Term
|
Definition
| the amount paid or payable (for example, an insurance policy premium) |
|
|
Term
|
Definition
| an amount to be paid by the before insurance will pay |
|
|
Term
|
Definition
| a structure of payment based on the number served |
|
|
Term
|
Definition
| limited; only for certain group |
|
|
Term
|
Definition
| the assignment of credential; approval given for meeting established standards. |
|
|
Term
|
Definition
| prior approval of insurance coverage and necessity of procedure. |
|
|
Term
| prefered provider organization |
|
Definition
| (PPO)- an organization of physicians who network together to offer discounts to purchasers of health care insutance |
|
|
Term
|
Definition
| something implied or suggested |
|
|
Term
|
Definition
| (HSA)- a tax-sheltered savings account, with contributions from the employer and employee, which can be used to pay for medical expenses. |
|
|
Term
| flexible spending account |
|
Definition
(FSA)- refered to as a cafeterial plan. There are three components to the plan:
Health insurance premiums
Qualified medical expenses
Dependent care expenses |
|
|
Term
| health reimbursement account |
|
Definition
| (HRA)- an account with employer contributions from the employer and employee, which can be used to pay for medical expenses. |
|
|
Term
|
Definition
| a government health care program for individuals or limited or low income. 1965 |
|
|
Term
|
Definition
| legally enacted; deriving authority from law |
|
|
Term
|
Definition
a federal health program for paying certain medical expenses of the aged. Administered under the Social Security Adm. for people over age 65 who meet requirements.
Disabled, receiving Social Security benefits, or in end-stage renal failure disease, regardless of age
red-white-and-blue cards are issued to verify coverage |
|
|
Term
|
Definition
| a sum of money to be received yearly, either in a lump sum or by installments |
|
|
Term
|
Definition
| refers to situations not covered by Medicare insurance |
|
|
Term
|
Definition
| something added; an additional or extra section |
|
|
Term
|
Definition
| compensation for damage done or loss caused |
|
|
Term
|
Definition
|
|
Term
|
Definition
| covering all areas; inclusive |
|
|
Term
|
Definition
| occurring, appearing, or done again and again, at regular intervals |
|
|
Term
| what does private commercial insurance companies control |
|
Definition
| the price of premiums and specifies the benefits they will provide |
|
|
Term
| Blue Cross was originally set up to pay for |
|
Definition
| hospital expenses, but now covers outpatient services as well |
|
|
Term
| Blue Shield was originally set up to pay for |
|
Definition
|
|
Term
| Name additional plans that Blue Cross and Blue Shield offers today |
|
Definition
a variety of
HMOs(Health Management Org.);
PPO(Preferred Provider Org.);
POS(Point of service);
HSA(Health Savings Acc.);
HRA(Health Reimbursement Acc.);
and indemnity plans |
|
|
Term
|
Definition
Staff model HMOs
Group model HMOs
Open-ended HMOs
Point of service (POS) |
|
|
Term
|
Definition
| all services are provided at the same location. True emergency does not require preauthorization. If traveling out of geo area, call and preauthorize nonemergency care. |
|
|
Term
|
Definition
| multispecialty practices contracted to provide care services to members. Physicians are paid on a capitated basis |
|
|
Term
|
Definition
| gained popularity in recent yrs. consists of a network of physicians and hospitals that contract to provide an insurance company or an employer with services for their members or employees at a discount rate |
|
|
Term
|
Definition
give members freedom in their choice of care.
If they choose nonpanel provider: indemnity plan with a deductible and coinsurance.
If they choose panel: receive HMO benefits. |
|
|
Term
| What type of insurance have the least amount of structural guidelines for patients to follow. |
|
Definition
|
|
Term
| Why does indemnity-type insurance have the least amount of structural guidelines for patients to follow. |
|
Definition
| because patients are able to see the physician of their choice without having to deal with listings and also see specialists without having to obtain referrals from another physicians. |
|
|
Term
| What is required to the patient from indemnity-type of insurance to have freedom of choices. |
|
Definition
| patient pays for their services in full at the time of service is provided. Patient's expenses will be covered after the annual deductible is satisfied. A encounter form should be filed by the patient to be reimbursed from the insurance carrier. |
|
|
Term
|
Definition
| 80/20: carrier will pay 80 percent of the expenses, and the insured will pick up the other 20 percent after the deductible has been satisfied. |
|
|
Term
|
Definition
plans set up to provide comprehensive health care with an emphasis on wellness and preventive medicine
patients are encouraged to have annual physicals to identify health problems early. |
|
|
Term
|
Definition
| Primary Care Physician/gatekeeper |
|
|
Term
| why does HMO have the subscriber choose a PCP |
|
Definition
| to oversee their med. care. who could refer patient to a specialist if needed. |
|
|
Term
precertification
preauthorization
predetermination |
|
Definition
| refer to a patient's eligibility for services |
|
|
Term
|
Definition
| refers to the discovery as to whether a treatment is covered under the patient's insurance |
|
|
Term
|
Definition
| relates not only to whether the service are covered, but also whether the proposed treatment is medically necessary |
|
|
Term
|
Definition
| refers to the discovery of the maximum amount of money that the carrier will pay for primary surgery, consultation service, postoperative care, etc. |
|
|
Term
| Most HMOs require patients to pay a copayment at the time service is rendered |
|
Definition
|
|
Term
|
Definition
| National Committee for Quality Assurance |
|
|
Term
| To qualify as an HMO, an organization must present proof of its ability to |
|
Definition
| provide comprehensive health care. |
|
|
Term
| To retain eligibility to qualify as an HMO, organizations must submit |
|
Definition
| periodic performance reports to the Department of Human Services |
|
|
Term
|
Definition
| assessing, measuring, and reporting outcomes of HMOs. Also, provide the accreditation for HMOs after reviewing the HMOs' performance and procedures. |
|
|
Term
| Levels of accreditation for HMOs from NCQA |
|
Definition
1. Full accreditation is given for 3 yrs...indicating excellent performance
2. HMOs that are well equipped to make recommended improvements are given a 1 yr accreditation.
3. Provisional accreditation for 1 yr is given if it appears that the potential for improving the HMO is there
4. Accreditation is denied if the HMO does not meet the NCQA standards. |
|
|
Term
|
Definition
| Independent Practice Association. |
|
|
Term
|
Definition
individual health care providers who join together to provide pre-paid health care to groups and individuals who purchase coverage.
restricted health plan: only hospitals, panel providers, labs, and other ancillary services. |
|
|
Term
|
Definition
| Preferred Provider Organization |
|
|
Term
|
Definition
not an HMO/no PCP
more patient care management than indemnity because of the limitations of the provider panel |
|
|
Term
| PPO affords the patient the option of |
|
Definition
| network or non-network physicians and hospitals. Although, network has greater benefits. |
|
|
Term
| responsibility of the gatekeeper of PCP |
|
Definition
| coordinating all care for the patient |
|
|
Term
| There is a special _______ on the CMS 1500 form that allows the claims processor to assign a unique identification number to the claim during microfilming |
|
Definition
|
|
Term
| If the physician provides a non covered service for a medicare patient, a(n) _____ must be signed by the patient |
|
Definition
| ABN (Advance Beneficiary Notice) |
|
|
Term
| Physicians who choose no to be participating providers must collect _________ for the services rendered |
|
Definition
| only Medicare-approved amount |
|
|
Term
| Medicare B is the coverage that pays for __________ |
|
Definition
| other medical expenses for example office visits, X rays and lab services. |
|
|
Term
| One common reason for delay in payment of claims is that they are _______ |
|
Definition
|
|
Term
| patients who has an industrial injury should have a(n) ____ set up for that injury and a separate account card. for that injury |
|
Definition
|
|
Term
| besides the 4 principles types of state benefits, workers' compensation also includes ___________ for severely disabled employees |
|
Definition
| comprehensive vocational rehabilitation |
|
|
Term
| one of the four levels of NCQA accreditation is full accreditation given for ____ indicating excellent performance |
|
Definition
|
|
Term
|
Definition
Consumer-driven Health plans
created in 2003 |
|
|
Term
|
Definition
|
|
Term
| which term is used to describe the maximum amount of money an insurance carrier will pay for a medical service |
|
Definition
|
|
Term
| in which type of HMOs are the physicians reimbursed on a capitated basis? |
|
Definition
|
|
Term
| which type of organization provides pre-paid health care to groups or individuals who purchase coverage? |
|
Definition
| IPA (Independent Practice Associations) |
|
|
Term
| Patients who must obtain a referral from their primary care physician to be seen by a specialist are part of what type of health care system? |
|
Definition
|
|
Term
| A tax sheltered acc, similar to an IRA, that can be used to pay for medical expenses is a (n) |
|
Definition
|
|
Term
| Medicare is only permitted to pay for services or supplies that are considered |
|
Definition
|
|
Term
| the centers for medicare and medicade services, or CMS, is the new name for |
|
Definition
|
|
Term
| In which account any amount not used in a given yr remains in the account and continues to gain interest |
|
Definition
| (HSA) Health Savings Account |
|
|
Term
| qualified expenses for CDHPs: HRA, HSA, and FSA |
|
Definition
| ambulance service, braces, home improvements to assist a disabled person, and telephone or TV equipment for the hearing or visually impaired. |
|
|
Term
| non qualified expenses for CDHPs: HRA, HSA, and FSA |
|
Definition
| babysitting and childcare for a healthy individual, funeral expenses, and diaper service. |
|
|
Term
| difference between HSA & HRA |
|
Definition
| In HRA an employer can contribute to an HRA, but an employee cannot |
|
|
Term
|
Definition
|
|
Term
| in fsa the money belongs to the employee, however, |
|
Definition
| any unused amount by the end of the yr, its lost and returned to the employer |
|
|
Term
| Workers' Compensation was first called _______. The name was changed because _______ |
|
Definition
Workman's compensation
to avoid connotation of gender bias |
|
|
Term
| In workers' compensation the injured employee pays the premiums based on |
|
Definition
| the risk in performance of the job |
|
|
Term
| 4 principal types of state benefits for Workers' Compensation |
|
Definition
1. medical treatment in or out of a hospital
2. if temporary disability: patient receive weekly cash benefits in addition to med. care
3. if permanent disability: patient receives weekly or monthly benefits, and maybe even settlement
4. if fatally injured: payments are made to dependents of employees, also comprehensive vocational rehab. |
|
|
Term
| Workers' Compensation requires that a patient have reevaluations at intervals with his or her physician, who must promptly give a supplemental report regarding the patient's condition |
|
Definition
|
|
Term
| A bill may be disallowed if |
|
Definition
| it is not filed within the statutory time limit |
|
|
Term
| Medicaid subscribers need to seek care from a physician participating provider |
|
Definition
| True. Physicians are not required to accept Medicaid members. |
|
|
Term
|
Definition
|
|
Term
|
Definition
| payments of other medical expenses, including office visits, Xrays, abd lab services, and the services of the physician in or out the hospital |
|
|
Term
| OBRA of 1989 required that all physicians and suppliers submit |
|
Definition
| Medicare claims for their patients. Unless, the service is not covered by Medicare or for filing other health insurance claims. |
|
|
Term
| physicians who choose to be a participating provider |
|
Definition
| can collect only the Medicare-approved amount for the service rendered |
|
|
Term
| the maximum amount a non-participating provider can collect is |
|
Definition
| 115% of the Medicare fee schedule |
|
|
Term
| Patients insured with Medicare Part B have a(n) ______ to satisfy (pay) before any portion of their medical expenses will be paid by Medicare |
|
Definition
|
|
Term
| Medicare pays 80% of the approved amount once the deductible is satisfied |
|
Definition
| and the patient pays the 20% |
|
|
Term
| Medigap is health insurance offered by Private companies to |
|
Definition
| persons eligible for Medicare benefits |
|
|
Term
| if the patient does not have a commercial supplemental insurance and is unable to pay the deductible or co-insurance, their 20%, the patient may be |
|
Definition
| eligible for medicaid. Which in this case, Medicare would be the primary insurance and Medicaid the secondary |
|
|
Term
| If a patient qualifies for Medicare by virtue of age, but still employed in a facility with more than 20 employees, the group plan would be |
|
Definition
| the primary insurance and Medicare the secondary |
|
|
Term
| The NPI is used in block 24k and 33 of the CMS-1500 to identify the location of the service |
|
Definition
|
|
Term
| Medicare Part B patients are usually responsible for the first |
|
Definition
|
|
Term
| Ideally, all insurance forms should be signed and dated by |
|
Definition
|
|
Term
| Medicare encourages all providers to file claims |
|
Definition
|
|
Term
TRICARE (CHAMPUS)
Civilian Health and Medical Program of the Uniformed Services |
|
Definition
| established to aid dependents of active service personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty |
|
|
Term
|
Definition
for the spouses and dependent children of veterans who have total, permanent, service-connected disabilities.
This service is also available for the surviving spouses and dependent children of veterans who have died as a result of service-connected disabilities. |
|
|
Term
| Easter Seal/Crippled Children |
|
Definition
| are now operated as private nonprofit org. |
|
|
