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Week 3

Chapters 11, 12, 13, & 14

A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is a/an PPG
A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a(n) point of service (POS) plan
A significant contribution to HMO development was the Health Maintenance Organization Act of 1973.
America's oldest privately owned, prepaid medical group is the Ross-Loos medical group
An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a(n) preferred provider organization (PPO)
How are physicians who work for a prepaid group practice model paid? salary paid by independent group
How does an HMO receive payment for the services its physicians provide? fee for service
In an independent practice association (IPA), physicians are not employees and are not paid salaries.
Kaiser Permanente's medical plan is a closed panel program, which means it limits the patients choice of personal physicians
Practitioners in an HMO program may come under peer review by a professional group called a quality improvement organization
A primary care physician who controls patient access to specialists is called a(n) gatekeeper
Beginning in ____________ , the passing of federal legislation in 2010 requires almost everyone to be insured or they will pay a fine. 2014
Benefits under the HMO Act fall under two categories: __________ health services and supplemental health services. basic
The abbreviation MCO stands for __________. managed care organization
The law states that an employer employing __________ or more persons may offer the services of an HMO clinic as an alternative health treatment plan for employees. 25
A copayment in a managed care plan is usually a fixed dollar amount (predetermined fee). True
Exclusive provider organizations (EPOs) are regulated by the federal government. False
If a primary care physician sends a patient to a specialist for consultation and the specialist is not in the managed care plan, the specialist may bill the primary care physician for payment. True
In a point-of-service (POS) program, members may choose to use a nonprogram provider at any time. True
In a staff model HMO, physicians are hired directly by the health plan that pays their salary. True
In certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists. True
In times past, physicians in private practice billed indemnity insurance plans, and professional services were reimbursed on a fee-for-service basis. True
Managed care plans allow laboratory tests to be performed at any facility the patient chooses. False
Managed care plans never require a CMS-1500 claim form to be completed and submitted. False
Medicare-eligible patients are not involved with HMOs or prepaid health plans. False
A claims assistance professional (CAP) may act on the Medicare beneficiary's behalf as a client representative.
A Medicare prepayment screen identifies claims to review for medical necessity & monitors the number of times given procedures can be billed during a specific time frame.
A participating physician with the Medicare plan agrees to accept 80% of the Medicare-approved charge
A program that contracts with CMS to review medical necessity and appropriateness of inpatient medical care is known as a(n) Quality Improvement Organization (QIO)
An explanation of benefits document for a patient under the Medicare program is referred to as the Medicare remittance advice document
Currently the Part B Medicare annual deductible is $147
If a check is received from Medicare and it is obvious that it is an overpayment, the insurance billing specialist should deposit the check and then write to Medicare to notify them of the overpayment
In the Medicare program, there is mandatory assignment for clinical laboratory tests.
Medicare is a _____ health insurance program. Federal
Medicare Part A is run by The Centers for Medicare and Medicaid Services.
A Medicare nonparticipating physician may bill no more than the Medicare __________. limiting charge
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 __________. Medigap, Medifill
An NPI number issued to a provider by CMS is the acronym for National Provider Identifier
Medicare outpatient coverage is referred to as Part B
Medicare provides insurance for people __________ years of age or older who are retired on Social Security. 65
A Medicare patient with an HMO does not need a supplemental insurance policy. True
A nonparticipating physician who is not accepting assignment may bill any fee he or she wants. False
All persons age 65 who meet eligibility requirements for Medicare receive Medicare Part B (outpatient coverage). False
Because Medicare is a federal program providing uniform benefits, payment of each medical service rendered to Medicare patients is consistent across the United States. False
Benefits of Medigap policies may vary from one state to another. False
Each Medicare hospital benefit period consists of 60 consecutive days in a hospital or nursing facility. True
Employee and employer contributions help pay for Medicare Part A health services. True
Funds for Medicare Part B come equally from those who sign up for it and the federal government. True
In the Medicare program, a physical examination is a covered benefit when performed within 12 months of enrollment. True
It is possible for an alien to be eligible for Medicare Part A and Part B. True
Basic Maternal and Child Health Program (MCHP) provisions offered in all states include children with handicap needs who require orthopedic treatment or plastic surgery
DEFRA and CHAP were responsible for expanding Medicaid eligibility requirements
If a physician accepts Medicaid patients, the physician must accept the Medicaid-allowed amount
In the Medicaid program, Congress authorized vendor payments for medical care, which are payments from the welfare agency directly to the physician
Medicaid eligibility must always be checked for the _____ of service. Both month of service and type of service
Medicaid is administered by the state government with partial federal funding
Medicaid is available to needy and low-income people such as the the blind, the disabled and the aged 65+
Medicaid managed care patient claims should be sent to the managed care organization and not the Medicaid fiscal agent
State Children's Health Insurance Programs (SCHIPs) operate with federal grant support under Title V of the Social Security Act
The federal aspects of Medicaid are the responsibility of the CMS
Medicaid identification cards are usually issued every __________. month
Medicaid was legally established by Title ____ of the Social Security Act. XIX
Most states have __________ for Medicaid payments if a patient requires medical care while out of state. reciprocity
Some Medicaid recipients in the medically needy category must pay a coinsurance payment and/or deductible, also known as a(n) __________ within the eligibility month before state benefits may be received. share of cost
The abbreviation for the Deficit Reduction Act of 1984 is DEFRA
A physician may accept or refuse Medicaid patients on the basis of the individual patient and his or her circumstances. False
All state Medicaid programs operate with a fee-for-service reimbursement system. False
All states processing medical claims must bill using the CMS-1500 claim form. True
Emergency care and pregnancy services are exempt by law from copayment requirements. True
Family planning is a Medicaid basic benefit. True
Home health care is never covered under Medicaid. False
If a service is totally disallowed by Medicaid, a physician is within legal rights to bill the patient. True
In some cases the welfare office may grant retroactive eligibility to a patient. True
It is not possible for a person to be eligible for Medicaid benefits and also have additional group health insurance coverage. False
It is not possible for an immigrant to have Medicaid coverage. False
A physician who chooses not to participate in TRICARE bills __________ charge. no more than 115% of the TRICARE allowable
A health care professional, usually a registered nurse, who helps the patient work with his or her primary care manager to locate a specialist or obtain a preauthorization for care is referred to as a(n) HCF
An NAS is a certification certification from a military hospital stating that it cannot provide the necessary care.
Enrollment in TRICARE Prime is for 1 year at a time
Health care professionals who may treat a TRICARE patient are doctors of medicine, osteopathy and psychologists
If a TRICARE Extra claim is submitted with several items and several dates of service, the time limit that would apply to the claim for filing would be Individual time limits for each item on the claim.
Medical care that is cost-shared by both TRICARE Standard and a civilian source is known as _____ care. cooperative
People NOT entitled to benefits under TRICARE are CHAMPVA beneficiaries.
The health maintenance organization provided for dependents of active duty military personnel is called TRICARE Prime.
The NAS catchment area is defined by ZIP codes and based on an area of about 40 miles in radius surrounding each USMTF
A certification from a military hospital stating that it cannot provide the care needed is called a(n) NAS
A person who has served in the Armed Forces of the United States, especially in time of war, who is no longer in the service and has received an honorable discharge is called a(n) veteran
All dependents __________ years of age or older are required to have a Uniformed Services (military) identification card. 10
An organization under contract to the government that handles insurance claims for care received under the TRICARE program is known as a(n) fiscal intermediary
Dependents of individuals who have died as a result of service-connected injuries qualify to receive __________ benefits. Veterans Health Administration (formerly CHAMPVA)
A certified nurse midwife is an authorized provider of health care for TRICARE beneficiaries. True
A partnership program permits TRICARE-eligible people to receive inpatient treatment from civilian providers of care in a military hospital. True
A person retired from a career in the Armed Forces is eligible for TRICARE until 65 years of age. True
Active duty service members are eligible for TRICARE Extra. False
All dependents 10 years of age or older are required to have a military identification card for TRICARE. True
All Privacy Act requests from patients must be made in writing. False
Enrollment in TRICARE Prime is voluntary. True
In the TRICARE Extra plan, the individual enrolls yearly and pays an annual fee. False
Individuals who qualify for TRICARE are known as subscribers. False
Nonparticipating providers may choose to accept TRICARE assignment on a case-by-case basis. True
Created by: csalamon722
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