Deck 3: The Payment Process: Insurance and Third-Party Payers

Question 1

The amount paid to a provider monthly to provide health care services to an employee is:

A) premium.
B) capitation.
C) copayment.
D) deductible.

Answer 1

capitation.

Question 2

Determining who is responsible for health claim payments is known as:

A) explanation of benefits.
B) COBRA.
C) coordination of benefits.
D) ERISA.

Answer 2

coordination of benefits.

Question 3

With EPOs all of the following are true except:

A) patients must select their care providers from those in the network.
B) patients may choose their physician or hospital.
C) if the patient chooses to go outside the network the services are not covered.
D) they are regulated by state insurance law.

Answer 3

patients may choose their physician or hospital.

Question 4

The _____________ calculates risk and helps set premiums.

A) actuary
B) government
C) benefits manager
D) employer

Question 5

This organization negotiates and manages provider's contracts.

A) Staff model HMO
B) PPO
C) Network HMO
D) IPA

Question 6

Premiums are the:

A) portion of services paid by the patient.
B) amount paid by the patient before the third-party payer begins to pay.
C) negotiated payment for services between the payer and the provider.
D) fee paid by employers and employees to the insurance company.

Question 7

All of the following are true except:

A) 22 states insist on mental health parity.
B) all 50 states mandate breast cancer screening.
C) 16 states mandate payment of prenatal care.
D) 44 states require external review of health plan decisions.

Question 8

A third-party payer may be:

A) an insurance company.
B) a government agency.
C) a service provider.
D) All of the above

Question 9

A policy is:

A) a binding contract between the payer and the employer.
B) the time in which employees can utilize benefits.
C) a time when employees can change providers.
D) a binding contract between the payer and the employee.

Question 10

A PPO:

A) is a delivery network.
B) does not receive premiums or assume financial risk.
C) decreases cost of service if a preferred provider is used.
D) All of the above

Question 11

John is known as a(n) _______________ in his HMO.

A) actuary
B) enrollee
C) subscriber
D) policy holder

Question 12

The copayment is the:

A) fee paid by employers and employees to the insurance company.
B) negotiated payment for services between the payer and the provider.
C) portion of services paid by the patient.
D) amount paid by the patient before the third-party payer begins to pay.

Question 13

A deductible is the:

A) portion of services paid by the patient.
B) amount paid by the patient before the third-party payer begins to pay.
C) fee paid by employers and employees to the insurance company.
D) negotiated payment for services between the payer and the provider.

Question 14

An enrollment period is a:

A) binding contract between the payer and the employee.
B) binding contract between the payer and employer.
C) time when employees can utilize benefits.
D) time when employees can change providers.

Question 15

Third-party payers are covered by both state and federal regulations. Two of the federal regulations are:

A) COBRA and PPO.
B) ERISA and HIPAA.
C) COBRA and EPO.
D) ERICA and HIPAA.

Question 16

Health insurance is:

A) a PPO.
B) shifting the risk of loss.
C) an HMO.
D) All of the above

Question 17

John's recent physician office visit was not paid by the insurance company. It was his first claim of the year. The claim totaled $200. The reason the claim was denied was likely related to John's:

A) copayment.
B) subscriber.
C) deductible.
D) premium.

Question 18

The typical fee charged by providers in a geographic area is known as:

A) usual charge, reasonable cost plan.
B) usual, customary, and reasonable..
C) universal charge and reimbursement plan.
D) ordinary and customary cost program.

Question 19

An HMO contracts with more than one group practice for service in which arrangement?

A) Staff model HMO
B) Network HMO
C) IPA
D) PPO

Question 20

A ______________________ is a system where payment is made in advance of services being provided.

A) prepaid health plan
B) preauthorization
C) coordination of benefits
D) copayment

Question 21

According to the text, _______________% of Americans under age 65 are uninsured.

Question 22

HIPAA regulates all of the following except:

A) portability.
B) coverage on a family plan until 26 years old.
C) access.
D) mandated benefits.

Question 23

Physicians are always independent contractors in third-party payer arrangements.

Question 24

Explain the gatekeeping concept, and include an example of how it benefits the patient, payer, and provider.

Question 25

Define the term third-party payer and describe the role of the insurance company as the third party in the patient-provider relationship.

Question 26

_______________ is a type of prepaid health care plan.

Question 27

Employers pay the entire insurance premium for their employees in most instances.

Question 28

The American Health Benefit Exchanges and Small Business Health Option Exchanges:

A) are part of the Patient Protection and Affordable Care Act.
B) require states to establish insurance options for the uninsured and small businesses.
C) require states to establish an office of health insurance consumer assistance.
D) All of the above

Question 29

Prepaid health plans :

A) are attractive to employers because they know in advance what the cost of providing health care will be.
B) all involve an IPO.
C) are attractive to the service provider because the number of patients is fixed and a certain revenue level is guaranteed.
D) Both A and C

Question 30

Like hospitals, insurance companies must be licensed.

Question 31

_______________-_______________ _______________ manage health care benefits and process claims for their clients.

Question 32

Once a policy is in place the employer is the insured.

Question 33

Employers must provide health insurance.

Question 34

_______________ insurance does not restrict a patient's choice of providers.

Question 35

In a _______________, the employer acts as the insurance company and pays for its employees' health care costs out of its own pocket.