Insurance

Question 1

Advance beneficiary notice (ABN)

Answer 1

A form provided to the patient when the provider believes Medicare will probably not pay for the services received

Question 2

Allowed amount

Answer 2

The maximum amount a third party payer will pay for a particular procedure or service

Question 3

Copayment

Answer 3

An amount of money that is paid at the time of medical service

Question 4

Coinsurance

Answer 4

A policy provision whereby the policyholder and the insurance company share the cost of covered losses in a specific ratio, such as 80/20

Question 5

Deductible

Answer 5

A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying

Question 6

Explanation of benefits

Answer 6

A statement from the insurance detailing what was pain, denied of reduced in payment

Question 7

Participating provider (PAR)

Answer 7

Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer

Question 8

Medicare

Answer 8

Federal. It generally covers patients age 65 and older by Part A (hospitalization or Part B (routine medical office visits) Part C (medications)

Question 9

Tricare

Answer 9

Authorizes dependents of military personnel to receive treatment from civilian providers at the expense of the federal government.

Question 10

CHAMPVA

Answer 10

Covers surviving spouses and dependent children of veterans who died as a result of service-relates disabilities.

Question 11

Managed care

Answer 11

Is an umbrella term for plans that provide health care in return for present scheduled payments and coordinated care through a defined network of providers and hospitals.

Question 12

Worker’s compensation

Answer 12

Protects wage earners against loss of wages and the cost of medical care resulting from an occupational accident or disease as long as the employee is not proven negligent

Question 13

The oldest and largest system of independent health insurers

Answer 13

Blue Cross and Blue Shield (BC/BS)

Question 14

Health insurer claim form that must be submitted by a provider of supplier for paper claims.

Answer 14

CMS-1500

Question 15

Accountable care organizations (ACOs)

Answer 15

Groups of physicians, hospitals and other healthcare providers that come together voluntarily to provide coordinated high-quality care to their Medicare program.

Question 16

Capitation (partial of full)

Answer 16

In this payment model, patients are assigned a per-member, per month payment based on their age race sex, lifestyle, medical history, and benefit design. Payment rates are tied to expected usage regardless of how often the patient visits the provider.

Question 17

Global budget

Answer 17

This is affixed total dollar amount paid annually for all care.

Question 18

Health maintenance organization (HMO)

Answer 18

This plan contracts with a medical center or group of providers to provide preventive and acute care for the insured person. Requires referrals, precertification and preauthorizations.

Question 19

Patient-centered medical home (PCMH)

Answer 19

In this care model, a primary care provider (PCP) coordinates treatment to make sure patient receive the required care when and where they need it.

Question 20

Pay for performance

Answer 20

This reimbursement model compensates providers only they meet certain measures for quality and efficiency

Question 21

Preferred provider organization (PPO)

Answer 21

These plans have more flexibility than HMO plans. The patient does not need a PCP, but can go directly to a specialist without referrals.

Question 22

Notice of Privacy Practices

Answer 22

Details how a patient’s medical records will be used and disclosed by a medical office

Question 23

Assignment of benefits

Answer 23

Document signed by a patient to authorize insurance payments directly to the provider

Question 24

Usual fee

Answer 24

The most commonly charged fee charged by a provider for a given service

Question 25

Reasonable fee

Answer 25

Is a fee for service that requires extra time and effort for the provider due to the level of complexity of the procedure

Question 26

Customary fee

Answer 26

A range of fees charged by providers who have similar training and experience and practice in the same geographical area

Question 27

Capitation

Answer 27

A fixed amount paid to a provider by a third party payer per individual enrollee for an established period