Final Review
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Who is generally eligible for Medicare? | Primarily for ages 65+ who have paid (or are spouse of payee) into the plan for 40 quarters or twenty years.
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| Other persons eligible for Medicare are? | Retired railroad workers; those currently receiving SS benefits; persons with end-stage (renal) kidney disease
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| When was Medicare enacted? | In 1965, under the SS Act. It is a federal insurance program.
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| Define Medicare Part A? | automatic when eligibility and deductible met; covers hospital (inpatient) costs; hospice; limited nursing home stays; home health
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| Define Medicare Part B? | (optional) premiums, deductibles, and co-ins. are required; covers physician costs; outpatient services; DME (Durable Medical Equipment) and medical supplies
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| Define Medicare Part C? | (HMO type coverage) called Medicare Advantage; Must be enrolled under part A & B to participate.
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| Define Medicare Part D? | (optional) Covers approved pharmaceuticals
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| Assignment of Benefits | when a pt gives written authorization for reimbursement to the physician for billed charges
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| Coordination of Benefits | one insurance plan working with another to determine how much each plan pays (who pays first?)
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| Insured | The person who is covered by the benefits plan
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| Dependent | Spouse or child covered under the insured's benefits plan
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| Fee Schedule | Amount that will be paid by the insurance plan for each procedure or service is based on this? (Dr.'s list of customary charges)
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| Medicaid | Government sponsored program that provides health benefits to low income or indigent persons.
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| Workers Compensation | Expenses that result form work-related illness/injuries are covered by this.
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| (EOB)Explanation of Benefits | Statement issued to both provider & Pt. that details a payment that has been made by the plan
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| Where could a patient find his/her co-pay, deductible, allowable amount and amount paid to the provider for health services? | On the Explanation of Benefits (EOB) statement.
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| Pre-existing condition | a disease diagnosed before the effective date of coverage by the insurance plan
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| Deductible | Amount of eligible charges each pt. must pay each calendar year before the plan begins to pay benefits.
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| Precertification | Process of determining whether a service or procedure will be covered by the insurance provider
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| What is CHAMPVA? | Plan under which medical bills of spouses/children of vets with total permanent, service-connected disabilities are covered.
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| Capitation | Making a payment to a provider based on a "fixed amount" per enrollee assigned to that provider regardless of services provided.
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| HMO - Health Maintenance Organization | A group of physicians who have a contract to provide services to participating pts. for a pre-determined fee.
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| QIO - Quality Improvement Organization | A group of physicians who review cases for appropriateness of hospitalizations & discharges (are visits necessary, cost effective?)
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| Usual, customary and reasonable | Database or list of charges for each procedure; indicates the charge by a majority of physicians in a geographic area.
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| Premium | Amount paid by an individual to purchase benefits of a health insurance policy.
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| PCP - Primary Care Physician | A general practioner who oversees pts. in an HMO or PPO.
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| Exclusion | A condition or circumstance for which the health insurance policy will not provide benefits.
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| Disability Income Insurance | Insurance coverage that provides a specific monthly or weekly income when an individual becomes unable to work because of illness/injury.
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| Co-payment | Amount of money owed by insured to the provider at the time of service is called this
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| Birthday rule | Determination of the primary carrier is according to birth month when a dependent child is covered by benefit plans of both parents.
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| DRG - Diagnosis Related Groups | Hospital payment system that catagorizes pts. by diagnosis/treatment.
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| UCR payment basis | Usual, customary, and reasonable; What a majority of physicians in a specific geographic area charge for procedures/services rendered
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| Participating Provider | If Medicare sends a check to a physician's office he/she is this type of provider?
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