fordney book Word Scramble

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Question	Answer
americas oldest privately owned, prepaid medical group is the	ross-loss medical group
kaiser permanente's medical plan is a closed panel program, which means	it limits the patient's choice of personal physicians
how are physicians who work for a prepaid group practice model paid?	salary paid by independent group
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
in an independent practice association (IPA), physicians are	not employees and are not paid salaries
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)
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
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
practitioners in an HMO program may come under peer review by a professional group called a	quality improvement organization
when a physician sees a patient more than is medically necessary, it is called	churning
referral of a patient recommended by one specialist to another specialist is known as _____ care	teritiary
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
medicare part a is run by	the centers for medicare and medicaid services
medicare is a _____ health insurance program	federal
the letter "d" following the identification number on the patient's medicare card indicates a	widow
the letters preceding the number on the patient's medicare identification card indicate	railroad retiree
the frequency of pap tests that may be billed for a medicare patient who is low risk is	once every 24 months
when a medicare beneficiary has employer supplemental coverage, medicare refers to these plans as	MSP
some senior HMOs may provide services not covered by medicare, such as	eyeglasses and prescription drugs
a participating physician with the medicare plan agrees to accept 80% of the	medicare-approved charge
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
under the prospective payment system (PPS), hospitals treating medicare patients are reimbursed according to	a new fee schedule established in 1983
payments to hospitals for medicare services are classified according to	DRGs
the 1987 omnibus budget reconciliation act (OBRA) established the	MAAC
the HCPCS national alphanumeric codes are referred to as level ____ codes	II
organizations handling claims from hospitals, nursing facilities, intermediate care facilities, long term care facilities, and home health agencies are called	fiscal intermediaries
the federal emergency relief administration made funds available to pay for	medical expenses of the needy unemployed
in the medicaid program, congress authorized vendor payments for medical care, which are payments from the	welfare agency directly to the physician
DEFRA and CHAP were responsible for	expanding medicaid eligibility requirements
the federal aspects of medicaid are the responsibility of the	CMS
state childrens health insurance program (SCHIPs)	operate with federal grant support under title V of the social security act
the omnibus budget reconciliation act	provided assistance for the aged and disabled who are receiving medicare and whose incomes are below the poverty level
medicaid is available to needy and low income people such as the	blind, disabled, aged (65 years or older)
basic maternal and child health program (MCHP) provisions offered in all states include children with	handicap needs who require orthopedic treatment or plastic surgery
if a physician accepts medicaid patients, the physician must accept	the medicaid-allowed amount
medicaid eligibility must always be checked for the ___ of service	month, type
the medicaid service for prevention, early detection, and treatment for welfare children is known as	EPSDT
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
people not entitled to benefits under tricare are	veterans health administration (formerly CHAMPA) beneficiaries
what is the system called that tricare claims processors use to verify beneficiary eligibility?	DEERS
an NAS is a certification	from a military hospital stating that it cannot provide the necessary care
medical care that is cost-shared by both tricare standard and a civilian source is known as ____ care	cooperative
the tricare fiscal year extends from	october 1 to september 30
health care professionals who may treat a tricare patient are	doctors of medicine, doctors of osteopathy, psychologists
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
a physician who chooses not to participate in tricare bills ____ charge	no more than 115% of the tricare allowable
the time limit within which a tricare outpatient claim must be filed is ______ a service is provided	within 1 year from the date
the time limit within which a tricare inpatient claim must be filed is within	1 year from a patients discharge from an inpatient facility
tricare prime and tricare extra claims are	filed by the provider to a tricare subcontractor
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
name two kind of statutes under workers compensation	federal compensation laws, state compensation laws
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
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
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
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
state compensation laws that may be accepted or rejected by the employer are known as	elective law
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
who pays the workers compensation insurance premiums?	employer
five types of workers compensation benefits	1)medical treatment 2)temporary disability 3)permanent disability 4)death benefits for survivors 3)rehabilitation benefits
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
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
weekly temporary disability payments are based on	percentage of employees earning at the time of the the injury
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
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
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
when fraud and abuse is suspected in a workers compensation case, the physician should report the situation to	the insurance carrier
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.
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
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
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
the process of carrying on a lawsuit is called	litigation
a proceeding during which an attorney questions a witness who answers under oath but no in open court is called a/an	depostition
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
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
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
a stamped physicians signature is acceptable on the doctors first report of occupational injury or illness form	false
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
name the states that have nonindustrial state disability programs	california, new york, new jersey, puerto rico, hawaii,, rhode island
four states that allow for maternity benefits in normal pregnancy are	california, hawaii, new jersey, rhode island
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)
when an individual becomes permanently disabled and cannot pay the insurance premium, a desirable provision in an insurance contract is	exclusions
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
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
another disability income insurance term for benefits is	indemnity
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
provisions that limit the scope of insurance coverage are known as	exclusions
a social security administration division that determines an individual's eligibility to be placed under the federal disability program is called	disability determination services
the time period from the beginning of disability to receiving the first payment of benefits is called a/an	waiting period
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
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
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
sliding scales for discounts and per diems	interim per diem paid for reach day in the hospital
discounts in the form of sliding scale	a percentage reduction in charges for total bed pays per year
stop loss	hospital buys insurance to protect against lost revenue and receives less of a capitation fee
withhold	method in which part of plan's payment to the hospital may be withheld and paid at the end of the year
charges	dollar amount that a hospital bills a case for services rendered
ambulatory payment classifications	outpatient classification based on procedures rather than on diagnoses
case rate	an averaging after a flat is given to certain categories of procedures
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
differential by service type	hospital receives a flat per admission payment for the particular service to which the patient is admitted
periodic interim payments	plan advances cash to cover expected claims to the hospital
bed leasing	when a managed care plan leases beds from a hospital and pays per bed whether used or not
differential by day in hospital	reimbursement method that pays more for the first day in the hospital than for subsequent days
capitation	reimbursement to the hospital on a per member per month basis
per diem	single charge for a day in the hospital regardless of actual cost
percentage of revenue	fixed percentage paid to the hospital to cover charges
hospital inpatient cases that cannot be assigned to an appropriate DRG because of atypical situations are referred to as	cost outliers
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
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
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
medicare implemented the diagnosis-related groups (DRG) based system of reimbursement to hold down rising health care costs	true
a resume format that emphasizes work experience dates is known as	chronological
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
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
when insurance billing is outsourced to a company, a document should be created, signed, and notarized by both parties known s a	service contract
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

Created by: PNSlagill