Healthcare System Terminology Quiz

Question 1

Adverse Selection

Answer 1

People in poor health are more likely to enroll in insurance and use healthcare services; if people are very sick, more likely to get health insurance

Question 2

Capitated Provider Reimbursement:

Answer 2

A type of physician reimbursement in managed care where the physician is prepaid a set amount of money to take care of a group of insured patients

Question 3

Co-insurance

Answer 3

A portion of healthcare charges that a person must pay that is determined by the insurance policy.
a percentage

Question 4

Consultant Pharmacist

Answer 4

This type of pharmacist often works in a long-term care setting to review patient charts for appropriateness of patient drug therapy.
CMS requires a consultant pharmacist to visit a licensed nursing facility on a monthly basis to provide drug regimen reviews for all patients within the facility. Duties in the facility include documenting proper medication use, making recommendations to prescribers for optimal use, evaluating medication distribution by the nurses to the patients, serving on quality assurance committees and a number of special duties needed by the facility. In a sense any medication related activity at the nursing facility needs the consultant pharmacist to oversee.

Question 5

Continuum-of-Care

Answer 5

Shift from fragmented care to continuum of care; the idea of healthcare providers following patients as they receive care at different times and locations (following patients through their healthcare journey); goal: better care and improved patient outcomes; Need communication and technology to make this happen

Question 6

Copay

Answer 6

A portion of healthcare charges that a person must pay that is determined by the insurance policy

Question 7

Discounted Fee-for-Service Reimbursement

Answer 7

A financial reimbursement system whereby a provider agrees to supply services on an FFS basis, but with the fees discounted by a certain percentage from the physician’s usual and customary charges. … This may be a fixed amount per service, or a percentage discount.

Question 8

Fee-for-Service (FFS) Reimbursement/Insurance:

Answer 8

Fee for service (FFS) is the most traditional payment model of healthcare. In this model, the healthcare providers and physicians are reimbursed based on the number of services they provide or their procedures. (doesn’t include quality of care)

Question 9

Formulary:

Answer 9

list of prescription drugs covered by a health insurance plan

Question 10

Gatekeeping/Gatekeeper

Answer 10

A health care professional, typically a physician or nurse, who has the first encounter with a patient and who thus controls the patient’s entry into the health care system.

Question 11

Gross Domestic Product (GDP)

Answer 11

The total value of goods produced and services provided in a country during one year.

Question 12

Health Maintenance Organization (HMO)

Answer 12

A type of managed care organization where a patient can’t receive care outside of the provider network.

Question 13

Healthcare Flexible Spending Account (FSA)

Answer 13

This type of account can help employees with private health insurance to set aside pre-tax dollars for eligible healthcare expenses that their health insurance doesn’t cover during a calendar year

Question 14

Insured/Enrollee

Answer 14

person protected from risk of financial loss via insurance.

Question 15

Integrated Healthcare Delivery System (IHDS)

Answer 15

Provide a coordinated continuum-of-services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced (different than continuum of care because it has that financial part); A network of organizations where there is a continuum of healthcare and providers are responsible for clinical outcomes and financial outcomes for the group of patients they are providing care.

Question 16

Long-term Care Services

Answer 16

A range of health, personal care, social and housing services; For people who can’t care for themselves independently due to chronic illness, or mental or physical disability

Question 17

Managed Healthcare Organization (MCO)

Answer 17

A type of healthcare organization that focuses on coordinating patient care to control costs, improve healthcare quality, andpatient wellness.

Question 18

Moral Hazard:

Answer 18

refer to people with medical insurance getting more medical care, aside from whether they need it or not; If you have insurance, you are more likely to use healthcare good and services than if you had to pay price out-of-pocket

Question 19

National Health Expenditures (NHE)

Answer 19

The total amount of money we spend yearly in the United States on healthcare.

Question 20

Out-of-pocket maximum/limit

Answer 20

The dollar amount a person must pay before their insurer pays 100% of the person’s healthcare costs. Out-of-Pocket maximum is set for a calendar year: only applies for covered services, includes deductibles, copays and coinsurance, Out-of-network costs DONT apply to out-of-pocket maximum

Question 21

Patient Protection & Affordable Care Act (ACA)

Answer 21

provides preventative care without cost sharing (for most plans); give people more access to healthcare; -insurance can’t deny coverage due to illness
-stay on parents until 26

Question 22

Point of Service Plan (POS)

Answer 22

Patient can choose a doctor when they need to see a doctor. Patient can see a doctor out of network. Patients usually need to get a referral to see a specialist.

Question 23

Preferred Provider

Answer 23

provider within network that the insurance covers

Question 24

Preferred Provider Organization (PPO)

Answer 24

A type of managed care organization that allows patients to receive care outside of the provider network, but they will payless if they receive care in the network.

Question 25

Premium:

Answer 25

​​The dollar amount a person pays for health insurance from an insurance plan

Question 26

Provider/Physician (PCP):

Answer 26

In managed care, financial risk is shifted from the insurance company to this stakeholder in the healthcare system.

Question 27

Private Health Insurance:

Answer 27

primarily employer based, self-insured via an individual health insurance policy

Question 28

Provider Network:

Answer 28

List of healthcare providers covered by a health insurance plan, Patients typically have lower out-of-pocket costs “in network”, Networks include physicians, pharmacies, hospitals, clinics, etc.

Question 29

Public Health Insurance:

Answer 29

This type of insurance is delivered and financed by the government.

Question 30

Skilled Nursing Facility (SNF)

Answer 30

Facility where medical care is provided by a licensed nurse and other health care professionals; Residents have a variety of medical conditions; often with cognitive problems
Residents have both ADL and IADL issues