What is Molecular Pharmacology?
It involves the interaction of drugs and sub-cellular entities such as DNA, or RNA, and enzymes.
What is the generic name of a drug?
A shorter and less complicated name that identifies the drug legally and scientifically; and may also be the trade name for some drugs.
What is the FDA and what does it do?
Food and Drug Administration.
It has the legal responsibility to decide if when a drug may be distributed and sold in this country.
Drugs are introduced into the body, how?
The route of administration determines its rate. Completeness of absorption into the blood.
Speed and duration of action
What are contraindications?
Factors that prevent the use of a drug or treatment.
(Factors in a patient's condition that makes the use of a drug dangerous or ill advised.)
A chemical substance produced by bacterium, yeast or mold. Some examples: tetracycline, penicillin.
(Relieve pain) A drug used to lessen or relieve pain. A non-steroidal anti-inflammatory drug (NSAID) is a non-narcotic option.
(Prevent blood clotting)A drug that lower the clotting ability of the blood. Example: warfarin, aspirin.
Controls anxiety and severe disturbances of behavior. Example: benzodiazepines, phenothiazines.
Blocks the action of epinephrine at sites on receptors of heart muscle cells, the muscle lining of blood vessels, and bronchial tubes; antiarrhythmic, antianginal, and anti-hypertensive.
Calcium channel blocker:
Prevent the entrance of calcium into the heart muscle and muscle lining of blood vessels. Also called calcium antagonist.
What is Tertiary care?
When a specialist recommends a referral to another specialist. Be sure the recommendation is in writing.
What is capitation?
A system of payments used by managed care plans in which the Primary Care Physician is paid a fixed amount for each patient enrolled regardless of the number of services provided.
What is a PPO (Preferred Provider Organization)?
It's where the members have the freedom to choose any physician or hospital but they receive a high level of benefits if a preferred provider is used.
What is an HMO ( Health Maintenance Organization)?
A type of policy where you choose a PCP and a referral must be obtained for outside care or the insurance will not pay for the services.
The QIO (Quality Improvement Organization) program is designed to?
Review the medical necessity of admission and discharge.
Settle disputes, evaluate the quality and efficiency of care.
When a managed care plan has denied a prior authorization, what should the provider do?
Advise the patient's decision before he/she sees the provider.
Ask the patient to file an appeal and write a letter pf appeal to the insurance as well as the patient.
The gatekeeper may issue a referral, how?
A formal written authorization mailed, faxed, handed to the patient; or verbally authorized when the appointment is made with another provider/
A FMC (Foundation for Medical Care) is an organization of physicians that is sponsored by?
The state or local medical association.
Does every state have a BXBS (Blue Cross Blue Shield) plan?
Yes, but in some states they are separated and even compete against each other.
IPAs ( Independent Practice Association) are paid on the basis of what?
They are paid for their services on a capitation or fee-for-services basis out of a fund drawn form the premiums collected form the subscriber, union or corporation. (The physicians are not employees and are not paid salaries.)
A managed care patient who has lab or x-rays done may use the facility of his/her choice? True or False.
False. The insurance carrier will not pay if the patient chooses to go out-of network.
A Statement of Remittance, or Remittance Advice is more commonly referred to as:
An Explanation of Benefits (EOB).
When a physician sees a patient more than medically necessary and is done to increase revenue through an increased number of services.
Is to transfer the sickest, high-cost patients to other physicians so that the provider appears to be a low utilizes.
A preset amount designated by the carrier and to be paid to the provider at the time of service.
What is the patient responsibility with most managed care plans?
A copay and an insurance premium. Most managed care plans do not have a deductible.
When is Medicare considered a secondary payer (MSP)?
Following qualities: MVA (motor vehicle accident), Disability, Employee Ins, Federal black lung act, WC (worker's compensation).
What does Medicare part B cover?
Labs, x-rays, regular office visits, as well as other outpatient services.
What situation does a locum tenens arrangement describe?
A physician in a rural solo practice requests vacation coverage form another physician.
What is Hospice Care?
Care for a terminally ill person who has less than 6 months to live and requires help with pain and support.
What is a crossover claim?
When Medicare automatically bills the patients secondary insurance carrier.
What is the RBRVS used for?
(Resource-based relative value scale) to convert a geographically adjusted relative value into a payment amount. Is the system Medicare uses for establishing fees.
What is the time limit for filling Medicare claims?
The end of the calendar year following the fiscal year in which the services were rendered. The time limit for filing claims for services from 10-1-10--09-30-11 is 12-31-12.
Payments for inpatient services for Medicare patients are based on what?
Diagnosis Related Group (DRG).
An ABN (Advance Beneficiary Notice) form is what?
It is wavier of liability; meaning the patient is responsible for any and all charges that Medicare does not pay.
When should the patient not be asked to sign an ABN?
When the patient is confused, under great duress, in a medical emergency, or after services have been rendered.
Under the PPS(Prospective Payment System) hospitals treating Medicare patients are reimbursed according to:
Set rates for each type of illness based on diagnosis.
When an overpayment is received form Medicare, what steps should be taken?
Deposit the check, then notify Medicare by letter of the overpayment.
What is Railroad Medicare and who is eligible?
Medicare coverage for RR (Railroad Retirement) workers, and their beneficiaries.
What about RR (Railroad Retirement) Medicare Letters A or MA?
A is a retired employee, and MA is the spouse of a retired employee.
How are premiums paid when the patient has Medicare part B?
If they are on SS (social security), it is deducted automatically form their monthly check.
When does the benefit period begin and end for Medicare part A?
It begins the day a patient enters a hospital and ends when the patient has not been a bed patient in any hospital or nursing facility for 60 consecutive days.
What are the benefits for a physical examination?
One time "Welcome Exam" within the first 12 months of part B coverage.
What are the benefits for a Pap test?
Once every 24 months for low risk and once every 12 months for high risk.
What is the Medicare Prepayment screen?
It limits the number of times a given procedure can be billed during a specific time frame.
What amount will Medicare pay a participating provider?
80% of the allowable after the deductible has been met.
Why is it important to see the Medicare ID card?
To verify coverage, part A, B or perhaps a different primary carrier.