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Chapters 11, 12, 13, & 14

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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   show
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show point of service (POS) plan  
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A significant contribution to HMO development was the   show
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America's oldest privately owned, prepaid medical group is the   show
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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)   show
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How are physicians who work for a prepaid group practice model paid?   show
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show fee for service  
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show not employees and are not paid salaries.  
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Kaiser Permanente's medical plan is a closed panel program, which means   show
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Practitioners in an HMO program may come under peer review by a professional group called a   show
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A primary care physician who controls patient access to specialists is called a(n)   show
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Beginning in ____________ , the passing of federal legislation in 2010 requires almost everyone to be insured or they will pay a fine.   show
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show basic  
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show managed care organization  
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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.   show
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A copayment in a managed care plan is usually a fixed dollar amount (predetermined fee).   show
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show False  
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show True  
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In a point-of-service (POS) program, members may choose to use a nonprogram provider at any time.   show
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In a staff model HMO, physicians are hired directly by the health plan that pays their salary.   show
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In certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists.   show
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In times past, physicians in private practice billed indemnity insurance plans, and professional services were reimbursed on a fee-for-service basis.   show
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Managed care plans allow laboratory tests to be performed at any facility the patient chooses.   show
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show False  
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Medicare-eligible patients are not involved with HMOs or prepaid health plans.   show
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A claims assistance professional (CAP)   show
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show 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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show Medicare-approved charge  
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show Quality Improvement Organization (QIO)  
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An explanation of benefits document for a patient under the Medicare program is referred to as the   show
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show $147  
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show deposit the check and then write to Medicare to notify them of the overpayment  
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In the Medicare program, there is mandatory assignment for   show
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show Federal  
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Medicare Part A is run by   show
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show limiting charge  
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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 __________.   show
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An NPI number issued to a provider by CMS is the acronym for   show
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show B  
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Medicare provides insurance for people __________ years of age or older who are retired on Social Security.   show
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show True  
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A nonparticipating physician who is not accepting assignment may bill any fee he or she wants.   show
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All persons age 65 who meet eligibility requirements for Medicare receive Medicare Part B (outpatient coverage).   show
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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 United States.   show
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show False  
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Each Medicare hospital benefit period consists of 60 consecutive days in a hospital or nursing facility.   show
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show True  
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show True  
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show True  
🗑
show True  
🗑
show handicap needs who require orthopedic treatment or plastic surgery  
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show expanding Medicaid eligibility requirements  
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show the Medicaid-allowed amount  
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show welfare agency directly to the physician  
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Medicaid eligibility must always be checked for the _____ of service.   show
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show state government with partial federal funding  
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show the blind, the disabled and the aged 65+  
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Medicaid managed care patient claims should be sent to the   show
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State Children's Health Insurance Programs (SCHIPs)   show
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show CMS  
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show month  
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show XIX  
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show reciprocity  
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show share of cost  
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show DEFRA  
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show False  
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All state Medicaid programs operate with a fee-for-service reimbursement system.   show
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All states processing medical claims must bill using the CMS-1500 claim form.   show
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show True  
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show True  
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Home health care is never covered under Medicaid.   show
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If a service is totally disallowed by Medicaid, a physician is within legal rights to bill the patient.   show
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In some cases the welfare office may grant retroactive eligibility to a patient.   show
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show False  
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It is not possible for an immigrant to have Medicaid coverage.   show
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A physician who chooses not to participate in TRICARE bills __________ charge.   show
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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 specialist or obtain a preauthorization for care is referred to as a(n)   show
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An NAS is a certification   show
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show 1 year at a time  
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show doctors of medicine, osteopathy and psychologists  
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show Individual time limits for each item on the claim.  
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show cooperative  
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People NOT entitled to benefits under TRICARE are   show
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show TRICARE Prime.  
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show defined by ZIP codes and based on an area of about 40 miles in radius surrounding each USMTF  
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A certification from a military hospital stating that it cannot provide the care needed is called a(n)   show
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show veteran  
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All dependents __________ years of age or older are required to have a Uniformed Services (military) identification card.   show
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An organization under contract to the government that handles insurance claims for care received under the TRICARE program is known as a(n)   show
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Dependents of individuals who have died as a result of service-connected injuries qualify to receive __________ benefits.   show
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show True  
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A partnership program permits TRICARE-eligible people to receive inpatient treatment from civilian providers of care in a military hospital.   show
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show True  
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show False  
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All dependents 10 years of age or older are required to have a military identification card for TRICARE.   show
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show False  
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Enrollment in TRICARE Prime is voluntary.   show
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In the TRICARE Extra plan, the individual enrolls yearly and pays an annual fee.   show
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Individuals who qualify for TRICARE are known as subscribers.   show
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show True  
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