The payment methodology that combines the professional and technical components of a procedure is

What is a private not-for-profit organization with the mission to improve healthcare quality by accrediting, assessing and reporting on the quality of managed care plans?

True or False: The Health Maintenance Organization Act of 1973 made it harder for HMOs to grow and attract clients and required all employers that offered traditional health care to their employees to sign up for an HMO if they had more than 35 employees.

Medicare enrollees are called ____ and must fall into a benefit category to be eligible for Medicare coverage.

People who are enrolled in both Medicare and Medicaid known as ____

____ includes verification that the patient is currently covered by the plan on the date of service the services being provided are covered by the plan.

What is a pre-established percentage of eligible expenses after the deductible is met?

____ is a cost-sharing measure in which the policy holder pays a fixed dollar amount per service.

____ means charging the patient for the remainder of the charges that were not paid by the insurance plan.

True or False: Health insurance payers have a variety of reimbursement plans and contract with individual providers and employers for payment meaning the same type of service to two different patients may be paid differently depending on the type of contract or insurance each patient has.

What is name of the form that details the way the payer processed the claim for payment?

True or False: Many Americans are covered by private insurance plans through their employer, purchased individually, or through a group, such as a professional association.

Typically, insurance plans that have very high deductibles or limited covered services is called what?

True or False: In a network HMO the HMO contracts with a network of providers who provide multispecialty group practices

In a ____ HMO the physicians are employed by the HMO. Physicians see only members of the HMO and are paid a salary by the HMO.

What type of HMO model contracts with more than one physician, such as a medical group that includes physicians in multiple fields of expertise?

True or False: The Health Information and Accountability Act established the hospital-acquired conditions reduction program to encourage hospitals to reduce HAC’s.

____ is the evaluation of medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.

What refers to the review that takes place prior to elective procedures or admissions?

True or False: Retrospective review involves screening for medical necessity and the appropriateness or timeliness of delivery of medical care from the time of admission until discharge.

____ is a collaboration between healthcare and service providers to aid in the process of assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet an individual’s and family’s comprehensive health needs.

A hospital’s ____ represents the average DRG relative weight for a particular hospital.

In what system are payments for services determined by the resource cost needed to provide them?

True or False: The Balance Budget Act (BBA) of 1997 modified how facilities are paid for skilled nursing facility (SNF) services. SNF’s are paid a comprehensive per diem under a PPS, meaning they receive a set amount for each day of service instead of being paid on itemized charges or services.

What is the term that is used to identify an insurance company that pays for the healthcare of covered individuals?

If a patient is covered by more than one insurance plan, the process of coordination of benefits (COB) takes place.

A Chargemaster is a financial management list that contains information about the organization’s charges for healthcare services it provides to patients.

____ is a type of incentive to improve clinical performance using the electronic health record resulting in additional

A type of prospective review involves ____ which is obtaining approval from a healthcare insurance company before a healthcare service is rendered.

What methodology involves payment that combines the professional and technical components of a procedure and disperses payments in a lump sum to be split between the physician and the healthcare facility?

Payment method in which the third-party has implemented some provisions to control the costs of healthcare while maintaining quality care.

An entity that combines the provision of healthcare insurance and delivery of healthcare services, characterized by an organized healthcare delivery system to a geographic area, a set of basic and supplemental health maintenance and treatment services, voluntarily enrolled members, and predetermined fixed, periodic prepayments for members’ coverage.

A federally funded health program to assist with the medical care costs of American 65 years of age and older.

Medicare prescription drug coverage

A joint federal and state program that helps with medical costs for some people with low incomes.

The federal healthcare program that provides coverage for the dependents of armed forces personnel and for retirees receiving care outside military treatment facilities.

A federal agency within the Department of of Health and Human Services that is responsible for providing federal healthcare services to American Indians and Alaska Natives.

Insurance that most employers in the US are required to carry and is used for employees who are injured on the job.

In what system are payments for services determined by the resource cost needed to provide them?

What is the term used by the insurance industry that refers to the process of paying?

What are the three therapy components used in the PDPM model for SNF payment quizlet?

Who is responsible for making payment for healthcare claims on behalf of the company?