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58 terms

week 6

STUDY
PLAY
hemorrhoids
a mass of unnaturally distended veins in the anal canal that lie just inside or outside the rectum
diabetes mellitus
a disorder of carbohydrate metabolizm that is characherized by high concentrations of sugar in the blood results from insufficient production or utilization of insulin
gastroscopy
examination of the stomach with an endoscope
hypoglycemia
abnormally low blood sugar is called
hiatal hernia
type of a gastrocele
anorexia
loss of appetite for food
appendectomy
excision of the vermiform appendix
kidney
what does the term Renal pertain to
hematura
blood in the urine is called
nephrotoxic
a term that means destructive to the kidney tissue
polyp
a tumor found on musosal surface such as the inner lining of the bladder
urinary incontinence
inability to hold urine in the bladder
urinary retention
inability to empty the bladder
nephrosonography
using ultrasound to study the kidney
dialysis
filtering blood to maintain proper balance
true
the health maintenance organization act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance
false
medicare-eligible patients are not involved with HMO's or prepaid health plans
false
exclusive provider organizations (EPO's) are regulated by the federal government
true
in a point of service (POS) program members may choose to use a nonprogram provider at any time.
true
the term "turfing" means to transfer the sickest high-cost patients to other physiciansso that the provider appears as a low utilizer
true
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
true
in certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists
false
manage care plans allow laboratory tests to be performed at any facility the patient chooses
false
managed care plans never require a CMS-1500 claim form to be completed and submitted
true
usually there are no deductibles for managed care plans
true
copayment in a managed care plan is usually a fixed dollar amount (predetermined fee)
health maintenance organization act of 1973
a significant contribution to HMO development was the
capitation
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
not employees and are not paid salaries
in an independent practice association (IPA) physicians are
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
managed care organization
the abbreviation MCO stands for
utilization review
UR is the abbreviation for
prior approval
when a managed care plan requires a primary care physician to seek approval before referring a patient to a specialist, it is called obtaining
with hold
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
true
meidcare provides insurance for disabled individuals if they have received social security disability benefits for 24 months
false
all persons age 65 who meet eligibility requirements for medicare receive medicare part B (outpatient coverage)
true
medicare provides insurance for disabled workers of any age
true
patients who elect medicare part B coverage pay annually increasing basic premium payments
true
it is possible for an alien to be eligible for medicare part A and part B
true
employee and employer contributions help pay for medicare part A health services
false
medicare part A is called supplementay medical insurance (SMI)
false
in the medicare program, a physical examination is a covered benefit when performed within 12 months of enrollment
false
when a medicare recipient chooses a medicare senior plan he or she forfeits the medicare card
false
once a patient changes from medicare to a senior HMO, the patient must stay with that HMO for the remainder of the calendar year.
false
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
true
the assignment on a patient with medicare-medicaid must always be accepted or medicad will not pick up the residual
true
medicare transmits medigap claims electronically for participating physicians when medigap information is provided on the original medicare claim
the centers for medicare and medicaid services
medicare part A is run by
federal health insurance program
medicare is a
widow
the letter "D" following the identification number on the patients medicare card indicates
railroad retiree
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
referral claim
when a medicare carrier transmits a medigap claim electronically to the medigap carrier, it is referred to as
part B
medicare outpatient coverage 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
national provider identifier
a NPI number issued to a provider by CMS is the acronym for