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a mass of unnaturally distended veins in the anal canal that lie just inside or outside the rectum
a disorder of carbohydrate metabolizm that is characherized by high concentrations of sugar in the blood results from insufficient production or utilization of insulin
the health maintenance organization act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance
in a point of service (POS) program members may choose to use a nonprogram provider at any time.
the term "turfing" means to transfer the sickest high-cost patients to other physiciansso that the provider appears as a low utilizer
if a primary care physician sends a patient to a specialist for consultation and the specialist is not in the managed care plan, the specialist may bill the primary care physician for the payment
in certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists
when an HMO is paid a fixed amount for each patient served without considering the actual number or nature of services provided to each person is known as
PPO preferred provider organization
an organization the 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
POS point of service plan
a program that offers a combination of HMO-style cost management and PPO-style freedom of choice is
when a managed care plan requires a primary care physician to seek approval before referring a patient to a specialist, it is called obtaining
when a certain percentage of the monthly capitation payment is held out of the premium fund to pay for operating an IPA, it is known as
meidcare provides insurance for disabled individuals if they have received social security disability benefits for 24 months
all persons age 65 who meet eligibility requirements for medicare receive medicare part B (outpatient coverage)
in the medicare program, a physical examination is a covered benefit when performed within 12 months of enrollment
once a patient changes from medicare to a senior HMO, the patient must stay with that HMO for the remainder of the calendar year.
when a CMS-1500 claim for is automatically transferred by medicare to a medigap carrier, there is not need to obtain a spearate signature authorization for the medigap carrier
the assignment on a patient with medicare-medicaid must always be accepted or medicad will not pick up the residual
medicare transmits medigap claims electronically for participating physicians when medigap information is provided on the original medicare claim
the letters preceding the number on the patients medicare identification card indicate wage earner, husbands number, widow, and disabled adult
80% of the medicare approved charge
a participating physician with the medicare plan agrees to accept
time limit for submitting a medicare claim is
the end of the calendar year following the fiscal year in which services were performed
when a medicare carrier transmits a medigap claim electronically to the medigap carrier, it is referred to as
$10,000 for each item of service
the civil monetary penalties law carries a sanction for a penalty of up to
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