An independent, not-for-prfit organization that setsstandards for healthcare in the United States
The Joint Commission
Managed care is a healthcare system where insurance companies attemt to control _____,____and_____ healthcare.
cost of, quality of and acess to
What type of managed care organization in which services may be furnished at discounted rates if the members recieve their healthcare from member providers but pay a higher cost when going outside the organization?
PPO - Prefered Provider Organization
Which of the following is not one of the five categories of problem debtors?
A. Pay-it-later debtors
A private organization that contracts with Medicare to pay Part A and some of Part B bills is referd to as______.
fiscal intermediary
Individuals pay for Medicare Part B coverage through ____ ___.
monthly premiums
Medicare's fee schedule is based on a system whereby each payment value is found within a reange of payments known as _______.
RBRVS - Resourse-Based relative value scale
When a medicare claim is filed, the beneficiary recieves a document explaning the claim adjudication called a/an ___.
MSN - Medicre Summary Notice
Studies preformed to improve the process and outcomes of patient care are called ____.
quality rveiw studies.
Unless an individual has health coverage through his or her employer, when he or she becomes eligible for Medicare, late enrollment can result in ____________________.
up to two penalties.
Providers that bill FIs can alsosubnit claims electronically using ____ _____ ____.
direct data entry
The TRICARE program is managed by ____ under the authority of the Office of the Assistant Secretary of Defence for Health Affairs (OSD/HA)
TRICARE Management Activity - TMA
Military personnel ad their TRICARE-eligible dependants recieve free healthcare at what places?
Nonprofit facility, federally funded hospital and a military treatment facility (MTF).
When Prime enrollees choose the POS option, all requirements applicable to Standard apply except ______.
the requirement for an NAS (nonavaliability statement)
The correct form to complete for the nonavailability statement is ______.
DD Form 1251
Non-Pars may charge up to ___ percent above the TRICARE allowable charge for their services.
15
Before the health insurance professional can completeand submit a health insurance claim, a ________ is typically necessary.
Signed and dated release of information.
To compete the entire claims process, a paper claim typically takes ____to_____ weeks
4-6
MEdicare's inpatient hospital classification system used to pay a hospital or other provider for services, categorizing illness/conditions by diagnosis and treatment, is called _____.
DRG - Diagnosis-Relaited Group
A computer softwere program that identifies a pationt's DRG category by interpereting certan coded information is called a ______.
DRG grouper
The federal entity that sets guidelines and rules that affect the entire healthcare industry and which everyone in this industrymust folow is the ______.
Centers for Medicare and Medicaid Services - CMS
Electronic transmissions were first used during what decade?
1960s
To help improve the healthcare administrative process and, at the same time, simplify it, ______was created
HIPAA - Health Insurance Portability and Accountability Act
Hospitals that recieve additional payments to ensure that communities have access to certain high-cost services are called ______.
disproportionate share hospitals
Insurance companies are referred to as ___ payers.
Third-Party
Many FFS policies set a limit for what they will reimburse thier members for any charges incurred, which is referred to as a/an ______.
lifetime maximum insurance cap
The kindof thealth insurancd paid for by a business entity other than the government is called ______.
Commercial health insurance
Many self-insured groups hire a specific type of organization to manage and pay claims called ______.
administrative service organizations. (ASOs)
If a claim is denied as "untimely"
and appeal can be submitted in certain cases
On the CMS - 1500 form, patient information is entered into ___________________.
The top of the form.
The most common format used for computer text files and on the enternet is
ASC II
Documente needed to complete a paper CMS-1500 include all fo the following EXCEPT
a. patient information form
b. patient insurance ID card
c. Patients driver's license
d. patient's health record
The answer is C. Patients drivers license
When the health insurance professional extracts certain informaion from a patient's health record tocomplete the CMS-1500 it's called___________.
abstracting
One of the recent technological advances that makes verification of patient insurance eligibility easier and faster is the __________________________________.
Interactive voice responce. (IVR)
The primary objective of a health insurance professional is to________________________.
submit clean claims.
Congress palssed the Health Maintenance Organization Act in ________
1973
Factors listed in the text that drive healthcare issues include all the following EXCEPT:
a. regulating managed care plans
b. expanding access for uninsured Americans
c. increasing healthcare costs
d. stabilizing emergency services
C. increasing healthcare costs
The acronym for the Congressional act that circumvents problems such as preexisting conditions and other healthcare-related issues is ____________.
HIPAA
Fee-for-Service healthcare plans are also referred to as, _____________.
Indemnity insurance
The state that has recently implemented a new law to cover its uninsured population is, __________.
Massachusetts
College entry-level skills necessary for success as a health insurance professional include all of the following except:
D. Coding
In order to develop effective study skills, it is suggested that students generate a ________ schedule.
time management
those who work in healthcare say themost important reward is, _____________.
helping people
One method of enhancing one's career as a health insurance professional is to aquire, _________.
certification
When a society tends to be hasty in bringing lawsuits, it is said to be, ____________.
litigious
Members of a medical team who are not physicians are called ________ members.
ancillary
The type of contract that exists between a healthcare provider and a patient is a/an ________contract
implied
That act tha tmade Medicare benefits secondary to employer group health plans for employees (or spouses) older than 65 is the, _________________________.
Tax equity and Fiscal Responsibility Act of 1982
The Office of Inspector General recommends to have a ________________.
HIPAA compliance plan.
A proposition to create a contract is the ________.
offer
The primary objectives of HIPAA include all of the following EXCEPT to
B. Lower healthcare costs
The dollar amount that a patient must pay each year before his or her insurance bennefits begin is called an/a ____________.
deductible
Insurance companies often cap what a patient must pay, which is referred to as the ____________________.
out-of-pocket maximum
When both basic and major medical coverage is combined into one insurance plan, it is called