Question 1

_______ gives an employee who is leaving a job the right to continue health coverage under the employers' plan for a limited time at his or her own expense.

Accepted Answer

COBRA gives an employee who is leaving a job the right to continue health coverage under the employers' plan for a limited time at his or her own expense.

Question 2

A (n) _____ is a medical insurance plan purchased by an individual.

Accepted Answer

An individual health plan is a medical insurance plan purchased by an individual.

Question 3

A (n) ________ is a health plan , often without riders or additional features associated with the group health plan, that people elect to enroll in to continue their health insurance between jobs.

Accepted Answer

People often elect to enroll in individual plans, although coverage is expensive, in order to continue their health insurance between jobs. Individual insurance plans have basic benefits without the riders or additional features associated with group health plans.

Question 4

The ____ is a national organization of independent companies and a Federal Employee Program that insures nearly 100 million people.

Accepted Answer

BlueCross BlueShield Association (BCBS) is a national organization of independent companies and a Federal Employee Program that insures nearly 100 million people.

Question 5

BCBS is the abbreviation for the _____.

Accepted Answer

BCBS is the abbreviation for the BlueCross BlueShield Association (BCBS)

Question 6

____ was founded in the 1930s to provide low-cost medical insurance.

Accepted Answer

Founded in the 1930s to provide low-cost medical insurance, the BlueCross BlueShield Association (BCBS) is a national organization of independent companies and a Federal Employee Program that insures nearly 100 million people.

Question 7

The _____ is an independent nonprofit organization and is the leader in accrediting HMOs and PPOs.

Accepted Answer

National Committee for Quality Assurance (NCQA) is an independent nonprofit organization. NCQA is the leader in accrediting HMOs and PPOs.

Question 8

________ sets and monitors standards for many types of patient care.

Accepted Answer

The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations or JCAHO) sets and monitors standards for many types of patient care.

Question 9

The ______ helps alleviate the pressures facing physicians, health plans, and hospitals by reducing costs and administrative effort while simultaneously documenting quality.

Accepted Answer

American Medical Accreditation Program (AMAP) helps alleviate the pressures facing physicians, health plans, and hospitals by reducing cost and administrative effort while simultaneously documenting quality.

Question 10

The _______ is another leading accrediting group addressing both the security and privacy of health information as required by HIPAA that is a nonprofit organization and establishes standards for managed health care plans.

Accepted Answer

URAC has accreditation programs addressing both the security and privacy of health information as required by HIPAA. Utilization Review Accreditation Commission (URAC) also known as the American Accreditation Healthcare Commission is another leading accrediting group. Like NCQA, it is a nonprofit organization that establishes standards for managed health care plans.

Question 11

What program emphasizes an assessment of clinical records, enrollee and provider satisfaction, provider qualifications, utilization of resources, and quality of care?

Accepted Answer

Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) has accredited managed care organizations for more than twenty years. Its program emphasizes an assessment of clinical records, enrollee and provider satisfaction, provider qualifications, utilization of resources, and quality of care.

Question 12

Which of the following is a nationwide program that makes it easy for patients to receive treatment when outside their local service area?

Accepted Answer

The BlueCard program is a nationwide program that makes it easy for patients to receive treatment when outside their local service area and also makes it easy for a provider to receive payment when treating patients enrolled in plans outside the provider's service area.

Question 13

______ links participating providers and independent BCBS plans throughout the nation with a single electronic claim processing and reimbursement system.

Accepted Answer

The BlueCard program links participating providers and independent BCBS plans throughout the nation with a single electronic claim processing and reimbursement system.

Question 14

Participating provider's local BCBS plan is called ____.

Accepted Answer

Host plan is participating provider's local BCBS plan.

Question 15

_____ is BCBS plan in the subscriber's community.

Accepted Answer

Home plan is BCBS plan in the subscriber's community.

Question 16

______ is BCBS consumer-driven health plan that combines a comprehensive PPO plan with an HSA, an HRA, or an FSA.

Accepted Answer

BlueCross and BlueShield consumer driven health plan named Flexible Blue combines a comprehensive PPO plan with either an HSA, an HRA, or an FSA.

Question 17

The types of services that the provider must offer to plan members are called ___.

Accepted Answer

Covered services are the types of services that the provider must offer to plan members.

Question 18

The payer's process for determining medical necessity is called _____.

Accepted Answer

Utilization review is the payer's process for determining medical necessity.

Question 19

When the practice decides to participate in a health care plan, it must follow the rules of the contract. Which is not one of the points to consider?

Accepted Answer

When the practice decides to participate, it must follow the rules of the contract, including these points: covered services, acceptance of plan members, referrals, preauthorization, quality assurance/utilization review, and other provisions.

Question 20

What is protection against large losses or severely adverse claims experience called?

Accepted Answer

Stop-loss provision is protection against large losses or severely adverse claims experience.

Quiz 8: Private Payers/Blue Cross and Blue Shield