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Insurance chapter 11

Chapter 11 Insurance

questionsanswers
MEDICARE ELIGIBLE PATIENTS ARE NOT INVOLVED WITH HMOS OR PREPAID HEALTH PLANS False
IN POINT OF SERVICE (POS) PROGRAM, MEMBERS MAY CHOOSE TO USE A NONPROGRAM PROVIDER AT ANY TIME True
In certain managed care plans there is an incentive for the gate keeper to limit patient referrals to specialists True
Managed care plans allow laboratory test to be preformed at any facility the patient chooses False
MANAGED CARE PLANS NEVER REQUIRE A CMS-1500 CLAIM FORM TO BE COMPLETED AND SUBMITTED False
USUALLY THERE ARE NO DEDUCTIBLES FOR MANAGED CARE PLANS True
A copayment in a managed care plan is usually A fixed dollar amount(predetermined fee) True
An organization that gives members freedom of choice amoung physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a Preferred provider organization (PPO)
a Program that offers a combination of HMO style cost management and PPO style freedom of choice is a Point of service (POS) plan
Practitioners in an HMO program may come under peer review by a professional group called Quality Improvement Organization
REFERRAL OF A PATIENT RECOMMENDED BY ONE SPECIALIST TO ANOTHER SPECIALIST IS KNOWN AS Teritary care
What is the correct procedure to collect a copayment on managed care plan? Collect the copayment when the patient arrives for the office visit
CAPITATION IS a rate paid to participating physicians on a per person basis when they belong to a health plan, whether the patient utilizes service or not
WHEN A MANAGED CARE PLAN REQUIRES THE PRIMARY CARE PHYSISICAN TO SEEK APPROVAL BEFORE REFERRING A PATIENT TO A SPECIALIST ITS CALLED OBTAINING Preauthorization
Utilization review all the above (used in managed care, formal assesment of the cost, result indenial of medical care)
__________ IS BASED ON THE CONCEPT OF PAYING PHYSICIANS FOR ACTUAL PATIENT VISITS Contract captiation
WHEN A PROVIDER USUALLY A SPECIALIST CONTRACTS WITH THE MCO FOR AN ENTIRE EPISODE OF CARE IT IS TERMED Case rate pricing
An agreement between a MCO and a provider which means that if the patients services are more than a certain amount the physician can begin asking the patient to pay for services Stop-loss cap
The abbreviation MCO stands for Managed care organization
THE ABBREVIATION PCP STANDS FOR Primary Care Physician
A SPECIFIC DOLLAR AMOUNT THAT MUST BE PAID BY THE INSURED BEFORE A MEDICAL INSURANCE PLAN OR GOVERNMENT PROGRAM BEGINS COVERING HEALTH CARE COSTS Deductible
Mrs. Fellini a patient of Dr. Practon, comes for a appointment and her UA indicates a + prego test. Dr. Practon completes an authorization request for during the visit and hands it to Mrs. Fellini, referring her to Dr. Bertha Caesar, for obstetrical care Direct Referral
Dr. Practon administrative medical assistant completes an authorization request for his patient Mrs Dye as required by her MCO contract to determine medical necessity for a mastectomy Formal referral
Mrs. Jones visits her gynecologist for her annual well- woman examination Self Referral
Dr. Practon called his patient, Mrs. Smith, telling her he is referring her to Dr.Patos, an oncologist. Dr. Practon then calls Dr.Patos to tell the specialist that Mrs. Smith is being referred for an appointment Verbal referral
Medical services not included with the capitation rate as benifits of a managed care contract and may be contracted for separetely Carve outs
Physicians seeing a high volume of patients more than medically necessary to increase revenue Churning
transferring the sickest high cost patients to other physicians so the provider appears to be a low utilizer in a managed care setting Turfing
Created by: Lea99 on 2012-03-14



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