what is a staff model
type of HMO model that employs salaried physicians in a managed care organization owned and operated by a HMO
do medical specialists negotiate managed care contracts
no. The contracts are negotiated by physicians and insurers
can a participating provider of a managed care plan balance bill a patient
no. The difference between the amount billed and amount allowed must be written off or adjusted
T/F: in emergency situations, a patient may be treated in an out-of-network facility without a referal
true, however once the patient is stablized he or she is transferred to a facility within the network
what organization awards accreditation to managed care organizations and providers
national committee for quality assurance (NCQA)
what elements of a provider's background does the NCQA review during the credentialing process
criminal activity, malpractice hx, and disciplinary actions
why would a provider accept a discounted fee for service agreement
to receive an increased number of patient referrals from managed heatlh care organizations and other network providers
managed care systems ensure the delivery of high quality care while managing costs thru
networks and discounted fees
What are the four goals of managed care?
Delivery of high quality care in a facitility that manages and controls costs;
Medical care provided is medically necessary and appropriate for patient's condition or diagnosis;
medical care is rendered by appropriate provider;
Medical care provided is rendered in most appropriate setting
what type of HMO model contracts with more than one multispecialty group to provide wider geographical coverage
what happens if an HMO enrollee sees an out of network provider without a referral
the HMO will not pay for the service and the patient may be responsible fot the full physician's charge
a managed care contract is considered a legal document between the physician and the insurer
physician and the insurer
what is the earliest example of managed care
western clinic in Tacoma, WA provided medical services to lumber mill owners and employees in 1910
scope of practice
the boundries of acceptable diagnosis and treatment by nurses, doctors, and a variety of midlevel medical personnel
medical professional misconduct which differs from negligence because it is performed by a licensed medical professional
a reference handbook explaining procedures to be followed when performing a task by which a legal right might be enforced
a record of being qualified to perform certain acts after passing an examination given by an accredited professional organization
A coexisting condition is reported when it affects the patient's primary condition or is also treated during an encounter.
In the ICD-9-CM, NOS, or not otherwise specified, indicates a code to be used when too little information is available to assign another, more specific code.
The primary diagnosis represents the patient's most serious condition, regardless of the reason for the current encounter.
Supplemental terms in the ICD-9-CM's alphabetic index are usually enclosed in parentheses or brackets.
The ICD-9-CM diagnostic codes are made up of either three, four, or five digits and a description.
In the ICD-9-CM, parentheses are used around descriptions that are not essential parts of a term.
what are the three key components of an E/M code
level of history, level of examination, level of MDM
what codes are used to bill for durable medical equipment and other supplies provided by medical practices to patients
hcpcs level ii
what is assumption coding
when items or services are reported that are not actually documented but the coder assumes they were performed
using a procedure code that provides higher reimbursement rate than the code actually reflects the services provided for is referred to as
what initiative is designed to edit coding errors such as unbundling codes, use of appropriate modifiers and mutually exclusive codes
national correct coding initiative (NCCI)
what federal publication includes the compliance program guidance for individual and small group physician practices
the federal register
what act prohibits a fradulent claimor making false statements or representation in connection with a claim
the federal civil false claim act
what act created the healthcare fraud and abuse control program
health insurance portability and accountability act
the duration of the patient's symptoms from the first sign of the illness to the present is known as
the history of present illness (HPI)