Enrollee - Study guides, Class notes & Summaries

HFMA CHFP MODULE 1 Business of Healthcare COMPLETE EXAM 2024 with Verified Answers Graded A+. 1. A hospital is planning to expand its services by adding a new wing with 50 beds and a state-of-the-art diagnostic center. The hospital has conducted a market analysis and projected the demand and revenue for the new services. The hospital also has estimated the capital and operating costs of the expansion project. What is the next step in the financial strategic planning process for the hospita...

Managed Care - CORRECT ANSWER- 1) acts as the insurance company and the providers of care. 2) Employs mechanisms to control (manage) utilization of medical services. 3) Determines the price at which the services are purchased and how much the providers get paid. 4) Is the most dominant health care delivery system in the United States and available to most Americans. This is includes both Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO). 5) Employers and g...

Steps used to control costs of managed care include: - ANSWER-Bundled codes Capitation Payer and Provider to agree on reasonable payment DRG is used to classify - ANSWER-Inpatient admissions for the purpose of reimbursing hospitals for each case in a given category w/a negotiated fixed fee, regardless of the actual costs incurred Identify the various types of private health plan coverage - ANSWER-HMO Conventional PPO and POS HDHP/SO plans - high-deductible health plans with a savings...

Medicare Advantage - -Cover all Part A and Part B benefits; -Provide plan cost-sharing actuarially equivalent to cost sharing under Medicare Parts A and B, but may be different for specific services; and -Include an annual maximum out-of-pocket (MOOP) limit on total enrollee cost sharing (deductibles, coinsurance, and copayments) for Part A and Part B services. -Cover the following services even when provided by non-network providers: emergency services: out-of-area urgently needed services...

Wisconsin Accident and Health Insurance Exam 2 Questions and Answers 2024 Alan is an enrollee of a health maintenance organization (HMO) which uses a gatekeeper system. If there ever comes a time when he needs emergency health services, what should he do? Receive permission from the primary physician to begin treatment. Call the HMO to verify coverage. Proceed to the nearest emergency room. Contact the HMO for a listing of approved providers. - CORRECT ANSWER-Proceed to the neares...

What does the acronym PHI stand for? a. Patient Healthcare Information b. Patient History of Illness c. Protected Health Information d. Protected Healthcare Index - Answer- c. Protected Health Information A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every Medicare patient you send to them for radiology services. What does this offer violate? a. Stark Laws b. HIPAA c. Anti-Kickback law d. Qui Tam - Answer- c. Anti-Kickback law ...

Wise Test Vocabulary Study Guide Rated A+ A fixed annual amount that an insured person must cover before their insurance company pays out a claim is called: Annual Deductible. This is the yearly amount or percentage that the insured must pay out-of- pocket, which the insurer will subtract from the claim payment. An insurance program designed for individuals who cannot secure auto insurance due to poor driving records, requiring them to obtain coverage at elevated rates through a s...

Capitation A covers all services an enrollee may need during an entire year Market Justice most equitably distributed through the market forces of supply and demand, rather than government interventions. Distributed on the basis of willingness and ability to pay Social Justice An ideal that embraces all aspects of civilized life and that is linked to fundamental notions of fairness and to cultural beliefs about right and wrong. defensive medicine Ordering more tests and procedures than...

Your license will be considered to be inactive when you: - correct answer No longer have any appointments On a "participating" health insurance policy issued by a mutual insurance company, dividends paid to policy holders are: - correct answer Not taxable since the IRS treats them as a refund of a portion of the premium paid All of the following are true regarding a non-contributory employer group medical expense insurance policy EXCEPT: - correct answer Premiums must be paid entirely...

Capitation A covers all services an enrollee may need during an entire year Market Justice most equitably distributed through the market forces of supply and demand, rather than government interventions. Distributed on the basis of willingness and ability to pay Social Justice An ideal that embraces all aspects of civilized life and that is linked to fundamental notions of fairness and to cultural beliefs about right and wrong. defensive medicine Ordering more tests and procedures than...