Study Guide HI231 Review -Sayles chapters 1-6 review questions in check your understanding, look up definition for medical terminology located in back of your book. Castro chapters 1-5 1. What type of HMO are physician's employees? 2. An accounting system of the physician office, the account is categorized as "self-pay." How should the insurance analyst interpret this category? 3. What services is most likely to be considered medically necessary? Investigational cancer prevention or standard of care for health condition 4. An insurance analyst at the large group practice is responsible for issues related to coordination of benefits. What does he or she do? 5. What is the name of the TRICARE program in which offers services to active duty family members (ADFMs) with no enrollment, deductible, or copayment fees for covered services? 6. An approval number received prior to surgery. What is the approval and what number should the insurance analyst record? 7 Which services has the highest likelihood of being a "covered service?" 8. What reason do insurers pool premium payments for all the insureds in a group, then use actuarial data to calculate the group's premiums? 9. What policy did the 6th Scope of Work for Quality Improvement Organizations (QIO) introduce? 10. Of all the types of MCOs, which one has the strictest procedures for control of costs? 11. A patient, who was a Medicaid recipient, asked about the types of financial incentives that the Managed Care Organization (MCO) used. What should the MCO's administrator do? 12. What is the term for contracts that separate out certain types of healthcare services to decrease MCOs' risk? 13. A patient belonging to a managed care plan had an elective surgery prior to obtaining approval from his healthcare plan. What should the patient expect? 14. The notice from the healthcare insurance plan used the abbreviation "PMPM." What does this stand for? 15. What is meant by the phrase "point-of-service" in "point-of-service healthcare insurance plan?" 16 What do you call the type of service when the physician practice manager works with a case manager? 17. Name the type of healthcare payment method in which healthcare plans pay for each service that a provider renders? 18. Gatekeepers determine the appropriateness of what component? 19. Integrated delivery systems uses a variety of degrees, which degree of integration is least binding? 20. Which type of healthcare payment method of healthcare plan oversee both the costs of healthcare and the outcomes of care? 21. What is the term for an explicit statement that directs clinical decision making? 22. In a group practice, the physicians have maintained their separate practices and offices. The individual practices share administrative systems to form a group practice. Which form of integrated delivery system does this arrangement represent? 23. What is the term for an MCO that serves Medicare beneficiaries? 24. What is the type of reimbursement methodology that has the greatest degree of risk? 25. What is the term for a healthcare service, to determine the appropriateness of its setting and its level of service? 26. What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk? 27. The health plan reimburses Dr. T $15 per patient per month. In January, Dr. T saw 300 patients so he received $4500 from the health plan. What method is the health plan using to reimburse Dr. T? 28. What type of healthcare payment method, does the healthcare plan pay providers with a fixed rate for each day a covered member is hospitalized? 29. From the patient's healthcare insurance plan, the rehabilitation facility received a fixed, pre-established payment for the patient rehabilitation after a total knee replacement. What type of healthcare payment method was the patient's healthcare insurance plan using? 30 Name a way in which a group of physicians increase the monthly payments the group receives from a healthcare plan that uses capitation? 31. What is name of the Medicare's payment system for home health services consolidates all types of services, such as speech, physical, and occupational therapy, into a single lump sum payment. 33. A member had gastric bypass surgery three years previously. As a result of losing over 200 pounds, loose skin hung from her arms, thighs, and belly. Upon referral from her general surgeon, she was scheduled to have a plastic surgeon remove the excess skin. When she called for prior approval as required by the plan, the clinical review indicated that the surgery was cosmetic resulting in a denial of the surgery. The member requested a peer review and submitted documentation from her physician that the excess skin was causing skin infections and exacerbating her eczema. A peer clinician denied the case also. If the member is determined to have the surgery, what is her next step? 34. Phil White had coronary artery bypass graft surgery. Unfortunately, during the surgery, Phil suffered a severe stroke. Phil's recovery included several settings in the continuum of care-acute care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted ten months. As a member of a Managed Care Organization (MCO) in an integrated delivery system, how will Phil's healthcare billing be handled? Study Guide HI231 Review -Sayles chapters 1-6 review questions in check your understanding, look up definition for medical terminology located in back of your book. Castro chapters 1-5 1. What type of HMO are physician's employees? Answer: Staff model 2. An accounting system of the physician office, the account is categorized as "self-pay." How should the insurance analyst interpret this category? Answer: It is self-pay because the patients or their guarantors (responsible persons, such as parents for children) pay a specific amount for each service received. The patients or guarantors make such payments themselves to the providers, such as physicians, clinics, or hospitals that rendered each service. The patients or guarantors then seek reimbursement from their private health insurance or the governmental agency that covers their health benefits 3. What services is most likely to be considered medically necessary? Investigational cancer prevention or standard of care for health condition Answer: Standard of care for health condition 4. An insurance analyst at the large group practice is responsible for issues related to coordination of benefits. What does he or she do? Answer: Estimates the proportions of the payments from the primary and secondary carriers 5. What is the name of the TRICARE program in which offers services to active duty family members (ADFMs) with no enrollment, deductible, or copayment fees for covered services? Answer: TRICARE Prime 6. An approval number received prior to surgery. What is the approval and what number should the insurance analyst record? Answer: Precertification 7 Which services has the highest likelihood of being a "covered service?" Answer: Medically necessary 8. What reason do insurers pool premium payments for all the insureds in a group, then use actuarial data to calculate the group's premiums? Answer: The pool is large enough to pay losses of the entire group 9. What policy did the 6th Scope of Work for Quality Improvement Organizations (QIO) introduce? Answer: Payment Error Prevention Program 10. Of all the types of MCOs, which one has the strictest procedures for control of costs? Answer: Staff model 11. A patient, who was a Medicaid recipient, asked about the types of financial incentives that the Managed Care Organization (MCO) used. What should the MCO's administrator do? Answer: Release summaries of the financial incentives 12. What is the term for contracts that separate out certain types of healthcare services to decrease MCOs' risk? Answer: Carve out 13. A patient belonging to a managed care plan had an elective surgery prior to obtaining approval from his healthcare plan. What should the patient expect? Answer: Denial of reimbursement for the surgery 14. The notice from the healthcare insurance plan used the abbreviation "PMPM." What does this stand for? Answer: Per member per month 15. What is meant by the phrase "point-of-service" in "point-of-service healthcare insurance plan?" Answer: Members choose the reimbursement model (HMO, PPO, fee for service) when they need healthcare services rather than during the open enrollment period 16 What do you call the type of service when the physician practice manager works with a case manager? Answer: Worker's compensation 17. Name the type of healthcare payment method in which healthcare plans pay for each service that a provider renders? Answer: Fee for service 18. Gatekeepers determine the appropriateness of what component? Answer: Level of healthcare personnel 19. Integrated delivery systems uses a variety of degrees, which degree of integration is least binding? Answer: Affiliation 20. Which type of healthcare payment method of healthcare plan oversee both the costs of healthcare and the outcomes of care? Answer: Managed care 21. What is the term for an explicit statement that directs clinical decision making? Answer: Evidence based practice guidelines 22. In a group practice, the physicians have maintained their separate practices and offices. The individual practices share administrative systems to form a group practice. Which form of integrated delivery system does this arrangement represent? Answer: Clinic without walls 23. What is the term for an MCO that serves Medicare beneficiaries? Answer: Medicare advantage 24. What is the type of reimbursement methodology that has the greatest degree of risk? Answer: Retrospective 25. What is the term for a healthcare service, to determine the appropriateness of its setting and its level of service? Answer: Utilization review 26. What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk? Answer: Policy 27. The health plan reimburses Dr. T $15 per patient per month. In January, Dr. T saw 300 patients so he received $4500 from the health plan. What method is the health plan using to reimburse Dr. T? Answer: Capitated rate 28. What type of healthcare payment method, does the healthcare plan pay providers with a fixed rate for each day a covered member is hospitalized? Answer: Per diem 29. From the patient's healthcare insurance plan, the rehabilitation facility received a fixed, pre-established payment for the patient rehabilitation after a total knee replacement. What type of healthcare payment method was the patient's healthcare insurance plan using? Answer: Case based 30 Name a way in which a group of physicians increase the monthly payments the group receives from a healthcare plan that uses capitation? Answer: Renegotiate the contract 31. What is name of the Medicare's payment system for home health services consolidates all types of services, such as speech, physical, and occupational therapy, into a single lump sum payment. Answer: Global payment 33. A member had gastric bypass surgery three years previously. As a result of losing over 200 pounds, loose skin hung from her arms, thighs, and belly. Upon referral from her general surgeon, she was scheduled to have a plastic surgeon remove the excess skin. When she called for prior approval as required by the plan, the clinical review indicated that the surgery was cosmetic resulting in a denial of the surgery. The member requested a peer review and submitted documentation from her physician that the excess skin was causing skin infections and exacerbating her eczema. A peer clinician denied the case also. If the member is determined to have the surgery, what is her next step? Answer: Panniculectomy should be performed to manage serious complications from abdominal apron 34. Phil White had coronary artery bypass graft surgery. Unfortunately, during the surgery, Phil suffered a severe stroke. Phil's recovery included several settings in the continuum of care-acute care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted ten months. As a member of a Managed Care Organization (MCO) in an integrated delivery system, how will Phil's healthcare billing be handled? Answer: One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare provider