In HMO Plans, you generally must get your care and services from doctors, other health care providers, and hospitals in the plan's network, except: HMO
Point-of-Service (HMOPOS) plans are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when the plan requires it. Find and compare HMO Plans in your area. In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want
Medicare drug coverage (Part D) , you must join an HMO Plan that offers prescription drug coverage. If you join an HMO plan without drug coverage, you can’t join a separate Medicare drug plan. In most cases, yes, you need to choose a primary care doctor in HMO Plans. In most
cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.
Which of the following statements is TRUE according to the "gatekeeper" concept? a. The primary care physician or another health care worker is the case manager for the patient. b. The insurance underwriter chooses the patient who received coverage. c. The medical coder chooses the charts that will be coded. d. The physician chooses the cases that generate higher reimbursement. a. The primary care physician or another health care worker is the case manager for the patient. What is the Healthcare Effectiveness Data and Information Set (HEDIS)? a. A set of performance measures used to compare managed care plan quality. b. A statistical report used for hospital contingency analysis. c. A numerical data set used for healthcare performance analysis. d. A set of alphabetic measurements for hospital comparison. a. A set of performance measures used to compare managed care plan quality. Medicare Part A covers inpatient hospital care and long term care when these services: a. are billed as supplemental outpatient services. b. exceed the average length of stay. c. are medically necessary. d. reduce the need for additional nusing care. c. are medically necessary. A provider is classified as a/an: a. beneficiary that provides information for insurance coverage. b. coder who provides medical record data. c. biller who submits claims to insurance carriers. d. individual or group of individuals that provide a health care service. d. individual or group of individuals that provide a health care service. Medicare Part D covers: a. occupational therapy visits. b. hospital inpatient stays. c. physician surgeries. d. prescription drugs. The term "active duty" would apply to: a. nurses who person duties while active in a specific radius. b. patients covered under TRICARE. c. physicians who perform duties on a 24 hour rotation. d. patients covered under Medicare Part D. b. patients covered under TRICARE. An organization that provides pain relief and supportive care to terminally ill patients is called a/an: a. inpatient hospital. b. hospice. c. nursing home. d. ambulatory surgery center. Businesses that provide support services to individual physicians are called: a. management service organizations. b. physician hospital organizations. c. group practices without walls. d. medical foundations. a. management service organizations. An HMO is an example of a/an _____ plan. a. occupational rehabilitation therapy b. supplemental physical therapy c. managed care d. prescription based A 67 year old patient is receiving home health care for physical therapy. A medical coder would submit the bill under: a. Medigap b. Medicare Part D c. Medicare Part A d. Medicare Part C If you need to see an orthopedic specialist for your broken leg, but are required to check with your primary care physician first, you most likely belong to a/an: a. POS b. HMO c. EPO d. PPO Healthcare providers who organize to treat Medicare patients are called _____ organizations. a. managed care b. geriatric care c. independent care d. accountable care Officer Browner is an active member of the Air Force. He visited the emergency room for treatment of a wrist fracture. The coder is billing for the emergency room visit and the treatment of the fracture. The coder will most likely submit the claim to: a. SCHIP b. CHAMPVA c. CHAMPUS d. TRICARE What is indemnity? a. A provision of security against hurt, loss, or damage with specific cash payments. b. The amount that the insured pays out of pocket. c. A portion of an insured loss paid by the insured. d. About 70% of the patients payment policy. a. A provision of security against hurt, loss, or damage with specific cash payments. Medicare Part B is classified as: a. supplemental coverage for physical therapy. b. additional coverage for dependents under the age of 18. c. supplemental medical insurance coverage. d. additional insurance for elderly patients over the age of 75. c. supplemental medical insurance coverage. Independent (or individual) practice associations (IPAs) are based on: a. PPO service contracts with groups of hospitals. b. IPO policy benefits established for new patients. c. HMO service contracts with organized groups of physicians. d. MCO contracts established with physicians. c. HMO service contracts with organized groups of physicians. Private health insurance is also called: a. Schip Third Party Payor Insurance b. individual insurance or non-group insurance. c. VA Administration Insurance d. Medicode insurance b. individual insurance or non-group insurance. Who is eligible for CHAMPVA benefits? a. Dependents of active duty military personnel. b. Military families not living in the US. c. Dependents and survivors of permanently and totally disabled veterans. d. Spouses of military personnel in combat zones. c. Dependents and survivors of permanently and totally disabled veterans. Employer groups that are trying to control costs might develop a/an: a. accountable care organization (ACO) b. integrated delivery system (IDS) c. health maintenance organization (HMO) d. exclusive provider organization (EPO) d. exclusive provider organization (EPO) Nonprofit organizations used for physician management are called: a. medical foundations b. health care management organizations c. medical trade groups d. health care fraternal organizations What is a characteristic of an HMO quizlet?An HMO features managed care, prepaid services, co-pays, a gatekeeper primary care physician, a limited choice of providers, and a limited service area.
What is the primary purpose of a health maintenance organization HMO?What Is the Purpose of a Health Maintenance Organization? The purpose of a Health Maintenance Organization is to focus on overall patient wellness and preventive healthcare while keeping costs low for its members by only covering in-network physicians and facilities.
Which of the following best describes a health maintenance organization?Which of the following statements best describes a health maintenance organization (HMO)? A provider that takes a yearly fee for private medical services.
What kind of care is emphasized by HMOs?HMOs emphasize integrated, preventive and wellness care in addition to treatment for illness and injury. Members of an HMO choose a Primary Care Physician (PCP) within the provider network.
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Which of the following statements is true of health maintenance organizations (hmos)?
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