Health Insurance Providers - Chapter points Flashcards
What is health insurance that may be written by a number of commercial insurers also known as?
Traditional Insurers
The design or structure of a policy and its provisions can have an impact on an insurer’s_______ ________ efforts.
Cost containment
Medical cost management is also know as ______ ________, _________ _______, _______ _______, and ______ _____.
Case Management, managed care, claims control, and cost containment.
Case management is sometimes referred to as?
Utilization Review
A _______ _______ involves analyzing a case before admission to determine what type of treatment is necessary and appropriate.
Prospective review
A ___________ __________ involves the monitoring of a hospital stay by a nurse while a patient is in the hospital to determine when they will be released, if they require home health care or if a transfer to another facility such as a hospice center or extended care facility is warranted.
Concurrent View
____ ______ involves an analysis of care after the fact to determine if it was necessary and appropriate.
Retrospective review
Concurrent review is sometimes called?
utilization review
_______ ______ or _______ _______ is part of a managed care program in which health care is reviewed as it is being provided.
Concurrent review or utilization review
All care is coordinated by the insured’s______ ______ _______.
Primary Care Physician
____’s often require subscribers to select a primary care physician.
HMO’s
a doctor who provides general medical care for a particular member and controls all referrals for specialized care, and in some cases, hospital care is know as?
gatekeeper system
A special kind of pre-approval that individual health plan members — primarily those with HMOs and POS plans — must obtain from their chosen primary care physician before seeing a specialist or another doctor within the same network is?
Primary Care Physician (PCP) Referral
Subscribers pay a fixed periodic fee to the _____’s.
HMO’s
Subscribers pay a fixed fee to an HMO instead of paying for services only when needed and are provided with a broad range of health services, from routine doctor visits to emergency and hospital car, also known as?
service incurred plan
Co-payment requirements can be found in the _______ __ _____ in the policy.
certificate of coverage
What is known as medical group model or group practice model?
Group Model
______ ______ offers a variety of medical services to subscribers.
Group model
Under a _____ ____ medical care is rendered by physicians and hospitals who participate in the HMO.
staff model
The ____ _____ involves more than one group of physicians.
network model
HMO’s may function on a ______ __ ____ _____ (___).
individual or independent practice association (IPA)
HMO’s many functions on an IPA basis, characterized by a network of physicians who work out of their facilities and participate in the HMO part-time; this is known as an ______ ______ network.
open panel network
If the HMO is represented by a group of physicians who are salaried employees and work out of the HMO’s facility, then they are called a?
Closed panel network
HMO’s must provide an open enrollment for ____ days.
30
Physicians, hospitals, and clinics offer their services to certain groups at _____ _____ _____.
Prearranged discount prices
PP0’s provide a wider choice of?
Physicians
Unlike HMO’s, preferred provider organizations usually operate on a ___-____-_____.
fee-for-service baisis
a free-for-service basis is_______________________.
where the cost of each service is scheduled
____’s provide a wider choice of physicians.
PPO’s
PPOs have agreed to offer their services to the group where _____ ____ ___ ______.
patient fees are discounted
When an HMO and a PPO are mixed together they are known as _____ _____ ______.
managed care systems
Medicare’s purpose is to provide hospital and medical expense insurance protection to those aged?
65 and older
Who handles enrollment for the Medicare program and provides information about Medicare to the public?
Social Security Administration
_________ __________ ___________ does not make Medicare policies.
Social Security Administration
Who administers all other parts of the medicate program except for public information and enrollment?
The Centers for Medicare and Medicaid Services.
_________ insurance companies handle services provided by hospitals and home health agencies, etc.
Intermediary Insurance
Insurance companies that handle benefit claims are know as _______.
carriers
What is a benefit that covers expenses of semiprivate room, meals, nursing services, drugs, tests, operation room, and other medical services and supplies?
Inpatient hospital care
______ _______ _____ expenses are sometimes covered by Medicare part A, but ONLY if the insured was hospitalized shortly before entering the facility.
Skilled nursing facility
The inpatient hospital care benefit period is ____ days.
60 days
_____ _____ _____ benefits will be provided for medical services, supplies and equipment’s, home health aides, part-time nursing care, and therapy services.
Home health care
_____ _____ benefits cover inpatient and outpatient services for terminally ill patients.
Hospice Care
Respite for usual caregivers may not exceed ______ _____ _____.
5 consecutive days
A doctor who accepts Medicare _________ is agreeing to not charge more than the amount Medicare pays for the service performed
assignment
A ______ _______ ______ means the employee is totally disabled and unable to return to work.
total permanent disability
a ______ ______ _______ means the employee is able to return to work, however, the employee is unable to perform all previous or some work duties due to the disability.
permanent partial disability
A _______ _______ _______ means the employee is totally disabled due to an injury for a short period of time.
temporary total disability
a _______ _______ ______ means the employee is able to work, but with diminished capability.
temporary partial disability
Workers’ compensation pay for survivor benefits, also known as ______ ______.
death benefits
Second Injury Funds are also known as _____ ______ ______.
subsequent injury fund
Under _____-_____ plans,the employer funds and pays for member claims and benefits.
self insured
Under a ______ ______-________ _____, an employer may share the risk of covering claims by buying stop-loss insurance coverage from an insurance company.
partially self-insured plan
Health insurance may be written by a number of commercial insurers. The list includes:
1)
2)
and 3)
life insurance companies, casualty insurance companies, and monoline companies
they also organize and deliver these health services at its own local health care facilities.
HMOs
The payment given to a physician for each member of an HMO assigned to them is called
capitation
________ are known for stressing preventive care
HMOs
Employers with ____ __ ____ employees to offer enrollment in an HMO if they provide health care benefits for their workers
25 or more
A preferred provider organization is a collection of health care providers such as physicians, hospitals, and clinics who offer their services to certain groups at ____ _____ _____.
prearranged discount prices.
are often employers, insurance companies, or other health insurance benefit providers
Groups that contract with PPOs
While these groups do not mandate that individual members must use the PPO, a ______ _____ is typical if they do not
reduced benefit
If a patient with a preferred provider organization (PPO) chooses to use a non-PPO, the patient usually can expect to have ______ __-___-___ _______.
higher out-of-pocket expenses
Physicians who agree to accept assignment on ALL Medicare claims are called
participating providers
The impairment must be expected to last at least ____ _____ or result in an earlier death
12 months
A ____ month waiting period is required before an individual will qualify for benefits, during which time he/she must remain disabled
five-month
With Medicaid, The benefits may be applied to ______ ______ and co-payment requirements
Medicare deductibles
Under Medicaid,______ _____ is an eligibility requirement for the payment of nursing home expenses
financial need
Under Medicaid, financial need is an eligibility requirement for the payment of _______ ______ _______.
nursing home expenses
___________ __________ ________ generally compensate employees for lost wages and medical expenses due to occupational accidents.
Workers compensation benefits
A method of marketing group benefits to employers who have a _____ number of employees is the multiple employer trust (MET).
small
Insurers may provide such services without responsibility for claims payment under an ________ _______ _______ (ASO) contract.
Administrative Services Only
