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Fundamental of Managed Care
Chapter 9 Unit 1
128
Medical
Post-Graduate
02/05/2012
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Term
When coding claims it is important that certain descriptors are used to define the level of E/M services. Which of the following is not one of those components?
 Definition
Place of service
Term
Patients insured with Medicare part B receive free lab services.
 Definition
True
Term
Which type of HMO offers it members the greatest flexibility in their choice of health care?
 Definition
Open-ended HMO
Term
The National Provider Identification Number used when filing Medicare claims is unique to each physician and replaced what prior identification numbers?
 Definition
UPIN and PIN
Term
Code books are updated every 5 years to ensure correct codes are being used.
 Definition
False
Term
In insurance billing the reason rule states that you must code the reason of the patient encounter first.
 Definition
True
Term
HMOs allow the patient the option of using network or nonnetwork physicians and hospitals
 Definition
False
Term
Which one of the following is the most appropriate term used to describe determining not only if services are covered, but if the purpose of the procedure is necessary?
 Definition
Preauthorization
Term
The birthday rule applies only to children of divorced parents
 Definition
False
Term
Under most managed care plans a patient will be required to make a copayment of $5.00 to $100.00 per visit depending on the insurance company's policies.
 Definition
False
Term
EOB stands for estimation of benefits
 Definition
False
Term
What would be an example of a HCPCS for orthotics?
 Definition
L 1234
Term
___________________ is when a person is given information about a patient without a signed authorization.
 Definition
Breach of confidentiality
Term
HCPCS codes are used only in hospitals settings
 Definition
False
Term
An insurance claim will be denied by an insurance company if an incorrect
ICD-9-CM code is used
 Definition
True
Term
What is the primary purpose of HMOs?
 Definition
Cost containment
Term
Indemnity type insurance has the most structural guidelines of all insurances that patients must follow
 Definition
False
Term
The physician is required to file Medicare claims for Medicare patients rather than the patients filing their own claims
 Definition
True
Term
Knowingly submitting a false Medicare claim is punishable by incarceration of up to 5 years for the person submitting the claim
 Definition
False
Term
Which part of Medicare is used for services of a physician in or out of the hospital?
 Definition
Medicare Part B
Term
Physicians who treat patients under workers' compensation plans to register with the Workers' Compensation Board every 2 years
 Definition
False
Term
Which type of insurance requires a patient to pay in full at the time service is provided.
 Definition
Indemnity
Term
Which major health insurance plan was originally set up to pay for hospital expenses?
 Definition
Blue Cross
Term
The two major types of health insurance are individual and group
 Definition
True
Term
The largest industry in the United States is insurance
 Definition
True
Term
A fee schedule is also referred to as an agreed rate for service
 Definition
True
Term
Large insurance companies publish their provider directories on their Web sites
 Definition
True
Term
When doing manual claims it is important to make a copy of the completed claim forms before you send them to the insurance company
 Definition
True
Term
Only a person who is 65 years old or older can receive Medicare
 Definition
False
Term
HMOs are also referred to as managed care
 Definition
True
Term
The purpose of insurance is to protect us or compensate us from losses we may incur
 Definition
True
Term
HMO
 Definition
Health Maintenance Organization
Term
PPO
 Definition
Preferred Provider Organization
Term
HSA
 Definition
Health Savings Accounts
Term
HRA
 Definition
Health Reimbursement Arrangement
Term
Managed care is a phrase regarding health insurance that became popular in the late 1980s in the US
 Definition
True
Term
Managed care insurance plans are referred to as
 Definition
HMOs Health Maintenance Organizations
Term
HMOs contracts offer people affordable health care plans because they are provided through their place of work at a reasonable cost
 Definition
True
Term
Standard claims form of the Centers for Medicare and Medicaid Services to submit for third-party payment
 Definition
CMS 1500 (Centers for Medicare and Medicaid Services)
Term
Federal government insurance program for persons over 62 and certain disabled persons
 Definition
Workers' compensation
Term
Private insurance to supplement Medicare benefits for non-covered services
 Definition
Medigap (Medifill)
Term
A group of physicians who continue to practice independently in their own offices
 Definition
Independent Practice Association (IPA)
Term
Coding system used to document diseases, injuries, illness, and modalities.
 Definition
International Classification of Diseases (current number), Revision, Clinical Modification (ICD-9-CM)
Term
Another name for encounter form
 Definition
superbill
Term
Transferring words into numbers to facilitate use of computers in claims processing
 Definition
Coding
Term
moneys paid for an insurance contract
 Definition
premium
Term
fee schedule based on relative value of resources that physicians spend to provide services to Medicare patients
 Definition
Resource-based relative value scale (RBRVS)
Term
The person who has been insured; insurance policy holder
 Definition
subscriber
Term
prior authorization must be obtained before the patient is admitted to the hospital or receives some specified outpatient or in-office procedures
 Definition
Precertification
Term
What type of medical insurance has created competition in the insurance industry over the years?
 Definition
HMOs
Term
Why are HMOs so popular
 Definition
because is a great employee benefit for its affordable health care plans
Term
How did the phrase "managed care" originates?
 Definition
in the early 1970s to convey the concept of promoting food health and preventive medicine
Term
Which of the two major types of insurance is more affordable?
 Definition
Group
Term
Describe managed care today
 Definition
an organized system of medical team members and groups who provide quality and cost-effective care that encompasses both delivery of health care and the payment of these services
Term
What is generally the cost of health care to employees who employer offers an HMO as part of their benefit package?
 Definition
reasonable group premium rate and a set co-pay
Term
What is critical to ensure successful reimbursement for medical services rendered to patients?
 Definition
legible writing or printing and correct information
Term
Attending physician
 Definition
physician who cares for patient in the hospital
(not necessarily the physician who admitted the patient in the hospital)
Term
Signed authorization
 Definition
permission to release medical information
Term
Advanced directives
 Definition
printed and signed statement to direct those who will take care of medical decisions for a patient when the patient becomes unable to make decisions. Also known as a living will
Term
Admitting physician
 Definition
physician who admits the patient to the hospital
(not necessarily the physician attending the patient)
Term
Capitation
 Definition
the health care provider is automatically paid a fixed amount per month regardless of provided services for each patient who is a member of a particular insurance company
Term
Balance billing
 Definition
the amount of the charges to the patient for medical services that the insurance did not pay
Term
Accounts receivable
 Definition
total amount of all charges that have not been paid to the physician yet
Term
Claim
 Definition
request for payment under an insurance company made by either the physician or the patient
Term
Group health insurance generally costs less and is more comprehensive
 Definition
True
Term
One of the most helpful points that the medical assistant can stress to patients is to have them check their insurance policy regarding their coverage
 Definition
True
Term
When greeting the patient in the office upon every arrival, ask the patient for a current insurance card.

make a copy of both sides
 Definition
True
Term
Accounts payable
 Definition
the total amount owed by the practice to suppliers and other service providers
Term
Assignment of benefits
 Definition
the authorized signature of the patient for payment to be paid directly to the physician for services
Term
CHAMPVA
 Definition
Civilian Health and Medical Program of the Veterans' Administration
Term
Civilian Health and Medical Program of the Veterans' Administration (CHAMPVA)
 Definition
established in 1973 for the spouses and dependent children of veterans who have total, permanent, service-connected disabilities
Term
coding
 Definition
transference of words into numbers to facilitate the use of computers in claim processing
Term
coordination of benefits (COB)
 Definition
procedures used by insurers to avoid duplication of payment on claims when the patient has more than one policy. one insurance becomes the primary payer, and no more than 100% of the costs are covered
Term
Copayment or coinsurance
 Definition
a specified amount that the insured must pay toward the charge for professional service rendered
Term
current procedural terminology code (CPT)
 Definition
coding system published by the American Medical Ass. that translates services received by a patient into a numeric value for convenience and continuity of reporting these services to third parties for payment. The system is recognized by governmental payers and private insurance companies.
Term
Deductible
 Definition
a predertemined amount that the insured must pay each year before the insurance company will pay for an accident or illness
Term
(DRG) Diagnosis Related group
 Definition
a system developed by Yale University to group together major diagnostic categories, organized by body systems, from which the 470 DRGs are drawn
Term
effective date
 Definition
the date when the insurance policy goes into effect
Term
electronic claims
 Definition
also referred to as electronic media claims, electronic data enterchange, and electronic claims processing
Term
encounter form
 Definition
also known as "Superbill". a printed form containing a list of the services with corresponding codes
Term
Endorser
 Definition
one who writes his/her signature on the back of a check that is made out to another person
Term
Early and periodic screening, diagnosis, and treatment (EPSDT)
 Definition
this program requires screening and diagnostic services to determine any diseases or disorders, as well as complete health care, in children form birth through 21 years

Also called healthcheck
Term
Explanation of benefits (EOB)
 Definition
a printed description of the benefits provided by the insurer to the beneficiary
Term
fee disclosure
 Definition
the action of health care providers informing patients of charges before the services are performed
Term
fee schedule
 Definition
a list of approved professional services for which the insurance company will pay with the maximum fee paid for each service
Term
fee slip
 Definition
a printed (computer) form with patient's info, listing the services and code numbers with the charges
Term
gatekeeper
 Definition
a term given to a primary care physician for coordinating the patient's care to specialist, hospital admissions, and so on
Term
group insurance
 Definition
insurance offered to all employees by an employer
Term
(HCPCS Code) Health Care Procedural Coding System
 Definition
alphanumeric coding system devised by the federal Centers for Medicare and Medicaid Services (CMS) are supplement to the CPT code and disctributed by the regional fiscal agents of Medicare, TRICARE (CHAMPUS), and Medicaid
Term
HMO (Health Maintenance Organization)
 Definition
a prepaid group practice serving a specific geographic area with a wide range of comprehensive health care at a fixed fee schedule; HMOs are interested in promoting good health and wellness, thus containing the cost of health care. These can be sponsored and operated by the government, medical schools, clinics, foundatoins, hospital medical plans, or the Veterans' Administration
Term
Indemnity plan
 Definition
a commercial plan in which the company (insurance) or group reimburses physician or beneficiaries for services
Term
Independent practice ass. (IPA)
 Definition
a group of independent physicians who provide health care to a group of patients who pay an annual fee in advance
Term
Individual insurance
 Definition
insurance purchased by an individual for self and any eligible dependents
Term
international classification of diseases (current number) revision, clinical modification (ICD-9-CM
 Definition
the coding system used to document injuries, illnesses, and mortalities
Term
loss-of-income benefits
 Definition
payments made to an insured person to help replace income lost through inability to work because of an insured disability
Term
managed care
 Definition
a system of medical team members organized into groups to provide quality and cost-effective care that encompasses both the delivery of health care and payment of the services
Term
medicaid
 Definition
a joint funding program by federal and state governments (excluding Arizona) for low-income patients on public assistance for their medical care
Term
medicare fee schedule
 Definition
a list of approved professiona services that Medicare will pay for with the maximum fee that it pays for each service
Term
Medigap (medifill)
 Definition
private insurance to supplement Medicare benefits for noncovered services
Term
member physician
 Definition
a physician who has contracted to participate to the reimbursed for services according to the company's plan
Term
(NCQA) National Committee for Quality Assurance
 Definition
nonprofit organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector
Term
Out-of-area
 Definition
HMO members are generally covered for emergency services out of their geographic area, but other coverages may not always be provided.
Term
Patient status
 Definition
refers to patient's eligibility for benefits. Insurance companies frequently have stipulations that services be provided on an inpatient or outpatient basis; there is also requirements for prior authorization fro the insurance company for certain services or procedures to be performed
Term
point-of-service (POS) plan
 Definition
an open-ended HMO, POS encourages their members to choose primary care physician:gatekeeper
Term
precertification
 Definition
prior authorization must be obtained before the patient is admitted to the hospital or some specified outpatient or in-office procedure
Term
preexisting condition
 Definition
a condition that existed before the insured's policy was issued
Term
(PPO) preferred provider organization
 Definition
this plan offers different insurance coverage depending on whether the patient receives services from a contracting network or non-network physician. The benefits are higher if the physician provider is a member of the PPO (or is a network physician)
Term
premium
 Definition
monies paid for an insurance contract
Term
release of medican information form
 Definition
a form that must be signed by the patient before any info may be given to an insurance company
Term
Resource-based relative value scale (RBRVS)
 Definition
fee schedule based on relative value or resources that physicians spend to provide services for Medicare patients
Term
Service area
 Definition
the geographic area served by an insurance carrier
Term
skilled nursing facility
 Definition
a medical facility is licensed to primarily provide skilled nursing care to patients
Term
subscriber
 Definition
the person who has been insured; an insurance policy holder
Term
third-party check
 Definition
a check from one person that is made out to a second person for payment of a third person
Term
third party payer
 Definition
an insurance carrier, who is not the doctor or patient, who intervenes to pay the hospital or medical bills per contract with one of the first two parties
Term
TRICARE-Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
 Definition
established to aid dependents of active service personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty, with a supplement for medical care in military or Public Health Service facility
Term
usual and customary fee
 Definition
the usual fee is the charge physicians make to their patients; the customary fee is one within the range of usual fees charged by physicians in a given geographic and socioeconomic area who have similar training and experience
Term
utilization management
 Definition
a panel that tracks what their member receive and checks if their medical care meets the standards of the organization
Term
utilization review
 Definition
a review carried our by allied health professionals at predetermined times to assess the necessity of the particular patient to remain in an acute care facility
Term
walkout statement
 Definition
a printed form with the patient's charges and the amount paid for the services rendered, which the patient takes with her
Term
workers' compensation
 Definition
government program that provides insurance coverage for those who are injured on the job or who have developed work-related disorders, disabilities, or illness
Term
Birthday Rule States that:
 Definition
1. parent whose bd occurs first in the calendar year is primary, and the other parent's plan is secondary

2. If both parents have the same bd, the plan in effect the longest is primary

3. If the parents are divorced and retain their plans, the parent with custody is primary

4. If a court order exist that dictates which parent is responsible for medical expenses, the court order supersedes the bd rule.
Term
1. Primary carrier

2. Secondary carrier
 Definition
1. responsible for payment first

2. responsible for payment after primary coverage
Term
If both parents have equal insurance coverage, what determines insurance coverage for the children
 Definition
Bd rule
Term
PAT
 Definition
Preadmission testing
Term
If a patient has Medicare and a Medicare HMO, which insurance is primary?
 Definition
HMO
Term
a contract is an agreement between two or more parties for certain services or obligations to be discussed
 Definition
F.

a contract is an agreement between two or more parties for certain services or obligations to be fulfilled.
Term
An indemnity plan is a company that bills the physician for medical services
 Definition
F.

An indemnity plan is a company that reimburses physician for medical services
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