HSM Quiz 1 || Fast Track Test: Real Questions, Expert
Answers!!
general categories of health service questions correct answers Access
Cost
Quantity
Quality
Efficiency
entrepreneurial correct answers type of US health care system
main components of US health care system correct answers privately funded - based on a
capitalistic philosophy with a free-market economy and competition
publicly or tax supported - based on a social philosophy that the government has the
responsibility to provide access to health care, especially to those in need
most responsive, superb in development of medical technology (increases cost), techniques
(increases cost), and new drugs (increases costs), has sufficient and well-educated work
force, and sufficient facilities
private health care component correct answers Employers offering health care to employees
as a benefit
Commercial insurance companies and managed care organizations
Individuals who pay for their own health care insurance or pay cash
Philanthropists (charity and pro bono care)
allows providers to meet health care demands as entrepreneurs who can make a profit and
allows consumers to choose where and from whom they obtain services.
public health care component correct answers includes Medicare and Medicaid programs that
evolved to care for the poor, disabled, and other needy segments of society.
Funded by payroll taxes and federal and state general revenues
This social philosophy reflects the recognition of responsibility of the greater community to
ensure access to health care for those least able to meet this need on their own.
Medicare is funded by taxes
Medicaid is more state funded
These are attempts to make sure older and low income people are able to receive health care
services
U.S. Multiparty Payer System correct answers Patient (first party)
Provider (second party)
Third party payers (third party -
payers other than service recipient)
Third party payers include private or public forms of insurance.
Health Care Claims processing correct answers procedure costs $100
pt pays co-pay of $10
claim goes to clearing house for $90 reimbursement
clearing house decides where it needs to go
,Then where it is sent decides what to do with it and determines if it was worth $90
If not worth that then is repriced
provider decides procedure was only worth $60
$90 Claim is 'processed' and the
provider is ultimately paid $30
Total Reimbursement for $100
charge is $40 ($10 co-pay + $30)
self-insure correct answers the employer collects premiums and uses the pool of funds to pay
health care expenses
Indemnity Insurance Plans correct answers type of commercial insurance plan
Few exclusions or limitations.
Cover costs of care of insured up to the dollar amount set by the policy.
Choice of providers and payments to providers is unrestricted.
Most costly to the insured since it is potentially the most costly to the insurance company.
Most of services are provided by anyone you choose to go to
You pay for it - premiums are high
The method of payment is called fee for service (FFS).
The provider can charge a fee for each individual service.
The amount paid to the provider is based on a "usual and customary rate".
Some providers accept this as full payment; in other cases the insured is responsible for the
difference
charge for each service individually
FFS is the most common type of payment methodology for outpatient PT services
Each service has a distinct code that is reported on either the CMS-1500 paper claim form or
on the electronic 837P form.
Managed Care Insurance Plan (MCO) correct answers type of commercial insurance plan
created with restrictions and limitations intended to decrease and control health care costs.
A majority of U.S. citizens are enrolled
Ones that are most restricted and have least amount of choice- lower premium
don't have to pay as much out of pocket
business entity that is a health care provider, insurer, or both
arranges and pays for delivery of care through its own providers, contractual arrangements
with individual groups or organizations, or through both.
Arrangements with selected providers to furnish a comprehensive set of health care services
to members;
Explicit standards for health care providers;
Formal programs for ongoing quality assurance and utilization review;
Significant financial incentives for members to use providers and procedures associated with
plan;
Financial incentives for plans &/or providers to limit unnecessary or questionable procedures
require some out of pocket costs: deductible. coinsurance, co-pay
types: HMO, PPO. POS
deductible correct answers the amount the individual must pay each year before the health
care plan begins to pay
, Coinsurance correct answers a portion of cost paid by the individual after the deductible is
met (i.e. 80% paid by the insurance company, 20% paid by the individual)
Co-payment correct answers the amount the individual must pay each time services are
received or prescription drugs are purchased
Health Maintenance Organizations (HMOs) correct answers An organization that provides
overall health care of a defined population of enrollees under a closed-panel of in-network
providers.
Closed-panel providers treat only the enrollees of the MCO plan.
may have open-panel or out-of-network providers but at an increased cost to the enrollee.
The enrollee must see a primary care physician first who acts as a "gatekeeper" to specialty
care.
Payment to the provider is a fixed amount paid per member per month.
PT is available through referral from a primary care physician.
Since payment to the provider is capitated (the payment is the same no matter how much or
little service is provided), there are provider incentives to treat efficiently and inexpensively.
Preferred Provider Organizations (PPOs) correct answers An individual, group, or
organization that accepts a contract from a MCO to be an approved or preferred provider.
differs from a health maintenance plan by offering a choice of providers and through the
method of payment.
For the increase in patient numbers managers negotiate a discounted FFS rate for services
Allows the option of seeking providers out of the panel.
These plans have increased premiums and out-of-pocket expenses compared to health
maintenance plans, but the enrollee can receive care outside of the panel if needed.
Insurance Coverage Guidelines correct answers legal requirements that beneficiaries and
participating providers are required to follow.
Specify administrative requirements that must be met before payment is made.
Specify which health care services are and are not covered by the plan
vary greatly between payers, geographical regions, and over time
Coverage Guidelines Include correct answers Services covered, partially covered and
excluded from coverage;
Coverage limits by amount, type or source of service;
Source of care, care giver qualifications, provider type, authorized service locations;
Service preauthorization requirements;
Service and charge documentation requirements, including required forms and submission
requirements;
Directions for obtaining preauthorization for covered services;
Procedures for addressing any disputed preauthorization decision of the payer;
Answers!!
general categories of health service questions correct answers Access
Cost
Quantity
Quality
Efficiency
entrepreneurial correct answers type of US health care system
main components of US health care system correct answers privately funded - based on a
capitalistic philosophy with a free-market economy and competition
publicly or tax supported - based on a social philosophy that the government has the
responsibility to provide access to health care, especially to those in need
most responsive, superb in development of medical technology (increases cost), techniques
(increases cost), and new drugs (increases costs), has sufficient and well-educated work
force, and sufficient facilities
private health care component correct answers Employers offering health care to employees
as a benefit
Commercial insurance companies and managed care organizations
Individuals who pay for their own health care insurance or pay cash
Philanthropists (charity and pro bono care)
allows providers to meet health care demands as entrepreneurs who can make a profit and
allows consumers to choose where and from whom they obtain services.
public health care component correct answers includes Medicare and Medicaid programs that
evolved to care for the poor, disabled, and other needy segments of society.
Funded by payroll taxes and federal and state general revenues
This social philosophy reflects the recognition of responsibility of the greater community to
ensure access to health care for those least able to meet this need on their own.
Medicare is funded by taxes
Medicaid is more state funded
These are attempts to make sure older and low income people are able to receive health care
services
U.S. Multiparty Payer System correct answers Patient (first party)
Provider (second party)
Third party payers (third party -
payers other than service recipient)
Third party payers include private or public forms of insurance.
Health Care Claims processing correct answers procedure costs $100
pt pays co-pay of $10
claim goes to clearing house for $90 reimbursement
clearing house decides where it needs to go
,Then where it is sent decides what to do with it and determines if it was worth $90
If not worth that then is repriced
provider decides procedure was only worth $60
$90 Claim is 'processed' and the
provider is ultimately paid $30
Total Reimbursement for $100
charge is $40 ($10 co-pay + $30)
self-insure correct answers the employer collects premiums and uses the pool of funds to pay
health care expenses
Indemnity Insurance Plans correct answers type of commercial insurance plan
Few exclusions or limitations.
Cover costs of care of insured up to the dollar amount set by the policy.
Choice of providers and payments to providers is unrestricted.
Most costly to the insured since it is potentially the most costly to the insurance company.
Most of services are provided by anyone you choose to go to
You pay for it - premiums are high
The method of payment is called fee for service (FFS).
The provider can charge a fee for each individual service.
The amount paid to the provider is based on a "usual and customary rate".
Some providers accept this as full payment; in other cases the insured is responsible for the
difference
charge for each service individually
FFS is the most common type of payment methodology for outpatient PT services
Each service has a distinct code that is reported on either the CMS-1500 paper claim form or
on the electronic 837P form.
Managed Care Insurance Plan (MCO) correct answers type of commercial insurance plan
created with restrictions and limitations intended to decrease and control health care costs.
A majority of U.S. citizens are enrolled
Ones that are most restricted and have least amount of choice- lower premium
don't have to pay as much out of pocket
business entity that is a health care provider, insurer, or both
arranges and pays for delivery of care through its own providers, contractual arrangements
with individual groups or organizations, or through both.
Arrangements with selected providers to furnish a comprehensive set of health care services
to members;
Explicit standards for health care providers;
Formal programs for ongoing quality assurance and utilization review;
Significant financial incentives for members to use providers and procedures associated with
plan;
Financial incentives for plans &/or providers to limit unnecessary or questionable procedures
require some out of pocket costs: deductible. coinsurance, co-pay
types: HMO, PPO. POS
deductible correct answers the amount the individual must pay each year before the health
care plan begins to pay
, Coinsurance correct answers a portion of cost paid by the individual after the deductible is
met (i.e. 80% paid by the insurance company, 20% paid by the individual)
Co-payment correct answers the amount the individual must pay each time services are
received or prescription drugs are purchased
Health Maintenance Organizations (HMOs) correct answers An organization that provides
overall health care of a defined population of enrollees under a closed-panel of in-network
providers.
Closed-panel providers treat only the enrollees of the MCO plan.
may have open-panel or out-of-network providers but at an increased cost to the enrollee.
The enrollee must see a primary care physician first who acts as a "gatekeeper" to specialty
care.
Payment to the provider is a fixed amount paid per member per month.
PT is available through referral from a primary care physician.
Since payment to the provider is capitated (the payment is the same no matter how much or
little service is provided), there are provider incentives to treat efficiently and inexpensively.
Preferred Provider Organizations (PPOs) correct answers An individual, group, or
organization that accepts a contract from a MCO to be an approved or preferred provider.
differs from a health maintenance plan by offering a choice of providers and through the
method of payment.
For the increase in patient numbers managers negotiate a discounted FFS rate for services
Allows the option of seeking providers out of the panel.
These plans have increased premiums and out-of-pocket expenses compared to health
maintenance plans, but the enrollee can receive care outside of the panel if needed.
Insurance Coverage Guidelines correct answers legal requirements that beneficiaries and
participating providers are required to follow.
Specify administrative requirements that must be met before payment is made.
Specify which health care services are and are not covered by the plan
vary greatly between payers, geographical regions, and over time
Coverage Guidelines Include correct answers Services covered, partially covered and
excluded from coverage;
Coverage limits by amount, type or source of service;
Source of care, care giver qualifications, provider type, authorized service locations;
Service preauthorization requirements;
Service and charge documentation requirements, including required forms and submission
requirements;
Directions for obtaining preauthorization for covered services;
Procedures for addressing any disputed preauthorization decision of the payer;
