Insurance I
A managed care plan that establishes a network of providers to perform services for plan member is known as which of the following?
a) PCMH
b) PCP
c) PPO
d) HMO
C- PPO
Which insurance covers a pt's who has been hospitalized up to 90 days for each benefit period?
a) CHAMPVA
b) Medicare Part B
c) Medicare Part A
d) Medicaid
C) Medicare Part A
Of the federal programs providing healthcare, the largest is _____ which provides health insurance for citizens aged 65 and older.
a) Blue Cross Blue Shield
b) Medicare
c) Cigna
d) Aetna
B- Medicare
Mrs. Lawrence is an elderly diabetic pt who is on Medicare. She recently injured her lower left leg, and since then has had trouble with open sores or ulcers on that leg. She came to the office today to have the provider examine and treat the ulcers. At that time, you checked and she qualified for Medicaid as well as Medicare. She will need to comeback for a follow-up & treatment. Which of the following should you do first?
a) Ensure that the provider signs the Medicaid claim
b) Contact Medicaid to verify her eligibility
c) Send the claim to Medicaid
d) Contact Medicare for preauthorization
B) Contact Medicaid to verify her eligibility
What does ICD stand for?
a) Internal Class of Disorders
b) International Class of Diseases
c) International Classification of Disease
d) Internal Classification of Disorders
1-Under a contracted or fixed prepayment called ____ providers are paid a fixed amount of money to provide needed care.
a) preauthorization
b) capitation
c) copayment
d) managed care
2- The payment system used by Medicare is based on _____.
a) the price of medical equipment
b) fee-for-service agreement
c) resources
d) prevailing rates in the region
1-B) capitation
2- C) resources
1) Which Medicare plan covers prescription medications?
a) Medicare Part A
b) Medicare Part B
c) Medicare Part C
d) Medicare Part D
2) What percentage of the allowable fee does Medicare pay the healthcare provider after the annual deductible is met?
a) 20%
b) 80%
c) 75%
d) 100%
1) D- Medicare Part D
2) B-80%
1) An organization that provides pain relief to terminally ill patients and supports their families is a ____.
a) respite care
b) hospice care
c) outpatient clinic
d) hospital
2) When a provider agrees to accept assignment for a Medicare patient, this means the provider ____.
a) bills Medicare the the cost of service not covered by Medicaid
b) will accept the amount of money Medicare pays for payment in full
c) will accept Medicare but not Medicaid patients
d) bills the patient for the cost of services not covered by Medicare
1) B- Hospice care
2) B- Will accept the amount of money Medicare pays for payment in full
What is the authorization called that directs an insurance carrier to pay the medical provider or the medical practice directly?
a) copayment
b) assignment of benefits
c) health insurance provider
d) Provider of medical services
B- assignment of bneits
1) What is does CPT stand for?
a) Classified Patient Terminology
b) Current Patient Terminology
c) Current Procedural Terminology
d) Current Protocol Terms
2) Which CPT coding system means resequenced code?
a) Bullet
b) Triangle
c) Hashtag #
d) Thunderbolt
1) C- Current Procedural Terminology
2) C- Hashtag #
1- Eligibility for Medicaid is __________
a) automatic for pts aged 65 and older
b) based on the pt's reported income and assets from the previous year.
c) based on the pt's reported income and assets from the previous month
d) based on the pt's reported income and assets from the previous three months
2- When the insured person pays an annual cost for healthcare insurance, it is called a ______
a) copayment
b) capitation
c) premium
d) coinsurance
1- C-based on the pt's reported income and assets from the previous month
2- C- premium
1) Greg Owens is in the office today for treatment of a small but deep cut he received while cutting laminate for the new floor in his kitchen. He has employer provided insurance and also is listed as a dependent on his wife's insurance. His DOB is 7/19/73 and his wife's DOB is 5/23/78. Who is the primary payer in this case?
a) Greg's insurance, because he is the policy holder on his primary insurance
b) Greg's wife's insurance, because her birthday occurs earlier in the calendar year
c) Medicare, because Greg is over 65
d) Medicaid, because Greg does not think he can afford to have sutures
2) Which of the following types of insurance covers injuries that are caused by the insured or that occurred on the insured's property
c) medical
b) liability
c) disability
d) medicare
1) A- Greg's insurance, because he is the policy holder on his primary insurance
2) B- liability
1) Which coding system has 72K codes?
a) CPT
b) ICD-9
c) HCPCS
d) ICD-10
2) Which statement is true regarding health maintenance organizations?
a) They focus on medical procedures and services rather than on wellness and preventative care
b) Providers with HMO contracts are often paid a capitated rate
c) They require subscribers to complete paperwork and file claims for routine procedures
d) Routine annual physical examination are discouraged
1) D- ICD-10
2) B- Providers with HMO contracts are often paid a capitated rate
In a typical medical practice, insurance claims are filed _____.
a) a few business days after the date of service
b) 9 months after the service is rendered
c) the day before the filling limit is reached
d) the day before the date of service
A- a few business days after the date of service
1- Which code below is an ICD-10 code:
a) K22
b) 99214
c) 436.0
d) 85987
2- Which code below is a CPT code?
a) E2345
b) 250.0
c) 99218
d) V70
1- A) K22
2- C) 99218
1- The request for approval for payment from a 3rd-party payer prior to a procedure is the _____
a) coinsurance
b) preauthorization
c) predetermination
d) elective procedure
2- Which of the following must be verbally discussed with a Medicare beneficiary to enable the beneficiary to consider options and make informed choices?
a) CHIP
b) DRG
c) ABN
d) RBRVS
2- Which statement is true about TRICARE?
a) TRICARE Extra can be used only after enrollment in the program
b) TRICARE for Life acts as a 2ndary payer to Medicare
c) TRICARE Standard is a health maintenance organization
d) Providers must accept all TRICARE patients.
1- C- ABN
2- B- Tricare for Life acts as a 2ndary payer to Medicare
1) To be covered under Medicare Part B pts must ___.
a) remain in the hospital for more than 90 days
b) receive medical care at home
c) enroll, because coverage is not automatic
d)purchase private insurance
2) Under a contracted or fixed prepayment called ___ providers are paid a fixed amount of money to provide needed care.
a) preauthorization
b) capitation
c) managed care
d) dual coverage
3) The fixed dollar amount a subscriber must pay or "meet" each year before the insurer begins to cover expenses is the ______.
a) copayment
b) deductible
c) coinsurance
d) premium
d) copayment
1) C-enroll because coverage is not automatic
2) B- Capitation
3) B- Deductible
1) How should data in medical billing programs be entered?
a) use prefixes such as Mr., Mrs., or Ms.
b) enter information using capital letters
c) use "see above" for repeated data
d) use hyphens, commas and apostrophes as appropriate
2) Level I of HCPCS are:
a) ICD-9 codes
b) ICD-10 codes
c) CPT codes
d) no codes at all
1) B- enter information using capital letters
2) C- CPT codes
Which of the following is correct regarding electronic claim submissions?
a) Claims cannot be transmitted directly be electronic data interchange (DEI)
b) Claims are prepared for transmission after all required data elements have been entered.
c) Claims cannot be entered into the health plan's computer system.
d) Claims submission cannot be integrated with EHR systems.
B- Claims are prepared for transmission after all required data elements have been entered.
Which CPT symbol below is used for FDA pending?
a) Thunderbolt
b) Red dot
c) Facing triangles
d) Bullet
Which symbol is used to indicate a new code for current year.
a) Thunderbolt
b) Facing triangles
c) Bullet
d) Red dot
1- A- Thunderbolt
2- C- Bullet
1- An insurance claims department compares the fee the doctor charges with the benefits provided by the pt's health plan. This is called the _____.
a) payment of benefits
b) review for allowable benefits
c) explanation of benefits
d) payment and remittance advice
2- In which program can enrollees who are aged 65 and older continue to obtain medical services at military hospitals and clinics as they did before they turned 65?
a) TRICARE standards
b) TRICARE for Life
c) TRICARE Extra
d) TRICARE PRIME
1- B) Review for allowable benefits
2- B) TRICARE for Life
1) Pts under the age of 65 who are blind or widowed or who have serious long term disabilities, such as ____ may be entitled to Medicare.
a) asthma
b) gallstones
c) kidney failure
d) stomach ulcers
2) Which of the following is not part of Medicare's resource-based relative value scale?
a) the nationally uniform relative value
b) a nationally uniform conversion factor
c) Medigap, to reduce the gap in coverage
d) a geographic adjustment factor
3) Which of the following is included under Workers' Compensation insurance in most states?
a) A monthly amount is paid to the pt for a temporary disability
b) Rehabilitation costs are covered to return an employee to work
c) Only selected medical expenses are covered, an no inpatient expenses are covered.
d) It covers workers who are injured while they are on vacation
1) C- Kidney failure
2) C- Medigap, to reduce the gap in coverage
3) B- Rehabilitation costs are covered to return an employee to work
1) An appropriate approach to maintaining pt. confidentiality on the computer is to ____.
a) make sure a coworker knows your password incase you are sick
b) change your password every 90 days
c) provide each pt. with a unique password
d) send confidential information only by fax, never by computer
2) Using a clearinghouse to transmit electronic media claims______.
a) makes more paperwork than paper claims
b) includes data elements that are transmitted in a computer file
c) enables a 30-day turnaround time from submission to payment
d) requires a translator and technology to conduct electronic dta interchange
1) B- change your password every 90 days
2) B- includes data elements that are transmitted in a computer file
The usual fees that are listed on the medical office's fee schedule are fees _____.
a) paid by the 3rd party provider
b) charged to most of their patients most of the time under typical conditions
c) charged as a professional courtesy
d) charged only to patents who have private insurance
B) charged to most of their patients most of the time under typical conditions.
1- There are _____ chapters in the ICD-10 book.
a) 14
b) 21
c) 25
d) 1
2) What are Level II HCPS used for all except
a) DME
b) Prosthetics
c) Ambulance services
d) Physician office visits only
3) What does HCPCS stand for?
a) The Health common purpose coding system
b) The Healthcare Common Purpose Coding Systems
c) The Human Common Procedural Coding System
d) The Humane Commission Proper Coding Systems
1-B) 21 chapters
2- D) Physician Office Visits Only
3- B) The Healthcare Common Purpose Coding System