Mod 10: Payment Basics

Question 1

one who purchases an insurance policy

Answer 1

subscriber

Question 2

DME

Answer 2

durable medical equipment
-prescribed by provider

Question 3

insurance cost that’s out of pocket

Answer 3

(insurance) premiums

Question 4

money that subscriber pays before insurance pays for cost of covered services

Answer 4

deductible

Question 5

flat fee paid for specific services

Answer 5

co-payment

Question 6

cost-sharing obligation (%) under health insurance policy

Answer 6

co-insurance

Question 7

bill submitted by HC provider for payment/reimbursement of services

Answer 7

claims

Question 8

insurance source: individual purchases directly from company

Answer 8

private non-group insurance

Question 9

insurance source: offered as benefit to employee & employer/ee pays cost

Answer 9

group insurance/employer-sponsored health insurance

Question 10

insurance source: federal and state funded programs

Answer 10

government insurance
(Medicare/aid)

Question 11

insurer pays cash

Answer 11

uninsured/self-pay

Question 12

insurance type: economic hazard insurance controlled/paid by govt. programs

Answer 12

social insurance
-w/ eligibility requirements

Question 13

insurance type: plan implemented by managed care organizations w/ PPS and provider network

Answer 13

managed care

Question 14

managed care: pt. choose PCP who acts as gatekeeper for all HC services (restrictive)

Answer 14

Health Maintenance Organization (HMO)

Question 15

managed care: open managed care model

Answer 15

Preferred Provider Organization (PPO)

Question 16

managed care: subscribers select type of HC provider when needed (higher cost, more choices)

Answer 16

Point of Service (POS)

Question 17

insurance type: protects individuals/companies that are responsible for another’s injury

Answer 17

casualty insurance (ex: worker’s comp)

Question 18

insurance type: reimburses pt. for out-of-pocket medical expenses that are covered by an ins. policy; doctor submits claim for reimbursement

Answer 18

indemnity insurance

Question 19

insurance type: pt. pays bill in full each time service provided

Answer 19

cash-based payment (not insurance)

Question 20

uniformed services health care program that now allows PTAs/COTAs to be authorized providers

Answer 20

Tricare

Question 21

Medicare ___: hospital insurance w/ inpatient admission requirements (100% coverage 1st 20 days)

Answer 21

Medicare Part A

Question 22

Medicare ___: supplemental medical insurance (SMI), mostly outpatient, preventative and DME

Answer 22

Medicare Part B

Question 23

Medicare ___ : Medicare Advantage; private insurance plans

Answer 23

Medicare Part C

Question 24

Medicare ___: optional; subsidizes cost of prescription drugs

Answer 24

Medicare Part D

Question 25

Children’s Health Insurance Program (CHIP) covers who?

Answer 25

uninsured children & pregnant women

Question 26

Medicare Administrative Contractors (MACs)

Answer 26

contract w/ private insurance companies;
determined by geographic region
Medicare part A/B

Question 27

MCOs

Answer 27

Managed Care Organizations- implement managed care plans
-negotiate contracts w/ providers
-restrict access to care to manage cost

Question 28

Are services provided by PTA reimbursible under Medicare Part A?

Answer 28

Yes