ch. 3 and 4 medical insurance

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Which statement is correct regarding the insurance industry
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The insurance industry is among the world’s largest businesses
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most legal issues of private health insurance claims fall under
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civil law
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when does the physician/patient contract begin
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when the physician accepts the patient and agrees to treat the patient
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most physician/patient contracts are
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implied
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When a patient carries private medical insurance, the contract for treatment exists between the
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physician and the patient
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an emancipated minor is a person
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younger than the age of 18 who lives independently
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the contract in a workers compensation case exists between the
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physician and the insurance company
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in health insurance, the insured is also known as the
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subscriber, member, policy holder
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the insured is always the
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individual enrollee or organization protected
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A policy in which the insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract is a _______ policy.
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noncancelable
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the reason for a coordination of benefits statement in a health insurance policy is to
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prevent duplication or overlapping of payments for the same medical expense.
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Mr. Talili has two medical insurance policies. to prevent duplication of payment for the same medical expense, the policies include a ______ statement.
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coordination of benefits
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in cases of divorce, the decision as to which parent should be responsible for payment of the child’s services should be made by the
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court system
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if a child has health insurance coverage from two parents, according to the birthday law
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the health plan of the person whose birthday (month and day) falls earlier in the calendar year will pay first
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according to the birthday law if both the mother and the father have the same birthday, the
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plan of the person who has coverage longer is the primary payer
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conditions that existed and were treated before the health insurance policy was issued are called
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preexisting
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an attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered is referred to as a
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waiver
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what is the correct term used to determine if a procedure is covered and medically necessary
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preauthorization
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mrs. thompsett leaves her place of employment. she is eligible to transfer her medical insurance coverage from a group to an individual contract this is known as _____ privilege
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conversion
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why would conversion from a group policy to an individual policy be advantageous
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benefits would be increased
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mr. Ott was laid off from his job. he is protected by consolidated omnibus budget reconciliation act (COBRA), which requires his employer to
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extend group health insurance coverage for 18 months
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What is the minimum number of employees a company must have to meet the criteria of the COBRA for continued medical benefits if an employee is laid off from a company
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20
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the act created to protect workers and their families so that they can get and maintain health insurance if they change or lose their jobs is called the
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HIPAA
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an organization of physicians, sponsored by a state or local medical association, concerned with the development and delivery of medical services and the cost of health care is known as a
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foundation for medical care
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a type of managed care organization created by the 1982 tax equity and fiscal responsibility act (TEFRA) that allows for enrollment of medicare beneficiaries into managed care plans is to a
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competitive medical plan (CMP)
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a state and federal program for children who are younger than 21 years of age and have special health care needs is
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maternal and child health programs (MCHP)
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A patient intake sheet is also called a
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patient registration form
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The first document obtained in the initial patient visit is a
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patient information form
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assignment of benefits is
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the transfer of ones legal right to collect an amount payable under an insurance contract
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an encounter form may also be known as a
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patient service slip
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the source document for insurance claim data is the
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superbill
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a daily record sheet used to record daily business transactions is called a
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day sheet
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under HIPAA guidelines, physicians must send all claims electronically if they have _____ full-time employees
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more than 10
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an insurance claims register facilitates
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follow-up of insurance claims
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when the physicians services have been submitted to the patients insurance company by the physicians office, the patient should
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be sent a monthly statement indicating the insurance company has been billed
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independent practice association (IPA)
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a medical capitation plan in which treatment is delivered via a clinic or independent physician that provides a number of basic medical services for a fixed capitation payment per month
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medicaid
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a program sponsored jointly by federal and state governments for medically indigent persons, aged individuals who meet certain financial requirements, and the disabled
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state disability or unemployment compensation disability (UCD)
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insurance that covers off the job injury or sickness and is paid by deductions from a persons paycheck
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tricare
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government sponsored program that provides hospital and medical services for dependents of active duty uniform service members, military retirees and their families, and survivors of uniformed services
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workers compensation insurance
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a contract that insures a person against on the job injury or illness
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CHAMPVA
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provides coverage for spouses and children of veterans with total, permanent, service connected disabilities or for the surviving spouses and children of veterans who died as a result of service connected disabilities
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health maintenance organization (HMO)
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an organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment
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disability income insurance
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a form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease
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medicare
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the hospital insurance system and supplementary medical insurance for those older than 65 years of age, created by the 1965 Amendments to the social security act
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treating or performing physician
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renders a service to a patient
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ordering physician
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directs selection, preparation, and administration of tests, medication, or treatment
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attending physician
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legally responsible for the care and treatment given to a patient
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consulting physician
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gives an opinion regarding a specific problem that is requested by another doctor
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referring physician
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sends the patient for tests or treatment or to another physician for consultation
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primary care physician
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oversees care of patients in managed care plans and refers patients to see specialists when needed
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teaching physician
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responsible for training and supervising medical students
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non physician practitioner
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clinical nurse specialist or licensed social worker who treats a patient for a specific medical problem and uses the results of a diagnostic test in managing a patients medical problem
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resident physician
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performs one or more ears of training in a specialty area while working at a hospital (medical center)
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RLQ
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right lower quadrant
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DC
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discharge
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WNL
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within normal limits
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R/O
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rule out
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URI
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upper respiratory infection
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C (line on top)
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with

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