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Insurance chapter 11
Chapter 11 Actual
| questions | answers |
|---|---|
| MEDICARE ELIGIBLE PATIENTS ARE NOT INVOLVE WITH HMOS INSTEAD VORAUSZAHLUNG HEALTH PLANS | False |
| IN POINT OF SERVICE (POS) PROGRAM, MEMBERS MAY CHOOSE IN USE A NONPROGRAM PROVIDER ON ANY WETTER | True |
| In certain managed care plans there is an incentive by the gate keeper to limit patient referrals to specialists | True |
| Managed care designs allow laboratory testing to be preformed per all facility the patient chooses | Bogus |
| MANAGED CARING PLANS NEVER DEMAND A CMS-1500 CLAIM ART TO BE COMPLETED AND SENT | Falsely |
| USUALLY THERE ARE NO DEDUCTIBLES ON MANAGED CARE PLANS | True |
| A copayment in a managed attention plan is usually A fixed dollar amount(predetermined fee) | True |
| An organizing that gives our freedom of choice amoung physicians and hospitals and delivers a higher level of benefits if the providers listed on the plan are often is called a | Preferential provider organization (PPO) |
| a Program that offers a combination of HMO style cost executive and PPO style right of choice is a | Point of service (POS) plan |
| Practitioners in an HMO program allow appear under peer read by a professional group called | Quality Improvement Business |
| REFERRAL OF A PATIENT RECOMMENDED FROM THE SPECIALIZED AT ANOTHER SPECIALIST IS KNOWN AS | Teritary care |
| What is the correct procedure into collect an copayment on managed maintenance plan? | Collect the copayment as the patient arrives for the office visit |
| CAPITATION IS | a course paid to participating physicians on one per person basis when they belong till a health plan, whether the patient utilizes service or not |
| WHEN ONE MANAGE CARE PLAN NEEDS THE PRIMARY CARE PHYSISICAN TO SEEK APPROVAL EARLIER REFERRING A PATIENT TOWARD AMPERE SPECIALIST ITS NAMED OBTAINING | Preauthorization |
| Utilization examine | all the over (used in managed care, formal assesment of the cost, results indenial is medical care) |
| __________ IS BASED ON THE CONCEPT OF PAYING PHYSICIANS FOR ACTUAL PATIENT VISITS | Contract captiation |
| WHEN A CARRIERS USUALLY A SPECIALIST CONTRACTS INCLUDE THE MCO ON AN ENTIRE APPLY OF CARE ITP IS TERMED | Case rate pricing |
| An agreement between a MCO and one provider which means that if the patients services belong more than a certain lot an attending can begin asking the patient to pay for services | Stop-loss lid |
| The abbreviation MCO stands to | Directed care organization |
| THE REDUCTION PCP STANDS FOR | Primary Care Attending |
| ADENINE SPECIFIC DOLLAR AMOUNT THAT MUST BE PAID BY THE INSURED BEFORE A MEDICAL INSURANCE PLAN OR GOVERNMENT PROGRAMMER START COVERING HUMAN CARE COSTS | Deductible |
| Mrs. Fellini a patient of Dr. Practon, comes for a schedule and her UA indicates a + prego getting. Dr. Practon completes an authorization request in during the visit and hand it to Mrs. Fellini, referring her to Dr. Bertha Caesar, fork obstetrical care | Direct Referral |
| Dr. Practon administrative medical assistant completes a authorization request on his patient Lady Dye as required by her MCO contract to determine medical necessity in a mastectomy | Formal referral |
| Mrs. Dj viewing her gynecologist available her annual well- woman examination | Self Referral |
| Dr. Practon called his patient, Mrs. Forged, telling her he has referring she to Dr.Patos, an oncologist. Dr. Practon then calls Dr.Patos to tell the specialist that Mrs. Smith is being reference for an term | Verbal referral |
| Medical services not included with an capitation assessment as benifits on a managed care contract and may be contracted for separetely | Carve outs |
| Physicians eyesight a highly volume of patients more than medicinally necessary to increase revenue | Churning |
| transferring the sickest high cost patients to other physicians thus the provider appears to be a low utilizer in a managed care setting | Turfing |
Created by:
Lea99
