Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
33 Cards in this Set
- Front
- Back
|
Name 4 Types of insurance
|
-Heath
-Disability -Life -Liability |
|
|
What is Health Insurance ?
|
Contract agreement which minimizes liability of illness or injury
|
|
|
What is Medical Insurance ?
|
Disease diagnosis ; treatment of patients by heath care provider
|
|
|
Difference between Medical Insurance & Health Insurance
|
Health Insurance includes preventive services (ex/screening, breast cancer)
|
|
|
What is Disability Insurance ?
|
Reimbursement for income; result of temp or perm illness
|
|
|
how to qualify for Disability
|
Unable to do regular work for a certain # of days
|
|
|
How can a patient continue receiving Disability?
|
must remain under care & treatment
|
|
|
How to disqualify for Disability
|
-already receiving unemployment
-getting work comp = to disability $ -in jail |
|
|
When does disability claim begin ?
|
date of disability;
|
|
|
What is Liability Insurance ?
|
Policy that covers losses to a 3rd party caused by the insured.
|
|
|
why are Liability claims made?
|
cover cost of medical care for traumatic injuries
-lost wages -pain & suffering |
|
|
what is OSHA?
|
Occupational Safety & Health Admin.
-protects employees from work hazards |
|
|
what is Managed Health Care
|
combines health care w/ financing of service
-replaces fee-for-services w/affordable care w/ restrictions |
|
|
who receives manages health care ?
|
only members of health care organizations
|
|
|
what is Consumer-Directed Health Care ?
|
type of 401k plan for health care
|
|
|
why was Managed Health Care developed ?
|
to provide:
-affordable -comprehensive -prepaid health care to policy holders |
|
|
what are Policyholders ?
|
employees & dependents who join managed care plan
|
|
|
Factors cause cost to rise ?
|
-technology ( MRI, ultra sounds)
-Dr. specialization -increase labor cost -malpractice suit |
|
|
Example of Cost Controls set by insurance companies
|
-limit patient access to specialists
-eliminate unnecessary services -impose cost before patient receive care |
|
|
what is a PCP ?
(primary care provider) |
gatekeeper; supervises health care @ lower costs
-refers patients to specialists -flat rate by age & sex |
|
|
which plans must comply with Mandates (laws)
|
plans that are "federally qualified"
|
|
|
what is a Quality Assurance Program ?
|
activities that asses the quality of care provided in in a health care setting
|
|
|
what is QISMC ? (Quality Improvement System for Managed Care)
|
made by Medicare; created to ensure the accountability of managed care plans by standards
|
|
|
what does the Report Card contain?
|
plans quality, utilization, consumer satisfaction, admin. effectiveness , financial stability & cost control.
|
|
|
what is Utilization Management ?
|
-controls cost & quality by reviewing necessity of care provided
|
|
|
how does it control costs ?
|
deciding if procedure if appropriate
|
|
|
what is Readmission Certification (PAC)
|
review for medical necessity of inpatient care before admission
|
|
|
what is Preauthorization
|
approval process for reimbursement of health care services
|
|
|
what is elective surgery ?
|
non-emergency
|
|
|
Case Management
|
-cost effective
-complicated cases -authorize some services |
|
|
2nd surgical opinion
|
-3rd party evaluation, reviews dr. opinion
-sometimes required before elective surgery |
|
|
Gag Clauses
|
-reduce costs
-prevents providers from discussion treat options -prohibited in many states & medicare |
|
|
Physician Incentives
|
-limit service
-stop patients from over utilizing -lower costs (ex. get generic brand) |
