Week 1; Chapters 11: The Blue Plans, Private Insurance, and Managed Care Plans/ Chapter 12: Medicare

Question 1

The Blue Cross/Blue Shield Association petitioned and was allowed to convert their status from a non-for-profit organization to a for-profit organization in the year

Answer 1

1994

Question 2

The name and address of the BCBS home company that should be used for claims submission can be found on the

Answer 2

identification card

Question 3

What refers to a group of techniques intended to offset the cost of providing health care while improving the access to care and the quality of care?

Answer 3

Managed care

Question 4

Define fee-for-service

Answer 4

a method of payment in which the patient pays the physician for each professional service performed from an established schedule of fees.

Question 5

Define a fee schedule

Answer 5

a list of charges or established allowances for specific medical services and procedures. see also relative value studies (RVS)

Question 6

Define relative value studies

Answer 6

it is list of procedure codes for professional services and procedures that are assigned unit values that indicate the relative value of one procedure over another

Question 7

Define ancillary services

Answer 7

it is a supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests

Question 8

Define buffering

Answer 8

it is a physician’s justifying the transference of sick, high-cost patients to other physicians in a managed care plan.

Question 9

Define Capitation

Answer 9

is a system of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan. Capitation can also mean a set amount to be paid per claim.

Question 10

Define Advanced Beneficiary notice of Noncoverage (ABN)

Answer 10

An agreement given to the patient to read and sign before rendering a serice if the participating physician thinks it may be denied for payment because of medical neccesity or limitation of liability by Medicare. The patient agrees to pay for the service; also known as a waiver of liabilty agreement or responsibility statement.

Question 11

Define Approved charges

Answer 11

is a fee that Medicare decided the medical service is worth, which may or may not be the same as the amount billed. The patient may or may not be responsible for the difference.

Question 12

Define assignment

Answer 12

Its a transfer after an event insured against or an individual’s legal right to collect to collect an amount payable under an insurance contract. When related to medicare, this an agreement in which a patient assigns the right to recieve payment from the medicare administrative contractor to the physician. Under this agreement, the physician must agree to accept 80% of the allowed amount as payment in full once the deductible has been met. For TRICARE, providers who accept assignement agree to accept 75% or 80% of the TRICARE allowable charge as the full fee, collecting the deductible and 20% or 25% of the allowable charge from the patient. With 25% of the allowable charge from the patient. With other carries, accepting assignement means that in return for payment of the claim, the provider accepts the terms of the contract between the patient and carrier.

Question 13

Define benefit period

Answer 13

1. it is a period of time during which payments for Medicare inpatient hospital benefits are available. A benefit period begins on the first day enrollee is given inpatient hospital care (nursing care or rehabilitation services) by a qualified provider and ends when the enrollee has not been an inpatient for 60 consecutive days. 2. In workers compenstaion cases, the maximum amount of time that benefits wil be paid to the injured or ill person for the disability. 3. For disablilty insurance, the maximum amount of time that benefits will be paid to the injured or ill person for a disability.

Question 14

Define Buffering

Answer 14

it is a physician’s justifying the transference of sick, high-cost patients to other physicians in a managed care plan.

Question 15

Define Capitation

Answer 15

it is a system of payment used bymanaged care plans in which phhysicians and hospitials are paid a fixed per capita amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month bais to cover costs for the members of the plan. Capitation can also mean a set amount to be paid per claim.

Question 16

Define Carve outs

Answer 16

medical service not included within the capitation rate as benefits of a managed care contract and that may be contracted for seperately.

Question 17

Centers for Medicare and Medicaid Services (CMS)

Answer 17

formerly known as the Health Care Financing Administration (HCFA), CMS divides responsibilites among three divisions: the Centers for Medicare Management the Center for Beneficiary Choices, and the Center for Medicaid and Stated Operations.

Question 18

Churning

Answer 18

is when physicians see a high volume of patients-more than medically necessary-to increase revenue. May be seen in fee-for-service or managed care environments

Question 19

Claims-review type of foundation

Answer 19

is a type of foundation that provides peer review by physicians to the numerious fiscal agents or carriers involved in its area.

Question 20

closed panel program

Answer 20

is a form of health maintenance organization (HMO) that limits the patient’s choice of personal physicians to only those doctors practocong in the HMO group practice within the geographis location or facility. A physician must meet narrow criteria to join a closed panel.

Question 21

Comprehensive type of foundation

Answer 21

is a type of foundation that designs and sponsor prepaid health programs or sets minimum benefits of coverage.

Question 22

what is a copayment or copay

Answer 22

1. A patient’s payment (for example, 20% of a bill or a flat fee of $10 per visit) of a portion of the cost at the time service is rendered; sometimes referred to as coinsurance. 2. in the Medicaid program, a required specific dollar amount that must be collected at each office visit for medical services recieved by an individua. Different copayment amounts may be set for each patient type and for certain medical procedures

Question 23

What is a cross over claim

Answer 23

is it a bill for services rendered to a patient recieving benefits simultaneously from medicare and medicaid or from medicare and a medigap plan. Medicare pays first and then determines the amount of unmet Medicare deductible and coinsurance to be paid by the secondary insurance carrier for additional payment. Also known as claims transfer.

Question 24

What is a deductibl

Answer 24

it is aspecific dollar amount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs.

Question 25

Diagnostic cost group (DCG)

Answer 25

is a system of Medicare reimbursement for health maintence organization (HMOs) with risk contracts in which emrollees are classified into various DCGs on the basis of each beneficiary’s prio 12-month hospitialization history.

Question 26

Direct reral

Answer 26

is a certain services in a managed care plan may not require preauthorization. The authorization request form is completed and signed by the physician and handed to the patient (for example obsetric care or dermatology) to be done directly.

Question 27

Define Disabled

Answer 27

for purposes of enrollment under Medicare, individuals younger than 65 years of age who have been entitled to disablilty benefits under the Social Security Act or the Railroad Retirement system for atleast 24 months are considered disabled and are entitled to Medicare.

Question 28

Define Disenrollment

Answer 28

a member’s voluntary cancellation of membership in a managed care plan.

Question 29

End-stage renal disease (ESRD)

Answer 29

individuals who have chronic kidney disease requiring dialysis or kidney transplant are considered to have ESRD. To qualify for Medicare coverage, an individual must be fully or currently insured under Social Security or the Railroad Retirement system or be the dependent of an isured person. Eligibilty for Medicare coverage begins with the third month after beginning a course of renal dialysis. Coveraged may commence sooner if the patient participates in a self-care dialysis training program or receives a kidney transplant with dialysis.