Payers Study guides, Class notes & Summaries

A ________ is health plan that is sponsored by employer or employee organization to provide health care to the employees, former employees and their families. Group health plan Who manages the group health care plan benefits, negotiating with payers and selecting a number of plans for the employer and employees? Human resources Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:00 Full screen What is a document modifyin...

What Act shaped how commercial insurance carriers approached the concepts of paying for medical care? - ANSWER-HMO Act of 1973 ACA - ANSWER-Affordable Care Act HMO (Health Maintenance Organization) - ANSWER-The organization is both the insurer and provider of a set of defined services. Patients within this network must use an in-network provider for their services to be covered. Capitation Payment - ANSWER-part of prospective payment in which healthcare providers receive fixed monthly p...

1.04 Practicing within a Defined Role - Answer- provide services only after defining and documenting their professional role with relevant parties in writing. Scope of practice - Answer- Defined at the level of the profession-The range of activities in which members of a profession may be authorized to engage in by virtue of holding a credential or license-The range of activities might be defined by a credentialing body, certifying agency, or licensing laws, Allows identification of individua...

CPQA - ANSWER-certified professional in quality assurance When did CPHQ begin to advance the profession of quality and when was the first certification administered? - ANSWER-1976; Sept 8 1984 Board of Director's Quality Role - ANSWER-1. set policy 2. financial and strategic direction 3. quality of care 4. goals and objectives 5. establish quality priorities Leadership - ANSWER-ability to influence an individual or group toward achievement of a goal and includes determining the ...

Drug formularies: - help manufacturers determine which drugs are efficacious. -help salesmen determine what to sell -determine which drugs will be covered by third-party payers -Answers b. and c. are correct. - Correct Answer--determine which drugs will be covered by third-party payers In North America it is typical for physicians to work in hospitals but not be employed by them. This is a form of: -vertical integration - horizontal integration -incomplete horizontal integration -in...

PCT Certification exam Correct 100% Providers - ANSWER people or organizations that provide health care (doctors, nurses, clinics, agencies Facilities - ANSWER places where care is delivered or administered Payers - ANSWER people or organizations paying for healthcare services (insurance companies, govt programs medicaid, medicare, and the individual person needing care) Long-Term Care (LTC) - ANSWER need 24 hr skilled care Skilled care - ANSWER medically-necessary care given by...

Providers people or organizations that provide health care (doctors, nurses, clinics, agencies Facilities places where care is delivered or administered Payers people or organizations paying for healthcare services (insurance companies, govt programs medicaid, medicare, and the individual person needing care) Long-Term Care (LTC) need 24 hr skilled care Skilled care medically-necessary care given by a skilled nurse or therapist, availabe 24 hrs a day home ...

All of the following are commonly recognized to be a right of each patient, except: a. The right to considerate and respectful care b. The right to receive a reasonable response to his/her requests c. The right to communicate with a caregiver in the language of the patients choosing d. For dying patients, the right to receive pain management. - Answer- C. Insurance companies and other payers have introduced pre-admission certification for elective hospital stays in order to: a....

1. Question: Which of the following are consistent with current data related to the prevalence of drinking alcohol? 2. Question: Discrepancy between anatomical sex and gender identity is known as which of the following? 3. Question: The fear of social situations, including situations that involve scrutiny or contact with strangers is known as which of the following? 4. Question: Recurrent preoccupation with sexual urges and fantasies involving the act of being humiliated, beaten, bound, or...

T/F: Pharmaceuticals are arguably the most socially important healthcare product. True Pg 1 T/F: Pharmaceutical development is a high-risk undertaking, in which many promising leads prove disappointing. True Pg 2 Pharmaceutical sales are highest in which geographical regions? The U.S., Western Europe, and Japan (Pg3) The U.S. accounts for about ____ of the world's pharmaceutical revenues. B. 50% (pg3) What has fueled recent growth in the pharmaceutical industry? population gr...