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Study sets matching "health insurance chapter 3"

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Study sets matching "health insurance chapter 3"

15 terms
Chapter 3 - Health insurance
Physician who serves as the gatekeeper…
Law that lets you pay to keep your hea…
Health insurance for low-income families
The portability law
Primary Care Physician
COBRA
Medicaid
HIPAA
Physician who serves as the gatekeeper…
Primary Care Physician
Law that lets you pay to keep your hea…
COBRA
20 terms
Understanding Health Insurance Chapter 3&4
Gatekeeper
Capitation
Primary care physician
Case Management
Primary care provider for essential health care services at t…
provider accepts pre-established payments for providing healt…
Responsible for supervising and coordinating health care serv…
Development of patient care plans to coordinate and provide c…
Gatekeeper
Primary care provider for essential health care services at t…
Capitation
provider accepts pre-established payments for providing healt…
50 terms
Health Insurance Chapter 3
Accreditation
Adverse Selection
Capitation
Case Management
A voluntary process that a healthcare facility or organizatio…
When an insurance plan covers who are sicker than the general…
Provider accepts pre-established payments for providing speci…
Development of patient care plans, to provide care for compli…
Accreditation
A voluntary process that a healthcare facility or organizatio…
Adverse Selection
When an insurance plan covers who are sicker than the general…
72 terms
UNDERSTANDING HEALTH INSURANCE CHAP 3
Accreditation
Adverse Selection
Amendment to the HMO Act of 1973
cafeteria plan
voluntary process that a health care facility or organization…
covering members who are sicker than the general population.
legislation that allowed federally qualified HMOs to permit m…
also called triple option plan; provides different health ben…
Accreditation
voluntary process that a health care facility or organization…
Adverse Selection
covering members who are sicker than the general population.
70 terms
Health Insurance Billing - Chapter 3
COB
EPO
HMO
IDS
coordination of benefits (applies when the individual is cove…
exclusive provider organization
health maintenance organization
integrated delivery system
COB
coordination of benefits (applies when the individual is cove…
EPO
exclusive provider organization
21 terms
Health Insurance chapter 3
respondeat superior
written contract
implied contract
5 elements of a contract
employer is responsible for the actions of employee
contract in writing
not in writing, but is legally binding (giving consent)
offer and acceptance... consideration ... legal object ... competent p…
respondeat superior
employer is responsible for the actions of employee
written contract
contract in writing
12 terms
chapter 3 health insurance
capitation
fee for service
integrated delivery system (IDS)
integrated provider organized ( IPO)
where providers accept pre established health care services t…
reimburse provides for individual health care services rendered
an organization of affiliated providers sites that offer join…
manages the delivery of health care services offered by hospi…
capitation
where providers accept pre established health care services t…
fee for service
reimburse provides for individual health care services rendered
20 terms
Chapter 3 Health Insurance
Enrollees
ERISA
Make a profit
Supervising and coordinating healthcar…
Employees and dependents who join a managed care plan
Act of legislation that permitted large employers
If a physician provides services that cost less than the mana…
The primary care provider is responsible for:
Enrollees
Employees and dependents who join a managed care plan
ERISA
Act of legislation that permitted large employers
25 terms
Chapter 3 Health Insurance Terms
Premium
Deductible
Coinsurance
Copayment
Fee to keep insurance active
Specific amount of money paid each year before benefit begin
Cost sharing requirement in which the insured assumes a perce…
Is a fix payment for covered services, paid when an individua…
Premium
Fee to keep insurance active
Deductible
Specific amount of money paid each year before benefit begin
22 terms
Health insurance chapter 3
Health maintenance organization
Implied contract
Expressed contract
Guarantor
Oldest in all medical coverage plan. patient must see network…
Not by word of patients but action of patient.
By the spoken word of patients
Person responsible for paying bill.
Health maintenance organization
Oldest in all medical coverage plan. patient must see network…
Implied contract
Not by word of patients but action of patient.
19 terms
Chapter 3. Health Insurance
PPO
Premium
State Children's Health Insurance Prog…
Statistics- cost of health care ( perc…
Preferred provider organization... 1) Usually provided by large…
Membership fee paid monthly or annually as cost of the insura…
date: 1997... provides health care to uninsured children of work…
15%
PPO
Preferred provider organization... 1) Usually provided by large…
Premium
Membership fee paid monthly or annually as cost of the insura…
23 terms
Chapter 3 health insurance
Infant mortality rate
Life expectancy
Patient protection and affordable care…
Affordable care act
Afghan- 175... Mexico- 17.29... USA- 6.1... France- 3.29... Sweden- 2.74
Australia- male: 80 female:84... Canada- male:79 female:83... Franc…
Health care for the United States ... Complex/multilayered ... New…
2010... Requires a huge change in the finances of the American h…
Infant mortality rate
Afghan- 175... Mexico- 17.29... USA- 6.1... France- 3.29... Sweden- 2.74
Life expectancy
Australia- male: 80 female:84... Canada- male:79 female:83... Franc…
Health Insurance Chapter 3
accreditation
adverse selection
cafeteria plan(triple option plan/flex…
capitation
voluntary process that a health care facility or organization…
covering members who are sicker than the general population
provides different health benefit plan and extra coverage opt…
providers accepts preetablished payments for providing health…
accreditation
voluntary process that a health care facility or organization…
adverse selection
covering members who are sicker than the general population
62 terms
Chapter 3-Basics of Health Insurance
accounts receivable management
applicant
assignment
blanket contract
The organization and administration of coding and billing in…
Person applying for insurance coverage
A transfer or an individual's right to collect an amount paya…
Comprehensive group insurance coverage through plans sponsore…
accounts receivable management
The organization and administration of coding and billing in…
applicant
Person applying for insurance coverage
21 terms
Chapter 3 Health Insurance
utilization management
case management
gatekeeper
SSO
review necessity prior to receiving services
a way to handle complex cases in a cost-effective manner
PCP
when a second surgeon is asked the opinion
utilization management
review necessity prior to receiving services
case management
a way to handle complex cases in a cost-effective manner
54 terms
Understanding Health Insurance - Chapter 3
Managed Health Care
Consumer-directed Health Plans (CDHP)
Enrollees
Medicare Risk Programs
Combines health care delivery with the financing of services…
Provide incentives for controlling healthcare expenses and gi…
(suscribers or policyholders) Employees and dependants who jo…
Allowed federally qualified HMOs and competitive medical plan…
Managed Health Care
Combines health care delivery with the financing of services…
Consumer-directed Health Plans (CDHP)
Provide incentives for controlling healthcare expenses and gi…
54 terms
Understanding Health Insurance - Chapter 3
Managed Health Care
Consumer-directed Health Plans (CDHP)
Enrollees
Medicare Risk Programs
Combines health care delivery with the financing of services…
Provide incentives for controlling healthcare expenses and gi…
(suscribers or policyholders) Employees and dependants who jo…
Allowed federally qualified HMOs and competitive medical plan…
Managed Health Care
Combines health care delivery with the financing of services…
Consumer-directed Health Plans (CDHP)
Provide incentives for controlling healthcare expenses and gi…
54 terms
Understanding Health Insurance - Chapter 3
Managed Health Care
Consumer-directed Health Plans (CDHP)
Enrollees
Medicare Risk Programs
Combines health care delivery with the financing of services…
Provide incentives for controlling healthcare expenses and gi…
(suscribers or policyholders) Employees and dependants who jo…
Allowed federally qualified HMOs and competitive medical plan…
Managed Health Care
Combines health care delivery with the financing of services…
Consumer-directed Health Plans (CDHP)
Provide incentives for controlling healthcare expenses and gi…
139 terms
Chapter 3 Basics of Health Insurance
AAMB
AAPC
ADSM
A/R
American Association of Medical Billers
American Academy of Professional Coders
Active Duty Service Member
Accounts Receivable
AAMB
American Association of Medical Billers
AAPC
American Academy of Professional Coders
20 terms
Guide to Health Insurance Billing Chapter 3
Fee- for service
Exclusion
Assignment of benefits
Accepts assignment
A price or fee is charged for each individual
Statement of the conditions not covered by the health insuran…
Identifies who actually receives the insurance payment.
Physician and providers who accept the benefits paid by the i…
Fee- for service
A price or fee is charged for each individual
Exclusion
Statement of the conditions not covered by the health insuran…
44 terms
Health Insurance, Chapter 3 Vocabulary
Managed Health Care... Provides health c…
Capitation Payment System
Primary Care Provider (PCP)
Quality Assurance (QA)... Types:
*Provides reasonably priced health care for consumers + provi…
*If services cost LESS than capitation amount, profit results…
-Supervises & organizes health care services... -Approves referr…
Activities that assess the quality of care in a health care s…
Managed Health Care... Provides health c…
*Provides reasonably priced health care for consumers + provi…
Capitation Payment System
*If services cost LESS than capitation amount, profit results…
75 terms
Medical Billing & Coding Heald College: Chapter 3 | Basics of Health Insurance
Health Insurance
Implied Contract
Expressed Contract
Guarantor
A contract between the policy holder or member and the insura…
A contract between physician and patient not manifested by di…
A verbal or written agreement.
An individual who promises to pay the medical bill by signing…
Health Insurance
A contract between the policy holder or member and the insura…
Implied Contract
A contract between physician and patient not manifested by di…
58 terms
Chapter 3 Basic of Health Insurance
noncancelable policy
independent or individual practice ass…
health maintenance organization
member
insurer cannot increase premium rates and must renew the poli…
type of HMO in which a program administrator contracts with a…
A comprehensive health care financing and delivery organizati…
person covered under an insurance program's contract, includi…
noncancelable policy
insurer cannot increase premium rates and must renew the poli…
independent or individual practice ass…
type of HMO in which a program administrator contracts with a…
129 terms
Health Insurance and Billing Chapter 3
Insurance Policy
Premium
Health insurance
Direct Pay
is a legal contract between the individual and the company th…
The cost of the contract, is a fee paid at regular intervals…
a CONTRACT that provides money to cover ALL or a PORTION of t…
the PATIENT or INDIVIDUAL pays the physician or health care p…
Insurance Policy
is a legal contract between the individual and the company th…
Premium
The cost of the contract, is a fee paid at regular intervals…
69 terms
Health Insurance Chapter 3: Types of Health Policies
Basic Hospital, Medical and Surgical P…
Basic Hospital Expense Coverage
Basic Medical Expense Coverage
Basic Surgical Expense Coverage
Referred to as "first-dollar" coverage because they do not re…
Covers room and board, miscellaneous expenses (labs and tests…
Referred to as Basic Physicians' Nonsurgical Expense Coverage…
-written in conjunction with Hospital Expense policies... -pays…
Basic Hospital, Medical and Surgical P…
Referred to as "first-dollar" coverage because they do not re…
Basic Hospital Expense Coverage
Covers room and board, miscellaneous expenses (labs and tests…
54 terms
Understanding Health Insurance - Chapter 3
Managed Health Care
Consumer-directed Health Plans (CDHP)
Enrollees
Medicare Risk Programs
Combines health care delivery with the financing of services…
Provide incentives for controlling healthcare expenses and gi…
(suscribers or policyholders) Employees and dependants who jo…
Allowed federally qualified HMOs and competitive medical plan…
Managed Health Care
Combines health care delivery with the financing of services…
Consumer-directed Health Plans (CDHP)
Provide incentives for controlling healthcare expenses and gi…
35 terms
Basics of health insurance chapter 3
health insurance
polizza
affordable care act
contract
_________ ________ is a contract between a policyholder and a…
policy, insurance
implementation of the ______ _____ ____ began in 2010 and wil…
a _______ is a legal and binding written document that exists…
health insurance
_________ ________ is a contract between a policyholder and a…
polizza
policy, insurance
61 terms
Chapter 3: Basics of Health Insurance
An agreement between two parties that…
The transfer of an individual's legal…
A physician who decides not to accept…
A physician/provider who accepts assig…
an implied contract
an assignment
nonparticipating provider.
participating provider.
An agreement between two parties that…
an implied contract
The transfer of an individual's legal…
an assignment
64 terms
Health Insurance - Chapter 3-Glossary
accreditation
adverse selection
Amendment to the HMO Act of 1973
cafeteria plan
voluntary process that a health care facility or organization…
covering members who are sicker that the general population
legislation that allowed federally qualified HMOs to permit m…
also called triple option plan; provides different health ben…
accreditation
voluntary process that a health care facility or organization…
adverse selection
covering members who are sicker that the general population
21 terms
Chapter 3: Health Insurance Basics
What are the 3 types of Health Insuran…
Disability Income Insurance
Medical Expense Insurance
Limited Policies
1. Disability Income Insurance... 2. Medical Expense Insurance... 3…
Provides benefits for loss of income due to accidental sickne…
Provides benefits for the cost of medical treatment, doctor's…
Specialized policies which provide specific benefits, such as…
What are the 3 types of Health Insuran…
1. Disability Income Insurance... 2. Medical Expense Insurance... 3…
Disability Income Insurance
Provides benefits for loss of income due to accidental sickne…
44 terms
Health Insurance Billing Chapter 3
Insurance Policy
Health Insurance
Direct pay
Prepaid health plans
document that describes the situations covered by particular…
a contract that provides money to cover all or a portion of t…
the patient or individual pays the physician or health care p…
forerunners of current health maintance organizations (HMO)
Insurance Policy
document that describes the situations covered by particular…
Health Insurance
a contract that provides money to cover all or a portion of t…
24 terms
Accident, Life, and Health Insurance Chapter 3
Insurance Policies
Contract
Contract Element 1
Agreement
Legal Contracts
Legally binding agreement between two or more parties where a…
Agreement
Composed of an offer and acceptance. An offer is made when th…
Insurance Policies
Legal Contracts
Contract
Legally binding agreement between two or more parties where a…
55 terms
health insurance reimbursement career chapter 3
Managed health care (managed care)
consumer-directed health plans (CDHPs
enrollees (or subscribers or policyhol…
Health Maintenance Organization (HMO)…
combines healthcare delivery with the financing of services p…
employer contributions and ask employees to be more responsib…
employees and dependents who join a... managed care plan; known…
Authorized grants and loans to develop HMOs under private spo…
Managed health care (managed care)
combines healthcare delivery with the financing of services p…
consumer-directed health plans (CDHPs
employer contributions and ask employees to be more responsib…
75 terms
Medical Billing & Coding Heald College: Chapter 3 | Basics of Health Insurance
Health Insurance
Implied Contract
Expressed Contract
Guarantor
A contract between the policy holder or member and the insura…
A contract between physician and patient not manifested by di…
A verbal or written agreement.
An individual who promises to pay the medical bill by signing…
Health Insurance
A contract between the policy holder or member and the insura…
Implied Contract
A contract between physician and patient not manifested by di…
79 terms
Health Insurance - Ch 3 (Managed Health Care)
Managed Health Care
Consumer-directed Health Plans (CDHP)
Enrollees
Medicare Risk Programs
Combines health care delivery with the financing of services…
Provide incentives for controlling healthcare expenses and gi…
(suscribers or policyholders) Employees and dependants who jo…
Allowed federally qualified HMOs and competitive medical plan…
Managed Health Care
Combines health care delivery with the financing of services…
Consumer-directed Health Plans (CDHP)
Provide incentives for controlling healthcare expenses and gi…
12 terms
health insurance chapter 3 scilla07
capitation
enrollees
fee-for-service
gate keeper
where providers accept pre-established payments for providing…
also called subscriber policy holder who care are employees a…
plans which reimburse provides for individual health care ser…
the PCP services as a by providing essential health care serv…
capitation
where providers accept pre-established payments for providing…
enrollees
also called subscriber policy holder who care are employees a…
32 terms
Chapter 3 & 4 health insurance
What are provisions included in a mana…
Who are contracts between the physicia…
What is a managed care contract
How do mcos develop a network
Time limits for submitting claims
The physician or upper management
A legal document between the provider and insurer
By contracting with physicians facilities and pharmacies
What are provisions included in a mana…
Time limits for submitting claims
Who are contracts between the physicia…
The physician or upper management
34 terms
Health Insurance Today Chapter 3 tiffany bradumn
litigious
respondeat superior
negligence
ancillary members
quick to bring lawsuits
"let the master answer" - key principle in business law that…
failure to exercise a reasonable degree of care
members of a medical team- nurses, medical assistants, health…
litigious
quick to bring lawsuits
respondeat superior
"let the master answer" - key principle in business law that…
23 terms
Chapter 3 Test Review - Health Insurance 1
Par Provider
Gate Keeper
Case Management
Utilization Management
Has a contract with HMO
Primary care physician; manage care through referrals and inp…
Process that promotes complicated cases with COST-EFFECTIVE o…
Controls COST by reviewing appropriateness and medical necess…
Par Provider
Has a contract with HMO
Gate Keeper
Primary care physician; manage care through referrals and inp…
65 terms
Insurance handbook Chapter 3: Basics of health care insurance-vocab
Accounts Receivable Management
Applicant
Assignment
Blanket Contract
Refers to functions required for the monitoring and follow-up…
is someone who has indicated an interest in a position at an…
The transfer of ownership of an insurance policy from one ind…
Comprehensive group insurance coverage through plans sponsore…
Accounts Receivable Management
Refers to functions required for the monitoring and follow-up…
Applicant
is someone who has indicated an interest in a position at an…
27 terms
Chapter 3 Review Questions: Basics of Health Insurance
Part I Fill in the Blank... Assignment 3-…
An individual promising to pay for med…
List five health insurance policy rene…
Insurance reimbursement or payment is…
insurance policy
Guarantor
a. cancelable... b. optionally renewable... c. conditionally renewa…
Indemnity
Part I Fill in the Blank... Assignment 3-…
insurance policy
An individual promising to pay for med…
Guarantor
44 terms
Understanding Health Insurance Chapter 3 Key Terms
accreditation
cafeteria plan
capitation
case management
voluntary process that a health care facility or organization…
Also called triple option plan.; provides different health be…
provider accepts preestablished payments for providing health…
developed of patient care plans to coordinate and provide car…
accreditation
voluntary process that a health care facility or organization…
cafeteria plan
Also called triple option plan.; provides different health be…
15 terms
Understanding Health Insurance Chapter 3 Review
The intent of managed health care was to
Which term best describes those who re…
The Medical Center received a $100,000…
A nonprofit organization that contract…
Replace fee-for-service plans with affordable, quality care t…
Enrollees
Retained by the Medical Center as profit
Medical foundation
The intent of managed health care was to
Replace fee-for-service plans with affordable, quality care t…
Which term best describes those who re…
Enrollees
30 terms
Understanding Health Insurance Abbreviations, Chapter 3
CMP
CDHP
CSCP
EPO
Competitive medical plan
Consumer-directed health plan
Customized sub-capitation plan
Exclusive provider organization
CMP
Competitive medical plan
CDHP
Consumer-directed health plan
33 terms
Understanding Health Insurance, Chapter 3 Terms
Managed care organization (MCO)
Capitation
Primary care provider (PCP)
Mandates
Responsible for the health of a group of enrollees and can be…
Where providers accept pre-established payments for providing…
Responsible for supervising and coordinating healthcare servi…
Laws
Managed care organization (MCO)
Responsible for the health of a group of enrollees and can be…
Capitation
Where providers accept pre-established payments for providing…
32 terms
Life and Health Chapter 3 (Insurance Law)
Contract
Agent
Express Authority
Implied Authority
An agreement enforceable by law.
A person authorized to act on behalf of another person, who i…
The explicit, definite authority which the insurer has given…
Not expressly granted under an agency contract, but it is act…
Contract
An agreement enforceable by law.
Agent
A person authorized to act on behalf of another person, who i…
44 terms
Understanding Health Insurance Chapter 3 Test Review
QISMC
QISMC
(PCP) Primary Care Physician
Joint Commission (JC)
Quality Improvement System for Manager Care
was established by Medicare to ensure accountability of manag…
provide care for enrollees on managed care plan
performs healthcare accreditation
QISMC
Quality Improvement System for Manager Care
QISMC
was established by Medicare to ensure accountability of manag…
Medical Billing & Coding Heald College: Chapter 3 | Basics of Health Insurance
Health Insurance
Implied Contract
Expressed Contract
Guarantor
A contract between the policy holder or member and the insura…
A contract between physician and patient not manifested by di…
A verbal or written agreement.
An individual who promises to pay the medical bill by signing…
Health Insurance
A contract between the policy holder or member and the insura…
Implied Contract
A contract between physician and patient not manifested by di…
71 terms
Understanding Health Insurance 13th Edition - Chapter 3 Terms
Accreditation
Adverse Selection
Amendment to the HMO Act of 1973
Cafeteria Plan... and... Flexible Benefit P…
Voluntary process that a health care facility or organization…
Covering members who are sicker than the general population.
Legislation that allowed federally qualified HMOs to permit m…
Also called Triple Option Plan; Provides different health ben…
Accreditation
Voluntary process that a health care facility or organization…
Adverse Selection
Covering members who are sicker than the general population.
13 terms
Chap3 Health insurance. Managed Health care
Managed Health Care
Managed Health Care
Managed Health Care
Managed Health Care
Also called managed care... Provides reasonably priced health ca…
Is currently being challenged by growing consumer-directed he…
Provides health care services that are:... Affordable... Comprehens…
Enrollees are subscribers or policyholders and usually:... Emplo…
Managed Health Care
Also called managed care... Provides reasonably priced health ca…
Managed Health Care
Is currently being challenged by growing consumer-directed he…
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