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Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was cancelled after the patient was diagnosed with mononucleosis. On today’s visit the patient is started on prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents who have health insurance through the mother’s employment at the State Department of Treasury. Who is the first party in this healthcare reimbursement scenario? (Answer in blank 1) a. Patient b. Parents c. Dr. Gilbert d. Insurance company Who is the second party in this healthcare reimbursement scenario? (Answer in blank 2) a. Patient b. Parents c. Dr. Gilbert d. Society Who is the third party in this healthcare reimbursement scenario? (Answer in blank 3) a. Patient b. Parents c. Insurance company d. State Department of Treasury

All of the following functions are ways that MCOs work toward their goal of controlling cost except:

The _______________ is a statement sent to the provider to explain payments made by third party payers.

Dayna is analyst at Community Hospital. She is examining inpatient cases for the payer Super Payer. She notices that all pneumonia cases have the reimbursement amount of $4,000 and that all CHF cases have a reimbursement rate of $4,200. The reimbursement is consistent for the entire year. Which reimbursement methodology is Super Payer using to reimbursement Community Hospital for inpatient admissions

A worker had group health insurance coverage through her employer. The worker’s household included her spouse, two natural children (ages 28 and 12), an adopted child (age 8), and the worker’s mother (age 58). Who may be included under dependent coverage in the health insurance policy?

Which part of the Medicare program does not include include a premium?

The CMS-HCC model uses ___________ and __________ to predict the patient’s healthcare costs

The term used to indicate that the service or procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care is

The coverage gap, which is a period of expanded cost-sharing, is applicable to which part of Medicare?

Which of the following is a service that is excluded from Medicare Part A and Part B, but may be provided under Part C?