Ch.8

The federal law that regulates companies which set up employee health and pension plans is known as:

ERISA

The health insurance program for federal government employees is:

FEHB

Identify what may be used to modify the terms of an insurance contract.

Rider

Identify the type of contract under which an insurance carrier works as a third-party claim administrator for a self-funded health plan.

Administrate services only contract

Which of the following is a common reason why people elect to enroll in individual health plans?

Because they are able to continue their health insurance coverage between jobs

Which of the following are not a common purchaser of IHPs?

Employers

How often do open enrollment periods usually occur?

Once per year

Which of the following is a way that an employer can reduce prices for their GHPs?

Carve out benefits during negotiations to change the coverage

Which of the following type of plan do employers or employee organizations offer to their employees?

Group health plan

Who may be covered under a GHP?

Employees, families, and former employees

How can employees customize their GHP policies?

By choosing levels of premiums and deductibles

Identify the document self-funded plan members receive that states their benefits and legal rights.

SPD

How can TPAs help self-funded health plans?

By handling collection of premiums, processing claims, and keeping list of members

Third-party claims administrators are classified as:

A separate company, often a managed care organization or insurance carrier

What type of contract binds a third-party administrator to provide administrative services to an employer for a fixed fee per employee?

ASO

Determine what law a practice would follow if a state law is more restrictive than the related federal law.

The state law is followed

Generalize the advantages provided by employers by offering GHPs:

They offer an important benefit to employees; thereby making the employer more attractive

What organization runs ERISA?

EBSA

Self-funded health plans pay premiums to:

No one because they assume the risk

Approximately what percent of the population are covered under IHPs?

10%

The amount of time that must pass before an employee can enroll in a health plan is called a(n):

Waiting period

Which term refers to an individual who enrolls in a health plan after the original enrollment date?

Late enrollee

Identify the type of deductible which must be met for each separate enrollee.

Individual deductible

Identify the type of deductible that can be met by combining payments.

Family deductible

The term maximum benefit limit applies to:

A monetary amount

What name is given to the time between the date of an employee's hire and the earliest effective date of insurance coverage?

A waiting period

A list of drugs that are covered under an insurance plan is called the:

Formulary

Compare and contrast the following types of provider performance to determine which would be reimbursed at the highest level in a tiered network.

Practice provides quality healthcare at a low cost

What type of plan is structured to permit the funding of premiums with pretax payroll deductions?

Section 125 cafeteria plan

Define parity as it relates to medical insurance.

Concept of equality with medical/surgical benefits

Explain the benefit that COBRA offers to employees who are leaving a job.

The right to continue health coverage under the employer's plan for a limited time at his or her own expense

In conjunction with COBRA, determine what must be considered when an employee joins a new plan.

Creditable coverage

What information is included in a formulary?

The list of a plan's selected drugs and proper dosages

Approximately what percent of all consumers with health insurance are enrolled in a PPO?

50%

The type of payment structure that PPO's usually offer in their contracts with providers is called:

Discounted fee-for-service

What type of private payer offers lower costs, but also has the most stringent guidelines and the narrowest choice of providers?

Health maintenance organizations (HMO's)

What type of plan requires premium, deductible, and coinsurance payments and typically covers 70 to 80 percent of costs for covered benefits after deductibles are met?

Indemnity plans

Which of the following is the most popular type of group health plan?

Preferred provider organizations (PPO's)

What type of plan is a hybrid of two networks where members may choose from a primary or secondary network?

Point-of-service (POS) plans

Which is the most appropriate method in handling the termination of patients within an HMO?

The PCP asks the payer for permission, then sends a certified letter to the patient, and receives the signed letter back from the patient

Which of the following could represent a member in a closed-panel HMO?

A physician of a group with a contract with the HMO

Which of the following examples demonstrates subcapitation?

A capitated provider prepays an ancillary provider

Name the structure that emphasizes communication among the patient's physicians.

Medical home model

Identify the type of managed care structure that is usually the first component of a consumer-driven health plan.

Preferred provider organization (PPO)

A consumer-driven health plan combines a savings option and what kind of health plan?

High deductible

Which type of consumer-driven health plan funding option is set up by individuals rather than employers?

A health savings account (HSA)

Determine which of the following criteria is important for payment under a CDHP.

Educating patients about their financial responsibility at the time of service

Which type of consumer-driven health plan funding option is set up and funded by employers?

A health reimbursement account (HRA)

Which type of consumer-driven health plan funding option can be funded by both employers and employees?

A flexible savings account (FSA)

A member of a CDHP has an HSA fund of $500 and a deductible of $1,000 (which has not yet been met), and the HDHP has a 80-20 coinsurance. Calculate the total amount this patient would owe if the bill for their services is $1,800.

$1,560

A member of a CDHP has an HSA fund of $820 and a deductible of $500 (which has not yet been met), and the HDHP has a 75-25 coinsurance. Calculate the total amount this patient would owe if the bill for their services is $2,100.

$1,515

Identify why the best situation for medical practices is an integrated CDHP in which the same plan runs both the HDHP and the funding options.

Reduced paperwork

BlueCross and BlueShield companies also offer a consumer-driven health plan called:

Flexible Blue

Identify the local BCBS plan in the provider's service area, where a claim is submitted after providing treatment.

Host plan

A patient's \_____ processes the BCBS claim and sends it back to the host plan.

Home plan

Which term describes the periodic verification that a provider or facility meets professional standards?

Credentialing

Identify an insurance service that private payers supply.

Processing claims

Identify a method that BCBS uses to improve healthcare.

Pay-for-performance programs with financial incentives

A member in an indemnity BCBS plan has an individual deductible of $500 and a family deductible of $1,000, with a coinsurance rate of 90 percent after the deductible has been met, up to an annual maximum out-of-pocket amount of $2,000. Calculate the total amount the patient owes if their first charges of the year total $2,400.

$1,590

A member in an indemnity BCBS plan has an individual deductible of $250 and a family deductible of $500, with a coinsurance rate of 70 percent after the deductible has been met, up to an annual maximum out-of-pocket amount of $1,000. Calculate the total amount the patient owes if their first charges of the year total $3,200.

$1,000

Name the term used to describe participating providers in BCBS plans.

Member physicians

What is the nation's largest health insurer in terms of enrollment?

WellPoint, Inc.

What type of managed care program does BCBS offer?

HMO, POS, and PPO

What is the purpose of the BlueCard program?

To make it easier for patients to receive treatment when outside their local service area

Which of these is the primary factor that providers examine to decide whether to participate in managed care plans?

The financial arrangements

Stop-loss provisions protect providers against:

Extreme financial loss

Which section of a managed care participation contract covers balance-billing rules?

Compensation and billing guidelines section

Which section of a managed care participation contract covers referrals and preauthorization rules?

Physician's responsibilities section

Which section of a managed care participation contract covers protection against loss?

Managed care plan obligations section

What term refers to the payer's process for determining medical necessity?

Utilization review

It is common for physicians to participation in more than \_____ health plans.

Twenty

Describe the features of managed care organizations that practices review when deciding about entering a participation contract.

Its licensure status, accreditation standing, and business history

Some managed care contracts require referrals to be made solely to:

Other participating providers

Which section of a managed care participation contract includes information about a claim turnaround time?

Managed care plan obligations section

A plan pays 50 percent of the provider's usual charge and requires the copayment of $5 to be applied toward the provider's payment. Calculate what the plan pays the provider when the usual charge is $200?

$95

A plan pays 75 percent of the provider's usual charge and requires the copayment of $15 to be applied toward the provider's payment. Calculate what the plan pays the provider when the usual charge is $380?

$270

What type of surgery is a procedure that can be scheduled ahead of time, but which may or may not be medically necessary?

Elective surgery

What might private payers use for a major course of treatment, such as surgery, chemotherapy, and radiation for a patient with cancer?

URO

Identify the additional component that should be included in a contract when a payer's fee schedule is based on the MPFS.

Which year's MPFS is going to be used

A physician practice lists a service at $130, but in the participating contract it has with a payer, the service is listed at $95. Calculate the amount that the practice will need to write off if balance billing is not permitted.

$35

What constitutes a silent PPO?

An MCO that does not have a contract, but purchases a list of participating providers with another plan and pays their enrollees' claims according to that contract's fee schedule

What is precertification?

Preauthorization for hospital admission or outpatient procedures

What entity generally hires a URO to evaluate the medical necessity of planned procedures?

Payer

Elective surgical procedures are done on a(n):

Both in-patient and out-patient basis

What should be prepared or updated for each participation contract?

Plan summary grid

Name the electronic format used to obtain approval for preauthorizations and referrals.

HIPAA 278

What billing information is summarized by the plan summary grid?

Patient financial responsibility, billing information, and referral requirements

Which of the following describes a consultation?

A physician examines the patient at the request of another physician and provides report to requesting physician

A repricer is a company that:

Works for a health plan and sets the discounts for out-of-network visits

Which of the following steps comes first in the standard medical billing cycle?

Preregister patients

Which of the following steps comes second in the standard medical billing cycle?

Establish financial responsibility for a visit

Which of the following steps comes after checking billing compliance in the standard medical billing cycle?

Prepare and transmit claims

What is the electronic format used to verify benefits?

HIPAA 270/271

Which of the following is a method a practice can use to avoid major problems with payers?

Use good communication skills in working with payers

In submitting paper claims, the best practice is to:

Check with each payer for specific information required on the form as well as the NUCC notes

Eligible members of a capitated plan are listed on the:

Monthly enrollment list

Careful attention must be paid to \_____ when the practice has a capitated contract.

Encounter reports and referral requirements | Patient eligibility and claim write offs | Referral requirements and billing procedures (All of these are correct)

Which of these is the best method for determining if a patient is eligible for services?

Verify the patient's insurance coverage

Which of the following is normally NOT included on the monthly enrollment list?

The name of the employer

Providers bill patients for services not covered by the cap rate under a(n):

Capitated contract