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Week 3
Chapters 11, 12, 13, & 14
| Question | Answer |
|---|---|
| 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 |
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csalamon722
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