minimizing risks in healthcare delivery.

26
Q

Fill in the blank: The term ____ refers to the portion of healthcare costs that the insured is responsible for paying.

A

cost-sharing

27
Q

What is a health savings account (HSA)?

A

A tax-advantaged account that allows individuals to save money for medical expenses.

28
Q

What are essential health benefits?

A

A set of health care service categories that must be covered by certain plans under the Affordable Care Act.

29
Q

True or False: High-deductible health plans (HDHPs) typically have lower premiums.

A

True

30
Q

What is the purpose of a provider network?

A

To negotiate rates with healthcare providers and control costs for insurance companies.

31
Q

What does the term ‘underwriting’ refer to in health insurance?

A

The process of evaluating risk and determining the terms of coverage.

32
Q

What is a catastrophic health insurance plan?

A

A plan designed to provide coverage for worst-case scenarios with low premiums and high deductibles.

33
Q

What is a pre-existing condition?

A

A health issue that existed prior to obtaining health insurance coverage.

34
Q

Fill in the blank: The term ‘self-insured’ refers to an organization that assumes the financial risk for providing health care benefits to its employees instead of purchasing _____.

A

insurance

35
Q

What is the role of the insurance commissioner?

A

To regulate insurance companies and protect consumers in a specific state.

36
Q

True or False: All insurance plans are required to cover preventive services without cost-sharing.

A

True

37
Q

What does ‘out-of-pocket’ mean in healthcare insurance?

A

Expenses for medical care that are not reimbursed by insurance.

38
Q

What is the purpose of a referral in managed care?

A

To obtain approval from a primary care provider before seeing a specialist.

39
Q

What is the difference between a copayment and coinsurance?

A

A copayment is a fixed amount, while coinsurance is a percentage of the total cost.

40
Q

Fill in the blank: The process of appealing an insurance claim denial is known as _____.

A

claims appeal

41
Q

What is a risk pool in health insurance?

A

A group of individuals whose health care costs are combined to calculate premiums.

42
Q

What is the significance of the Affordable Care Act?

A

It expanded access to health insurance and implemented protections for consumers.

43
Q

True or False: Insurance companies can deny coverage based on gender.

A

False

44
Q

What is the role of the Centers for Medicare & Medicaid Services (CMS)?

A

To oversee the Medicare and Medicaid programs and ensure compliance with federal regulations.

45
Q

What does ‘medically necessary’ mean?

A

Services or treatments deemed appropriate for a patient’s diagnosis and condition.

46
Q

Fill in the blank: The term ‘underinsurance’ refers to having health insurance that does not provide adequate _____.

A

coverage

Healthcare Ecosystems - D391 (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions