chp 11-18
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| americas oldest privately owned, prepaid medical group is the | ross-loss medical group
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| kaiser permanente's medical plan is a closed panel program, which means | it limits the patient's choice of personal physicians
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| how are physicians who work for a prepaid group practice model paid? | salary paid by independent group
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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 independent practice association (IPA), physicians are | not employees and are not paid salaries
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| 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)
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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 plans is a(n) | PPG
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| a program that offers a comination of HMO-style cost management and PPO-style freedom of choice is a(n) | point-of-service (POS) plan
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| practitioners in an HMO program may come under peer review by a professional group called a | quality improvement organization
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| when a physician sees a patient more than is medically necessary, it is called | churning
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| referral of a patient recommended by one specialist to another specialist is known as _____ care | teritiary
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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 run by | the centers for medicare and medicaid services
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| medicare is a _____ health insurance program | federal
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| the letter "d" following the identification number on the patient's medicare card indicates a | widow
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| the letters preceding the number on the patient's medicare identification card indicate | railroad retiree
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| the frequency of pap tests that may be billed for a medicare patient who is low risk is | once every 24 months
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| when a medicare beneficiary has employer supplemental coverage, medicare refers to these plans as | MSP
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| some senior HMOs may provide services not covered by medicare, such as | eyeglasses and prescription drugs
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| a participating physician with the medicare plan agrees to accept 80% of the | medicare-approved charge
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| 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
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| under the prospective payment system (PPS), hospitals treating medicare patients are reimbursed according to | a new fee schedule established in 1983
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| payments to hospitals for medicare services are classified according to | DRGs
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| the 1987 omnibus budget reconciliation act (OBRA) established the | MAAC
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| the HCPCS national alphanumeric codes are referred to as level ____ codes | II
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| organizations handling claims from hospitals, nursing facilities, intermediate care facilities, long term care facilities, and home health agencies are called | fiscal intermediaries
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| the federal emergency relief administration made funds available to pay for | medical expenses of the needy unemployed
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| in the medicaid program, congress authorized vendor payments for medical care, which are payments from the | welfare agency directly to the physician
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| DEFRA and CHAP were responsible for | expanding medicaid eligibility requirements
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| the federal aspects of medicaid are the responsibility of the | CMS
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| state childrens health insurance program (SCHIPs) | operate with federal grant support under title V of the social security act
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| the omnibus budget reconciliation act | provided assistance for the aged and disabled who are receiving medicare and whose incomes are below the poverty level
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| medicaid is available to needy and low income people such as the | blind, disabled, aged (65 years or older)
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| basic maternal and child health program (MCHP) provisions offered in all states include children with | handicap needs who require orthopedic treatment or plastic surgery
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| if a physician accepts medicaid patients, the physician must accept | the medicaid-allowed amount
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| medicaid eligibility must always be checked for the ___ of service | month, type
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| the medicaid service for prevention, early detection, and treatment for welfare children is known as | EPSDT
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| the three choices of health care coverage for families of active duty military personnel, military retirees, and their dependents are | tricare standard, tricare prime, and tricare extra
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| people not entitled to benefits under tricare are | veterans health administration (formerly CHAMPA) beneficiaries
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| what is the system called that tricare claims processors use to verify beneficiary eligibility? | DEERS
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| an NAS is a certification | from a military hospital stating that it cannot provide the necessary care
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| medical care that is cost-shared by both tricare standard and a civilian source is known as ____ care | cooperative
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| the tricare fiscal year extends from | october 1 to september 30
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| health care professionals who may treat a tricare patient are | doctors of medicine, doctors of osteopathy, psychologists
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| a health care professional, usually a registered nurse, who helps the patient work with his or her primary care manager to locate a specialists or obtain a preauthorization for careis referred to as a(n) | HCF
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| a physician who chooses not to participate in tricare bills ____ charge | no more than 115% of the tricare allowable
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| the time limit within which a tricare outpatient claim must be filed is ______ a service is provided | within 1 year from the date
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| the time limit within which a tricare inpatient claim must be filed is within | 1 year from a patients discharge from an inpatient facility
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| tricare prime and tricare extra claims are | filed by the provider to a tricare subcontractor
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| if a tricare extra claim is submitted with ever 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
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| name two kind of statutes under workers compensation | federal compensation laws, state compensation laws
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| an unexpected, unintended event that occurs at a particular time and place, causing injury to an individual not of his or her own making, is called a/an | accident
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| maria cardoza works in a plastic manufacturing company and inhales some fumes that cause bronchitis. Because this condition is associated with her employment, it is called a/an | occupational illness or disease
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| name the federal workers compensation acts that cover workers | 1)workmens compensation law of the district of columbia 2)federal coal mine health and safety act 3)federal employees compensation act 4)longshoremens and harbor workers compensation act
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| state compensation laws that require each employer to accept its provisions and provide for specialized benefits for employees who are injured at work are called | compulsory law
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| state compensation laws that may be accepted or rejected by the employer are known as | elective law
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| state five methods used for funding workers compensation | 1)monopolistic state or provincial fund 2)territorial fund 3)self insurers 4) competitive state fund 5)private insurance company
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| who pays the workers compensation insurance premiums? | employer
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| five types of workers compensation benefits | 1)medical treatment 2)temporary disability 3)permanent disability 4)death benefits for survivors 3)rehabilitation benefits
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| two types of workers compensation claims and the differences among them | 1) none disability claim- simplest type, generally involves a minor injury, does not require weekly TD 2)temporary disability claim- TD occurs when worker has a work related injury/illness, is unable to perform duties for a period of time
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| one type of workers compensation claim | permanent disability claim- patient is usually on TD benefits for a period of time and then goes on permanent disability
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| weekly temporary disability payments are based on | percentage of employees earning at the time of the the injury
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| after suffering an industrial injury, mr. fields is in a treatment program in which he is given real tasks for building strength and endurance. This form of therapy is called | work hardening
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| when an industrial case reaches the time for rating the disability, this is accomplished by what state agency? | industrial accident commission or workers compensation board
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| may an injured person appeal his or her case if he or she is not satisfied with the rating? to whom does he or she appeal? | Yes. The workers compensation board or the industrial accident commission
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| when fraud and abuse is suspected in a workers compensation case, the physician should report the situation to | the insurance carrier
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| third party subrogation | "to substitute" one party for another. A transfer of the claims and rights from the original creditor to the 3rd party liability carrier.
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| when an individual suffers a work related injury or illness, the employer must complete and send a form called a/an______ to the insurance company and workers compensation state offices. | employers report of occupational injury
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| if the employee is sent to a physicians office for medical care, the employer must complete a form called a/an ______, which authorizes the physician to treat the employee | medical serive order
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| employers are required to meet health and safety standards for their employees under federal and states statutes known as the | occupational safety and health administration (OSHA) act of 1970
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| the process of carrying on a lawsuit is called | litigation
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| a proceeding during which an attorney questions a witness who answers under oath but no in open court is called a/an | depostition
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| the legal promise of a patient to satisfy a debt to the physician from proceeds received from a litigated case is termed a/an | lien
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| when a physician teats an industrial injury, he/she must complete a first treatment medical report or doctor's first report of occupational injury or illness and send it to the following | insurance carrier, employer, state workers compensation office
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| the first thing an employee should do after he/she is injured on the job is to notify his/her employer or immediate supervisor | true
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| a stamped physicians signature is acceptable on the doctors first report of occupational injury or illness form | false
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| in a workers compensation case, bills should be submitted monthly or at the time of termination of treatment, and a claim becomes delinquent after a time frame of 45 days | true
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| name the states that have nonindustrial state disability programs | california, new york, new jersey, puerto rico, hawaii,, rhode island
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| four states that allow for maternity benefits in normal pregnancy are | california, hawaii, new jersey, rhode island
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| two federal programs for individuals younger than 65 years of age who have a severe disability are | social security disability insurance (SSDI), social security income (SSI)
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| when an individual becomes permanently disabled and cannot pay the insurance premium, a desirable provision in an insurance contract is | exclusions
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| when an individual who is insured under a disability income insurance policy cannot perform one or more of his/her regular job duties, this is known as | residual or partial disability
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| health insurance that provides monthly or weekly income when an individual is unable to work because of nonindustrial illness or injury is called | individual disability income insurance
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| another disability income insurance term for benefits is | indemnity
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| when the purchase of insurance is investigated, the word/words to look for in the insurance contract that mean the premium cannot be increased at renewal time is/are | noncancelable clause
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| provisions that limit the scope of insurance coverage are known as | exclusions
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| a social security administration division that determines an individual's eligibility to be placed under the federal disability program is called | disability determination services
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| the time period from the beginning of disability to receiving the first payment of benefits is called a/an | waiting period
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| when a person insured under a disability income insurance policy cannot, for a limited period of time, perform all functions of his or her regular job duties, this is known as permanent disability | false
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| to be eligible to apply for disability benefits under social security, an individual must be unable to perform any type of work for a period of not less than 12 months | true
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| when a claim form is submitted for a patient applying for state disability benefits, the most important item required on the form is the claimant's social security number | true
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| sliding scales for discounts and per diems | interim per diem paid for reach day in the hospital
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| discounts in the form of sliding scale | a percentage reduction in charges for total bed pays per year
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| stop loss | hospital buys insurance to protect against lost revenue and receives less of a capitation fee
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| withhold | method in which part of plan's payment to the hospital may be withheld and paid at the end of the year
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| charges | dollar amount that a hospital bills a case for services rendered
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| ambulatory payment classifications | outpatient classification based on procedures rather than on diagnoses
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| case rate | an averaging after a flat is given to certain categories of procedures
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| diagnosis-related groups | classification system categorizing patients who are medically related with regard to diagnosis and treatment and are statistically similar in lengths of hospital stay
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| differential by service type | hospital receives a flat per admission payment for the particular service to which the patient is admitted
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| periodic interim payments | plan advances cash to cover expected claims to the hospital
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| bed leasing | when a managed care plan leases beds from a hospital and pays per bed whether used or not
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| differential by day in hospital | reimbursement method that pays more for the first day in the hospital than for subsequent days
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| capitation | reimbursement to the hospital on a per member per month basis
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| per diem | single charge for a day in the hospital regardless of actual cost
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| percentage of revenue | fixed percentage paid to the hospital to cover charges
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| hospital inpatient cases that cannot be assigned to an appropriate DRG because of atypical situations are referred to as | cost outliers
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| an individual who receives medical service in a section or department of the hospital and goes home the same day is called a/an | outpatient
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| a surgical procedure that may be scheduled in advance, is not an emergency, and is discretionary on the part of the physician and patient is called | elective surgery
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| a preexisting condition that will, because of its effect on the specific principal diagnosis, require more intensive therapy or cause an increase in length of stay (LOS) by at least 1 day in approximately 75% of cases is called a | comorbid condition
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| medicare implemented the diagnosis-related groups (DRG) based system of reimbursement to hold down rising health care costs | true
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| a resume format that emphasizes work experience dates is known as | chronological
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| when an individual plans to start an insurance billing company, he/she should have enough funds to operate he business for a period of | 1 year or more
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| under HIPPA regulations, if a physician's insurance billing is outsourced to a person, this individual is known as/an ____ because he/she uses and discloses individuals identifiable health information | business associate
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| when insurance billing is outsourced to a company, a document should be created, signed, and notarized by both parties known s a | service contract
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| a guide who offers advice, criticism, and guidance to an inexperienced person to help him/her reach a goal is known as a/an | mentor
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