2. Which coding system is used to report procedures and services on claims?

3. The Healthcare Common Procedure Coding System (HCPCS) consists of __________ codes.

4. Which coding system is used to report procedures and services on inpatient hospital claims?

5. Which are published by CMS and used to report procedures, services, and supplies not classified in CPT?

1. Managed health care was developed as a way to provide affordable, comprehensive, prepaid health care services to __________.

2. The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the __________ and created standards to assess managed care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators.

3. A managed care organization (MCO) is responsible for the health of a group of __________ and can be a health plan, hospital, physician group, or health system.

4. With managed care’s capitation financing method, if the physician provides services that cost less than the capitation amount, there is a profit, which the physician ___________.

5. The primary care provider (PCP) is responsible for __________.

6. Managed care plans that are “federally qualified” and those that must comply with state quality review mandates, or __________, are required to establish quality assurance programs.

7. A quality assurance program includes activities that __________ the quality of care provided in a health care setting.

8. Many states have enacted legislation requiring a(n) __________ to review health care provided by managed care organizations.

9. The National Committee for Quality Assurance (NCQA) reviews managed care plans and develops report cards to __________.

10. Which is a method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care or after care has been provided?

11. Reviewing the appropriateness and necessity of care provided to patients prior to the administration of care is called __________ review, and such review after care has been provided is called __________ review.

12. Which is a review for medical necessity of inpatient care prior to the patient’s admission?

13. Which is a review that grants prior approval for reimbursement of a health care service?

14. Which is a review for medical necessity of tests and procedures ordered during an inpatient hospitalization?

15. Which involves arranging appropriate health care services for the patient who is being released from an inpatient hospitalization?

16. Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.

17. Which involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner?

18. Prior to scheduling elective surgery, managed care plans often require a __________ during which another physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery.

19. Medicare and many states prohibit managed care contracts from containing __________, which prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.

20. Physician incentives include payments made directly or indirectly to health care providers to __________ so as to save money for the managed care plan. Managed care plans that contract with Medicare or Medicaid must disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.

21. An integrated delivery system (IDS) is an organization of __________ that offer joint health care services to subscribers.

22. A physician-hospital organization (PHO) is owned by hospital(s) and physician groups that obtain managed care plan contracts. The physicians __________ and provide health care services to plan members.

23. A management service organization (MSO) is usually owned by physicians or a hospital and provides practice management (administrative and support) services to __________.

24. A group practice without walls (GPWW) establishes a contract that allows physicians to maintain their own offices and share services, such as __________.

25. An integrated provider organization (IPO) manages the delivery of health care services offered by hospitals, physicians, and other health care organizations. Physicians associated with an IPO are considered __________.

26. A medical foundation is a nonprofit organization that contracts with and __________ the clinical and business assets of physician practices.

27. A health maintenance organization (HMO) is an alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a __________ basis.

28. Which is associated with health care that is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO?

29. Which is associated with health care that is provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO?

30. Which is associated with contracted health care services that are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice?

31. Health care services provided to subscribers by physicians employed by the HMO are associated with a __________. Premiums and other revenue are paid to the HMO, and usually all ambulatory services are provided within HMO corporate buildings.

32. Which is associated with contracted health care services that are delivered to subscribers by individual physicians in the community?

33. Which is associated with contracted health care services that are provided to subscribers by two or more physician multispecialty group practices?

34. Which type of HMO contracts health services that are delivered to subscribers by physicians who remain in their own office settings?

35. To create flexibility in managed care plans, some HMOs and preferred provider organizations have implemented a(n) __________, under which patients have freedom to use the managed care panel of providers or to self-refer to out-of-network providers.

36. A managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee is called a(n) __________.

37. Which is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees’ health status, age, sex, and occupation?

38. Which is a private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for consideration when selecting a managed care plan?

39. Which consumer-directed health plan funds health care expenses with insurance coverage and the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium?

40. Which consumer-directed health plan provides tax-exempt accounts offered by employers to any number of employees, which individuals use to pay health care bills? The employees contribute funds through a salary reduction agreement and withdraw funds to pay medical bills. Funds are exempt from both income tax and Social Security tax (and employers may also contribute). By law, employees forfeit unspent funds at the end of the year.

41. Which consumer-directed health plan allows participants to enroll in a relatively inexpensive high-deductible insurance plan and open a tax-deductible savings account to cover current and future medical expenses? Money deposited (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax-free. Money can be withdrawn for purposes other than health care expenses after payment of income tax plus a 15 percent penalty. Unused balances “roll over” from year to year, and if an employee changes jobs, he or she can continue to use the fund to pay for qualified health care expenses.

42. Which consumer-directed health plan allows tax-exempt accounts to be offered by employers with 50 or more employees, which individuals then use to pay health care bills? Funds must be used for qualified health care expenses, and unspent money can be accumulated for future years. If an employee changes jobs, he or she can continue to use the funds to pay for qualified health care expenses.

43. Which is a voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law?

44. Accreditation organizations develop standards that are reviewed during an evaluation process that is conducted both offsite and onsite. The evaluation process is called a(n) __________.

1. Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?

2. Health insurance plans may include a(n) __________ provision, which means that when the patient has reached that limit for the year, appropriate patient reimbursement to the provider is determined.

3. Which person is responsible for paying the charges?

4. A participating provider (PAR) contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. This means that PARs __________ allowed to bill patients for the difference between the contracted rate and their normal fee.

5. A nonparticipating provider (nonPAR) is an out-of-network provider who does not contract with the insurance plan, and patients who elect to receive care from non-PARs will incur higher out-of-pocket expenses. The patient __________ expected to pay the difference between the insurance payment and the provider’s fee.

6. Which is the insurance plan responsible for paying health care insurance claims first?

7. Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider’s office has received a(n) __________ from the primary payer.

8. When a child lives with both parents, and each parent subscribes to a different health insurance plan, the primary and secondary policies are determined by applying the birthday rule. The individual who holds the primary policy for dependent children is the spouse whose birth __________.

8. When applying the birthday rule, if policyholders have identical birthdays, the policy in effect the __________ is considered primary.

9. A child is listed as a dependent on both his father’s and his mother’s group insurance policies. The father’s birth date is March 20, 1977, and the mother’s birth date is March 6, 1979. Which policy is primary?

10. Which is the financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current visit?

11. Which is the financial record source document used by health care providers and other personnel in a physician’s office setting to record treated diagnoses and services rendered to the patient during the current visit?

12. Which is the financial record source document used by health care providers and other personnel in a hospital outpatient setting to select codes for treated diagnoses and services rendered to the patient during the current visit?

13. Which is a manual permanent record of all financial transactions between the patient and the practice?

14. Which is a computerized permanent record of all financial transactions between the patient and the practice?

15. The manual daily accounts receivable journal is also known as the __________, and it is a chronologic summary of all transactions posted to individual patient ledgers/accounts on a specific date.

16. Which is the electronic or manual transmission of claims data to payers or clearinghouses for processing?

17. When selecting a clearinghouse, providers may also want to determine whether it is accredited by the __________.

18. Covered entities are required to use mandated national standards when conducting any of the defined transactions covered under HIPAA. Which is an example of a covered entity?

19. Electronic claims are submitted directly to the payer after being checked for accuracy by billing software or a health care clearinghouse, which results in a __________ claim that contains all required data elements needed to process and pay the claim.

20. A claims attachment is __________ documentation associated with a health care claim or patient encounter.

21. Coordination of benefits (COB) is a provision in __________ health insurance policies intended to keep multiple insurers from paying benefits covered by other policies.

22. Which involves sorting claims upon submission to collect and verify information about the patient and provider?

23. Which involves comparing the claim to payer edits and the patient’s health plan benefits to verify that the required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures performed or services provided are covered benefits?

24. Any procedure or service reported on the claim that is not included on the master benefit list is a noncovered benefit and will result in claims __________.

25. Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization, are called __________ services.

26. The claim is also checked against the __________, which is an abstract of all recent claims filed on each patient and helps determine whether the patient is receiving concurrent care for the same condition by more than one provider.

27. Claims adjudication involves making a determination about __________ charges, which is the maximum amount the payer will permit for each procedure or service, according to the patient’s policy.

28. Which is the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits?

29. A policyholder or __________ is the person in whose name the insurance policy is issued.

30. Which is the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid?

31. Which is the fixed amount the patient pays each time he or she receives health care services?

32. A remittance advice submitted to the provider electronically is called an electronic remittance advice (ERA), and __________.

33. Medicare calls its remittance advice a(n) __________.

34. Providers have the option of arranging for __________, which means that payers deposit reimbursement for health care services to the provider’s account electronically.

35. Which is considered a financial source document from which an insurance claim is generated?

36. Which claims are organized by month and insurance company after submission to the payer, but for which processing is not complete?

37. Which claims are filed according to year and insurance company and include those for which all processing, including appeals, has been completed?

38. Which claims are organized by year and are generated for providers who do not accept assignment?

a.

cl Explanation & Answer: 1 Page Tags: CPT managed health care icd National Committee for Quality Assurance medical practice Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to help in the learning process and in accordance with Studypool’s honor code & terms of service. Explanation & Answer View attached explanation and answer. Let me know if you have any questions. 1 Health & Medical Questions First Name Last Name Department, College Course Code: Course Name Instructor’s Name Due Date 2 Health & Medical Questions Chapter 01: 1. B – Diagnoses and procedures/ services 2. A – CPT 3. A – CPT and national 4. C – ICD-10-CM 5. D – National codes Chapter 02: Introduction to Health Insurance None Chapter 03: Managed Health Care 1. A – Enrollees 2. C – National Committee for Quality Assurance (NCQA) 3. A – enrollees 4. B – Keeps to reinvest in the medical practice. 5. D – supervising … rfcbve007 (1274) University of Virginia Completion Status: 100% 15 Million Students Helped! Sign up to view the full answer Examine Honor Code flag Report DMCA Review Review Honor Code flag Report DMCA Anonymous Great content here. Definitely a returning customer. Studypool 4.7 Trustpilot 4.5 Sitejabber 4.4 24/7 Homework Help Stuck on a homework question? Our verified tutors can answer all questions, from basic math to advanced rocket science! 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Question details… Post question Most Popular Content Discussion on Variation in Approaches to Care (300 words), health and medicine homework help Discussion on Variation in Approaches to Care (300 words), health and medicine homework help Variations in Approaches to Care Choose a specific culture or ethnicity of an immigrant or refugee population.   Analyze their cultural and social norms.   Discuss how they experience the healthcare system in America.   Include an evaluation of how both the community and market-oriented approaches to health care, as highlighted in Chapter 10 of your text, (PROVIDED BELOW) can assist your chosen culture in getting the care they need.  Provide an analysis of a multidisciplinary approach that can be used to deliver the best care to your population. Discuss a program in your community, or the nearest large community, that serves immigrants and refugees.  Are the services truly accessible to a wide population of immigrants and refugees?  Identify one approach which could improve accessibility, cost, or the quality of care for the population. Your initial contribution should be 250 to 300 words in length. Your research and claims must be supported by your course text and at least one other scholarly source. Use proper APA formatting for in-text citations and references as outlined in the Ashford Writing Center. chapter_10.pdf Case #3 Structure and Present staff education, health and medicine homework help Case #3 Structure and Present staff education, health and medicine homework help You are the director of health information services at a medium-size health care facility providing general, emergency, and pediatric care.  Because of downsizing and consolidation of managerial functions, you are also responsible for staff education in your facility.  Discuss how you would structure and present an in-service program to staff members of various departments that addresses confidentiality policies and procedures of your facility, and the legal bases underlying these policies and procedures. 5 simple questions, health and medicine homework help 5 simple questions, health and medicine homework help Please answer each question in complete sentences and make sure that the answer is correct. Read all the directions and follow them. Chapters7_8activity2.docx  Ethics Around the Globe: Project for Health Care students, health and medicine homework help Ethics Around the Globe: Project for Health Care students, health and medicine homework help Ethics Around the Globe: Project for Health Care students Review the scenario below. Throughout the course, you will be referring to this scenario, coming up with an appropriate solution, and reflecting on your thinking process. Your 82-year-old patient is in kidney failure and requires hemodialysis but this sort of medical intervention goes against her religious beliefs. Without this treatment she will certainly die. With the treatment she can expect to live a relatively normal life for years to come. She has no other diseases or conditions. Part 1: In such serious situations it is important to have a good foundation for your perspective. Consider the patient’s decision to refuse the treatment and respond to the following: 1.  Define the problem using your own words. 2.  What do you think someone following Kant’s moral perspective would say about the patient’s decision? 3.  How do you feel about this patient’s decision? Should patients have the right to refuse reasonable treatment? Your assignment should be 1-2 pages and in APA format. Part 2: In the first part of this project you defined the problem outlined in the scenario. Now you will consider possible solutions based on different ethical perspectives. 1.  What would someone do from the perspective of Aristotle’s virtue based ethics? Explain why. 2.  What would someone do from the Buddhist ethical perspective? Explain why. 3.  What would you do in this situation? Why? Your assignment should be 1-2 pages in APA format. Part 3: In providing healthcare to individuals you will encounter many different perspectives and some you will disagree with. Specifically, you will encounter patients and their family members who will have different opinions about what they should to for their own or a loved one’s wellbeing. 1.  Consider the idea of pluralism. How would you balance your own belief in what was good for the patient with his or her own wishes? 2.  Reflect on your responses in the previous parts of this project and the other theories covered in this course. Of all of the theories covered in the course which one most closely matches your own ethical perspective on this issue? Explain your stance. 3.  Now, consider a new patient. This patient is being treated for a life threatening illness. The patient’s family wishes that treatment be stopped. But, you feel that the patient has a chance of recovery if treatment continues. What would you do? Use the theory you chose in response to the previous question to respond/frame your response to this question. Your responses to these questions should total 3-4 pages and be in APA format. Principles of Total Quality, health and medicine homework help Principles of Total Quality, health and medicine homework help There are three principles of total quality: customer focus, continuous improvement, and teamwork. Using an Online Library, find three articles that describe current practices in healthcare organizations. Each article should illustrate one principle of total quality. Refer to professional journals such as Modern Healthcare, Provider Magazine, and Nursing Homes. Write a paper based on your review of the articles. Include the following in the paper: Describe each quality principle and show how it is illustrated in the article. Analyze the relationships among the three quality principles. Examine whether the principle in one example might apply to other examples. Submission Details: Present your analysis as a 5-page report in a Microsoft Word document formatted in APA style. On a separate page, cite all sources using APA format. Assignment 3 Grading Criteria Maximum Points Selected articles according to given criteria and from authoritative sources. 5 Described how each quality principle is illustrated in articles. 10 Analyzed the relationships among the three principles. 20 Examined whether each principle might apply to other examples. 10 Applied APA standards for writing style, spelling, grammar, and citation of sources. 5 Total: 50 How is Pluralism Different from Relativism, health and medicine homework help How is Pluralism Different from Relativism, health and medicine homework help A fundamental part of ethics is the search for the good life and how to live rightly. Most of us have goals and dreams. You probably have a vision of what the good life would look like for you. With this in mind, do you think pluralism would help you to live in a diverse society, one in which other people’s opinions and lifestyles may clash with your pursuit of the good life? Does relativism offer a better or worse alternative? Explain your reasoning.Your paper should be 2-3 pages in APA format. 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