Us Healthcare Basics
-What is the Fundamental difference between Medicare and Medicaid?
- What is your specific humana role?
- and then Name 2 of Humana's Competitors.
- Medicaid is Welfare while Medicare is retirement benefits to working Us citizens,.
- I am a healthcare advocate for Medicare (and some medicaid basics, for brownie points )
- Aetna,BcBs, United health care , Cigna Etc.
Define in your own words, what is Utilization management in U.s healthcare
Utilization Management (UM) in Medicare is the process used by Medicare Advantage plans and other health insurers to ensure that healthcare services are medically necessary, appropriate, cost-effective, and provided at the right level of care.
- right time, right place,right care
What is PPO VS An HMO?
- WHAT DOES IN MEAN TO BE IN NETWORK.
-what is a provider ?
-is a pharmacy considered a provider?
- Preferred provider
- you have a contract with the plan.
- a Qualifiedmedical service provider.
- sometimes
- What is HIPPA unabbreviated,
- Health insurance portability and affordability act
What are the four parts of Medicare?
Part A ? , please define them.
- a,b,c,d
- What does the Abbreviation A.C.A stand for? \Please define what it does or what is its other name.
- who introduced the law. (which year for brownie points)
- why was it necessary in the first place. Historically speaking.
- Affordable care act, whose main goal was to tackle affordability and to try make healthcare more affordable in the us.
- Introduced by President Barack Obama. {2010}
- The ACA was designed to expand health insurance coverage, protect people with pre-existing conditions, improve access to preventive care, and make healthcare more affordable for Americans
- Define the Prior authorization process from the moment the member knows what service they need, to what happens whan it is approved or denied.
- the member gets the prescription, the call humana or use online platforms to determine if it needs a PA or not, their Provider needs to get in contact with our clinical review team , an appeal is launched if denied, member proceeds with the service oif its approved
- what is a Service area,
- what is a Deductible,
- what is a copay,
- what is Co-insurance,
- area where the plan is active.
- paid before your benefits kick in, OOP
- MEMBERS PORTION OF THE csp
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- What do we consider as Protected health information.
- Name 3 examples.
-Protected Health Information (PHI) is any health-related information that can be used to identify a patient and is protected under HIPAA (Health Insurance Portability and Accountability Act).
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Patient Name,Medical Record Number,Diagnosis or Medical Condition,
What is a Dual Eligible Member?
- What is a formulary?
- Name 3 type of Medicare premiums
- A dual eligible member qualifies for both Medicare and Medicaid at the same time.
- A formulary is a list of prescription drugs covered by a health plan.
- ,Part A Premium,Part B Premium ,Covers prescription drug coverage through a Medicare drug plan.
- What is Group Coverage and what is Individual coverage?
- What is Original Medicare vs Medicare Advantage.
- what is Medicare part D
- Employer and Individual insurance
- A&B WITH THE GOVERNMENT or a&b with humana or its fellow competitors
- Drug Coverage.
- What are the four possible outcomes or a PA status
- Define Medical neccessity in your own words
- denied , pending, approved, voided
- a medical reason stated by a professional for why a procedure needs rto be done.
- what is the difference between urgent care and emegency care?
"Urgent care is for non-life-threatening illnesses and injuries that need prompt treatment, such as minor infections, sprains, or cuts. Emergency care is for serious or life-threatening conditions, such as chest pain, stroke symptoms, severe bleeding, or difficulty breathing. Emergency departments are open 24/7 and are equipped to provide advanced, lifesaving treatment."
what is a First Element in the Authentication process:name 3
- how many Items do we use to aunthenticate a member, ? name 3 examples.
- in a call, when are you allowed gto share a member's infomation.
- SSA, Medicare ID, hUMANA iD
- 3, zip, name, dob, first element
- ideally never, but after the call has been fully aunthenticated.{we never give out first elements however, under any circusmtacnces.}
- what is Eligibility and what is enrollment in Medicare
- Try and name 3 reasons why Medicare application could pend
- Eligibility means a person qualifies to receive Medicare benefits based on Medicare's rules
- Enrollment is the process of signing up for Medicare coverage after becoming eligible.
-Missing or Incomplete Information, Eligibility Verification Issues Enrollment Processing Delays, etc
- What is C.M.S
-WHAT IS S.S.A
-WHAT IS R.R.B
- Define all parts of Medicare {A,B,C,D}
-What IS another name for Medigap?
- Centers of Medicare and Medicaid services
- Social Security Administration
- Rail road Retirement Board
- inpatient, outpatient, advantage, drug
- Medicare supplement
Name 5 services which all would require Prior Authorization
- Name 2 Examples or atleast 3 of the srvices mentioned.
- Advanced Imaging, Cosmetics Reconstrive surgery
- DME
HOME health ,non urgent surgery, Inpatient stays , Pain management and infusions, Substance abo=use treatment
- What are healthcare benefits?
- What is a medical Claim by definition?
- Who qualifies for medicare ?[mention the qualifying criteria
- Benefits are the healthcare services and treatments covered by a health insurance plan.
- A claim is a request submitted by a provider or member to an insurance company for payment of healthcare services.
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Individuals generally qualify for Medicare when they turn 65 years old. People under 65 may also qualify if they have received Social Security Disability benefits for 24 months, have End-Stage Renal Disease requiring dialysis or a kidney transplant, or have ALS. Medicare is designed to provide health coverage for seniors and certain individuals with disabilities or specific medical conditions."
- What is Compliance?
- What is an Authorized Representative?
- What is F.W.A STAND for ?
- Unabbreviate and Define the F.D.A
- Following all laws, regulations, policies, and ethical standards that govern healthcare operations.
- {A person approved by the member to act on their behalf regarding healthcare information or decisions.including POA and EOE .}
Define the following specialties and procedures :
- SNF, Home Health services, Surgery centers, Rehab center, PCP,
- Name 2 types of Eye doctors and the difference between the 2.
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SNF (Skilled Nursing Facility)
Definition:
A Skilled Nursing Facility (SNF) is a healthcare facility that provides short-term skilled medical care and rehabilitation services after a hospital stay.
Services Provided:
In your own words,
What makes healthcare administration complex in the U.S.?. please explain in detail.
- from its complex expoensive and out ill regulated history, to its relationship with the citizens and a lack of trust in the governments intentions .
- to costs, the structure which is so unique, to the relationship with the actual work culture in the us and its unique needs.
- Define the following Terms :
- Concurrent
- Retrospective
- Prospective
-what is A prior authorization and what is it mainly used for?
- During
- After
- Before
- Prior authorization is approval from an insurance company before certain treatments, procedures, or medications are covered.
- what is a Diagnosis
- What is a prescription
- What is Inpatient and OutPatient
- Who is humana's pharmacy ,
- What is an APPEAL
- A diagnosis is the identification of a disease, condition, or injury by a healthcare provider after reviewing a patient's symptoms, medical history, physical examination, and any test results.
-A prescription is a written, electronic, or verbal order from a licensed healthcare provider that authorizes a patient to receive a specific medication or treatment from a pharmacy.
-An inpatient is a patient who is admitted to a hospital and stays at least overnight (or longer) to receive treatment.An outpatient is a patient who receives medical care without being admitted to the hospital and goes home the same day.
-An appeal is a formal request made by a member, provider, or authorized representative asking a health insurance company to review and reconsider a decision that denied, reduced, or stopped coverage for a healthcare service, medication, or claim.
-What are the possible consequences of a HIPAA violation?
- TRY YOUR BEST TO EXPLAIN IN YOUR OWN LOGIC WHAT IS THE UNISHMENT TO ALL PARTIES INVOLVED, NAME THE PARTIES IDEALLY.
A HIPAA violation can impact employees, healthcare organizations, members (patients), and providers. Consequences may include disciplinary action, financial penalties, legal action, and loss of trust.
- Consequences for Employees
- Consequences for Healthcare Organizations
- Consequences for Patients/Members
- Legal and Financial Consequences
- what is Diabetes,
- what is Haemophilia :
- what are the common terms/definitions for the following :
Hypertension,COPD, ESRD, Alzheimer's Disease and Dementia, ALS. myocardial infarction,
- a lack of sugar/glucose processing in the body
- lack OF BLOOD CLOTTING
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- High blood pressure
- COPD (Chronic Obstructive Pulmonary Disease)
Definition: A chronic lung disease that makes it difficult to breathe due to blocked airflow.
-ESRD (End-Stage Renal Disease)
Definition: Permanent kidney failure where the kidneys no longer function adequately
Alzheimer's Disease
Definition: A progressive brain disorder that affects memory, thinking, and behavior.
-Dementia
Definition: A general term for a decline in memory and cognitive abilities severe enough to affect daily life.
-ALS (Amyotrophic Lateral Sclerosis)
Definition: A progressive disease that affects nerve cells controlling voluntary muscles.