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Insurance > Insurance > Flashcards

Insurance Flashcards

1
Q

Annual Healthcare Expenditures?

A
  1. 5 Trillion

17. 9% of GDP

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2
Q

Projected Growth in National Health Expenditures?

A

6 Trillion by 2027

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3
Q

Financial Loss due to fraud in healthcare?

A

3% (most conservative)

~$300 billion

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4
Q

When was Medicare created?

A

1965 for individuals over 65

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5
Q

When did Medicare expand to ESRD?

A

1972

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6
Q

What does Medicare Part A cover?

A

Inpatient hospital and skilled nursing and hospice

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7
Q

What does Medicare Part B cover?

A

optional medical insurance (requires premium), covering doctors’ visits, outpatient medical and surgical services and supplies, diagnostic tests, and DME

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8
Q

What does Medicare Part C (Advantage) cover?

A

Established in 1997 to allows Medicare beneficiaries to join privately operated MCO’s.

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9
Q

What does Medicare Part D cover?

A

Established in 2003 to cover prescription drugs for eligible enrollees.

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10
Q

When was Medicaid established?

A

1965 to cover certain low-income families, as well as certain low income, blind, and disabled individuals. Medicaid is a joint federal/state program.

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11
Q

When was CHIP established?

A

1997 and provides federal matching funds to states to
provide health care coverage to children of families with incomes that are too high to qualify for Medicaid, but who can’t afford private health insurance coverage.

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12
Q

What is TRICARE?

A

Regionally managed health care program for active duty,guard, reserves, and retired members of the uniformed services and their families. It is managed by the Defense Health Agency

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13
Q

Federal agencies?

A

CMS, HHS-OIG (LEIE), NPDB, DOJ

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14
Q

State agencies?

A 
Medicaid Program Integrity Units (MPIU), 
Medicaid Fraud Control Units (MFCU), 
Medical Board, 
Nursing Board, 
Licensing Boards, 
OAG, 
DOI
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15
Q

Independent Organizations?

A

NAIC
JACOH
NCQA

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16
Q

What does ERISA stand for? When was ERISA established?

A

Employee Retirement Income Security Act of 1974

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17
Q

Health insurance coverage that you purchase on your own, on an individual or family basis, as opposed to through an employer.

A

Individual Health Insurance

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18
Q

This insurance is usually based on an employer - employee relationship but may be offered to groups who join together out of a common interest, such as trade associations or unions.

A

Group Health Insurance

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19
Q

Insurance plan where members can see any health care provider in the network, including specialists, without a referral.

A

PPO

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20
Q

Insurance plan where an entire network of health care providers agrees to offer you its services. Members have to select a primary care provider (PCP) who coordinates all of your health services and care.

A

HMO

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21
Q

Insurance plan where members have access to all of the health care providers within the EPO network, including specialists. Whereas PPO plans may offer some coverage outside of the network, EPO plans typically will not.

A

Exclusive Provider Organization (EPO) plans

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22
Q

Hybrid of HMOs and PPOs. Members typically designate a primary care physician for regular check-ups and referrals. Members can also use out-of-network providers and pay more out of pocket including a copayment and deductible.

A

Point of Service (POS) Plans

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23
Q

Requires any employer with 20 or more employees to extend Group Health coverage to terminated employees and their families for up to a period of 36 months after a qualifying event.

A

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requirements

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24
Q

When was HIPAA established?

A

1996

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25
Q

What type of statute is HIPAA?

A

Federal Criminal and; Civil (Knowingly violating HIPAA is civil)

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26
Q

What type of statute is Anti-Kickback Statute?

A

Criminal and; Civil

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27
Q

What type of statute is STARK Anti-Referral Statute?

A

Civil

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28
Q

What type of statute is False Claims Act?

A

Civil

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29
Q

What type of statute is the Civil Monetary Penalties?

A

Civil

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30
Q

What type of statute is the Health Care Fraud Statute?

A

Criminal and; Civil

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31
Q

What type of statute is the Health Care Benefit Program False Statements Statute?

A

Civil

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32
Q

What type of statute is the Mail Fraud (Frauds and Swindles)?

A

Criminal

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33
Q

What type of statute is Wire Fraud?

A

Criminal

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34
Q

What type of statute is Money Laundering?

A

Criminal

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35
Q

What type of statute is Criminal False Statements?

A

Criminal

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36
Q

What are the four entities with responsibility for health

care fraud within the DOJ?

A

a. Criminal Division
b. Civil Division
c. U.S. Attorney Offices
d. Federal Bureau of Investigation (FBI) – has investigatory jurisdiction for commercial health care fraud (along with state law enforcement) as well as
responsibility for investigating fraud in Medicare and in Medicaid, along with HHS‐OIG and MFCUs.

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37
Q

Source that records actions taken by
authorized organizations regarding health care practitioners, entities, providers, and
suppliers who do not meet professional standards.

A

NPDB

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38
Q

Physicians with an active license by 2020?

A

971,817

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39
Q

What year did Medicare & Medicaid program integrity functions align within CMS?
What is it called?

A

April 2010

Center for Program Integrity (CPI)

40
Q

What are the four main components of HHS-OIG?

A

Audit services
Evaluation and Inspection
Policy
Investigations

41
Q

Who does OIG report to?

A

HHS Secretary

Congress

42
Q

How often does CMS review the effectiveness of the states Program Integrity efforts?

A

Every 3 years

43
Q

How many MFCU offices are located in the Attorney General’s office?

A

44

44
Q

What states have MFCU offices outside of the Attorney General’s office?

A 
CT
DC
IL
IA
TN
WV
45
Q

Who conducts statewide programs for the investigation and; prosecution of healthcare fraud?

A

MFCU

46
Q

State agency that protects the public from unprofessional, improper, unlawful, fraudulent and/or incompetent practice of medicine?

A

State Medical Boards

47
Q

What do state medical boards do?

A

License physicians, investigate complaints, discipline, conduct physician evaluations, and facilitate rehab of physicians where appropriate.

48
Q

Who represents the 70 medical and osteopathic boards of the U.S. and it’s territories?

A

Federation of State Medical Boards

49
Q

What do Medical Specialty Boards do?

A

Certify specialists in more than 145 specialties and; sub specialties

50
Q

What is the key task force of the NAIC?

A

Antifraud Task Force which is part of the Market Regulation & Consumer Affairs (D) Committee

51
Q

What is the NAIC?

A

National Association of Insurance Commissioners

52
Q

Accreditation program for hospitals, ambulatory care, behavioral health, home care, laboratory services, and long term care?

A

Joint Commission (formerly JCAHO)

53
Q

Accreditation programs for various healthcare organizations, as well as functional areas of organizations?

A

URAC

54
Q

Provides accreditation for over 4500 ambulatory health care entities?

A

Accreditation Association for Ambulatory Health Care (AAAHC)

55
Q

Who provides educational and accreditation programs for home care accreditation?

A

Community Health Accreditation Partner (CHAP)

56
Q

If an employer self insures its health benefit plan it falls under what Act making it not subject to state regulation?

A

ERISA

57
Q

Employers who create self-insured plans can contract with who to provide claims processing or access to an insurance network?

A

Administrative Services Only (ASO)

Third Party Administrator (TPA)

58
Q

Agency of the department of labor (DOL) responsible for pension and welfare benefit plans?

A

Employee Benefits Security Administration (EBSA)

59
Q

Act that preempts state law to establish and preserve uniform and exclusive federal regulation of covered employee benefit plans?

A

ERISA

60
Q

State anti-fraud regulatory requirements?

A
  1. Reporting to fraud bureau w/in DOI
  2. Anti-fraud plan
  3. Establishing an SIU
  4. Training requirements
  5. Annual reporting of fraud activity
61
Q

Civil statute which prohibits physicians w/ direct or indirect financial interests in an entity from making referrals to that entity?

A

STARK Anti-Referral Statute

62
Q

STARK Anti-Referral statute applies to how many designated health services?

A

12

63
Q

Effective Jan. 2018 violation of the ________ range between $11,181 to $22,363 per claim, plus triple the amount of damages to the federal government.

A

Civil False Claims Act

64
Q

According to the False Claims Act an overpayment must be returned

A
  1. 60 days after the date on which the overpayment was identified or;
  2. The date any corresponding cost report is due (if applicable)
65
Q

This rule established that a person has identified an overpayment when he/she has or should have, through the exercise of reasonable diligence, determined an overpayment was received.

A

Final Overpayment Rule?

66
Q

Civil Monetary Penalties applies to what?

A

False claims
Upcoding
Non-licensed provision of services
Contracting with excluded individuals

67
Q

What is the daily penalty for failure to provide timely access to HHS-OIG for audits and investigations?

A

$15k per day

68
Q

What is the penalty for violating the Health Care Fraud Statute?

A

Fines and imprisonment for not more than 10 years; if serious bodily injury occurs, then imprisonment for not more than 20 years; and if death occurs, imprisonment for life if available

69
Q

This statue prohibits executing or attempting to execute a scheme or artifice to defraud or to fraudulently obtain money or property from a health benefit program.

A

Health Care Fraud Statute

70
Q

This statute prohibits falsifying or concealing a material fact or making false statements in connection with delivery of health care benefits, items or services.

A

Health Care Benefit Program False Statements Statute

71
Q

Penalty for violating this statute includes fines and up to 5 years in prison

A

Health Care Benefits False Claims Statute

72
Q

Mailing a fraudulent health care claim or premium payment constitutes a violation of this statute.

A

Mail Fraud (frauds and swindles)

73
Q

Penalty for violating this statue includes fines and up to 20 years in prison?

A

Mail Fraud

74
Q

Federal Criminal Statute that prohibits knowingly and willfully within the jurisdiction of any branch of the federal government making a materially false, fictitious or fraudulent statement or representation.

A

Criminal False Statements

75
Q

What are the seven elements of an effective compliance plan?

A
  1. Written standards of conduct
  2. Designation of a Compliance Officer
  3. Regular training and education
  4. Effective lines of communication
  5. Audits and risk evaluation
  6. Disciplinary procedures
  7. Policies to respond to and report detected offenses
76
Q

What Rule required the Secretary of HHS to draft rules aimed to increase the efficiency of the U.S. healthcare system by creating standards for the use and dissemination of health cafe information?

A

HIPAA

77
Q

What rule creates and mandates use of a single NPI?

A

HIPAA Unique Identifiers Rule

78
Q

What year was an NPI required per the HIPAA Unique Identifiers Rule?

A

May 2007

79
Q

What rule applies specifically to electronic PHI?

A

HIPAA Security Rule

80
Q

What is HITECH?

A

Health Information Technology for Economic & Clinical Health Act

81
Q

Who has authority to enforce HIPAA rules?

A

State attorneys general

82
Q

Which Act does not require a showing of risk of harm to trigger the notification requirement?

A

HITECH Act

83
Q

The purpose of this law is to protect consumers by preserving free competition in the market for goods and services.

A

Federal Antitrust Laws

84
Q

Which law has dual enforcement by both the DOJ and the FTC?

A

Federal Antitrust Laws

85
Q

The following are examples of what type of illegal Antitrust activity:

  1. Collective decisions not to do business with certain providers (group boycott).
  2. Collective decisions not to cover or pay for certain items or services.
  3. Collective decisions on premium rates or market allocations.
  4. Discussions among competitors about such topics.
A

Per se

86
Q

Under this law some activities are per se illegal, while others are analyzed for illegality under a rule of reason test.

A

Federal Antitrust

87
Q

This law prohibits the exchange of information among competitors directed at fighting fraud are generally recognized as lawful, at least in circumstances where participants in the information exchange remain free to make their own independent decisions regarding whether to pursue an investigation or take action.

A

Anti-Fraud Information Sharing

88
Q

These statutes are designed to prevent an insurer from being sued for good faith efforts to investigate fraud. They will not protect against “bad faith” or “malice”

A

Immunity

89
Q

What law provides protections for certain communications?

A

Privilege

90
Q

Are anti-fraud communications and information sharing generally considered privileged?

A

Yes

91
Q

How can an insurer defeat a claim of defamation?

A

By demonstrating the statement(s) or actions were privileged

92
Q

Dental plans are generally categorized into what two groups?

A

Basic (scheduled) plans

Nonscheduled Plans

93
Q

In what two ways does an enrollment broker assist with enrollment?

A

Determine solution

Enroll customer

94
Q

What is the enrollment broker licensing process?

A

Licensed by state

Appointment by company

95
Q

How can health plan products be marketed?

A

Face to face
Brand awareness
Referral networks
Social media

96
Q

What is the enrollment application process?

A
  1. Quoting and benefit selection
  2. Application completeness & selection
  3. Issue & delivery
97
Q

Enrollment channels for group and individual markets?

A

Face to face
Telephone
Direct to consumer
Employer portal

Insurance (1 decks)

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