Chap 11/12
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| Kaiser Permanente's medical plan is a closed panel program, which means:a. Limits the patient's choice of a PCP. b. Limits the patient's choice of a hospital for ER care. c. Services are provided on a FFS basis. d. Only certain illnesses are covered. | Limits the patient's choice of a personal physician (PCP)
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| When an HMO is paid a fixed amount for each patient served, this is known as? a: customary charge. b: FFS. c: Usual charge. d. Capitation. | Capitation
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| What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care? | Foundation for medical care.
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| In an Independant Practise Association (IPA), phyicians are? a. paid salaries by the practise association. b. not employees and are not paid salaries, c. paid salaries by their own independent group. d. Not paid until the end of the year. | Not employees and are not paid salaries.
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| An organization that gives members freedom of choice among providers and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an? | Preferred Provider Organization (PPO)
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| A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its' own plan is a/an? A: PPO B: PPG C: POS D: IPA | PPG (Physician Provider Group)
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| A program that offers a combination of HMO style cost management and PPO style freedom of choice is known as a? A: EPO B: POS C: MCO D: PPG | POS (Point of Service Plan)
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| What is the correct procedure to collect a copayment on a managed care plan? | Collect the copayment when the patient arrives for the office visit.
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| Medicare Part A is administered (run) by who? | The Center for Medicare and Medicaid Services.
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| Part A of Medicare covers? A: Hospice care B: Physician outpatient services C: Blood transfusions D: Physical therapy | Hospice Care
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| Part B of Medicare covers? A: Diagnostic tests B: Nursing facility care C: Hospice care D: Hospital rooms | Diagnostic tests
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| Medicare Part A benefit period ends when? | Has not been a bed patient in any hospital or NF for 60 consecutive days.
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| Medigap insurance may cover? A: 75% of the Medicare allowed amount B: The deductible not covered under Medicare C: All physicians and hospital deductibles D: 80% of the Medicare allowed amount. | The deductible not covered under Medicare.
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| Some senior HMOs may provide services not covered by Medicare, such as? A: Vaccines and ambulance services. B: Mammograms and Pap smears. C: Laboratory and X-ray services. D: Eyeglasses and Prescription drugs. | Eyeglasses and Precription drugs. THINK MEDICARE C IN THIS QUESTION.
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| The abbreviation MCO stands for? | Managed Care Organization.
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| A primary care physician who controls patient acces to specialists is called a/an? | PCP and/or Gatekeeper.
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| UR is the abbreviation for (BLANK) which is necessary to control costs in the health care setting. | Utilization Review. REMEMBER, USUALLY PERFORMED BY A RN IN A INPATIENT SETTING.
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| When a Managed care plan requires the PCP to seek approval before referring a patient to a specialist, it is called obtaining a (BLANK)? | Preauthorization or Preapproval.
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| Medicare outpatient coverage is referred to as Part (BLANK)? | Part B
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| The alpha letter (BLANK) following the identification number on a females patient's Medicare card indicates that it is her husband's number. | The letter B
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| A specialized insurance policy that is predefined by the federal government for the Medicare beneficiary to cover the deductible and copayment amounts is referred to as a (BLANK)? | Medigap.
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| A Medicare Nonparticipating provider may bill no more than the Medicare (BLANK). | Limiting Charge
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| For all elective surgeries for which the actual charge will be (BLANK) or more, a Medicare Nonparticipating provider who does not accept assignement must provide the beneficiary in writing with the estimated fee for any elective surgery. | $500.00
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| An NPI number is issued to a provider by CMS is the acronym for (BLANK) | Natinal Provider Identifier.
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| A patient classified with ESRD may be provided benefits from Medicare. What does ESRD stand for? | End stage renal disease.
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| What type of coverage does a Medi-Medi patient have? | Medicare and Medicaid.
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| The HMO Act of 1973 require most employees to offer HMO coverage to their employees as an alternative to traditional health insurance. | True
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| Medicare eligible patients are not involved with HMOs or prepaid health plans. | False. Think Medicare C Plans.
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| In a staff model HMO, providers are hired directly by the health plan that pays their salary. | True.
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| A: 80% of the limiting charge. B: 80% of the provider's usual and customary charges. C: 80% of the billed amount. D: 80% of the Medicare approved charge. | 80% of the Medicare approved charge.
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| In the Medicare program, there is mandatory assignment for? A: Surgery performed in the Physician' office. B: E/M Services C: Clinical Laboratory Tests. D: ECGs | C: Clinical Laboratory Tests. THINK CLIA.
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| When a Medicare patient signs an ABN, the procedure code for the service provided must be modified using the HCPCS Level II modifier? A: GB B: GA C: HB D: LA | B: GA
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| Payments to hospitals for Medicare services are classifed according to? A: CPT codes B: DRGs C: ICD-9-CM codes D: PTMs. | DRGs Diagnotic Related Groups.
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| Oranizations handling claims from hospitals, NFs, IMCFs, LTCFs, and home health agencies are called? A: Fiscal intermediaries B: Regional intermediaries. C: Fiscal agents. D: Local intermediaries. | A: Fiscal Inermediaries.
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| The time limit for submitting a Medicare claim is?` | The end of the calender year following the fiscal year in which services were performed.
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| When a Medicare carrier transmits a Medigap claim electronically to the Medigap carrier, it is referred to as/a? | Crossover claim.
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| The HMO Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance. | True
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| Medicare- eligible patients are not involved with HMO or prepaid health plans. | False. Think Medicare C Programs.
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| In a staff model HMO, physicians are hired directly by the health plan that pays their salary. | True.
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| In a Point of Service Plan (POS), members may choose to use a nonprogram provider at any time. | True.
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| In certain managed care plans, there is an incentive for the gatekeeper to limit patient referrals to specialist. | True.
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| Managed care plans allow laboratory tests to be performed at any facility the patient chooses. | False.
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| Managed care plans never require a CMS 1500 claim form to completed and submitted. | False.
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| A copayment in a managed care plan is usually a fixed dollar amount or predetermined fee. | True.
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| Medicare provides insurance for disabled individuals if they received SS diability benefits for 24 months. | True.
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| All persons age 65 who meet eligibiltiy requirements for Medicare receive Medicare Part B (outpatient coverage). | False. Think Election into or Electing out of.
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| Medicare provides insurance for disabled worker of any age. | True.
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| Patients who elect Medicare Part B coverage pay annually increasing basic premium payments. | True.
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| It is possible for an alien to be eligible for Medicare A and B. | True.
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| Employee and Employer contributions help pay for Medicare Part A health services. | True.
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| There is a limit on the number of Medicare benefit periods a patient can have for hospital care. | False.
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| Medicare Part A is called supplementary medical insurance (SMI) | False. This is Medicare Part B.
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| Funds for Medicare B come equally from those who sign up for it and the federal government. | True.
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| Once a patient changes from Medicar to a senior HMO, the patient must stay with that HMO for the remainder of the year. | False. Penalties apply.
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| Nonparticipating physicnas have an option regarding accepting assignment on the Medicare patient. | True. Case by case basis.
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| A nonparticipating physician who is not accepting assignment may bill any fee he/she wishes. | False. Think Limiting Charge.
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| Because Medicare is a federal program providing uniform benefits, payment of each medical service rendered to Medicare patients is consistent across the U.S. | False. Think geographic cost index (cost of living index)
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| Medicare transmits Medigap claims electronically for the participating physicians when Medigap information is provided on the original Medicare Claim. | True. Think Cross Over Claim
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| Medigap payments go directly to the beneficiary. | False. But occasionaly true if the the beneficiary submits for payments paid at time of service.
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