Insurance
Scenerios
Insurance
miscellaneous
Miscellaneous
100

Medicare covers ____ percent of the approved medical expenses once the deductible is satisfied

80%
100

A patient has Medicare Part B and visits a healthcare provider for a check-up. The total cost is $200, and the Medicare-approved amount is $150. The patient has already met their deductible. How much will Medicare pay, and how much is the patient responsible for paying?

Medicare will pay 80% of the approved amount, which is $120. The patient is responsible for the remaining 20%, which is $30.

100

A person’s __________________ is the fixed amount they pay at the time of service for a covered healthcare service.

copayment

100
  1. The __________________ Act of 1965 led to the creation of Medicare and Medicaid.

Social security

100
  1. The CMS-1500 form is primarily used to submit claims to __________________ and certain government insurers.

medicare

200
  1. Part __________________ of Medicare provides coverage for prescription drugs, including both generic and brand-name medications.

D

200

 A patient covered by an HMO visits their primary care physician (PCP) for an evaluation. The PCP determines that the patient needs further evaluation by a cardiologist. Describe the process the patient must follow to receive care from the cardiologist.

The PCP must submit a referral to the HMO. The HMO will review the referral, and if approved, the patient can schedule an appointment with the cardiologist.

200
  1. The __________________ is the amount an insured individual must pay out-of-pocket before their insurance begins to pay.

Deductible

200
  1. A patient’s __________________ is the amount billed by a provider for healthcare services.

Charges

200
  1. A __________________ is a request for payment submitted to an insurer for services rendered.

Claim

300
  1. A document sent by an insurance company that details what was covered for a medical service and what the patient owes is called an __________________ .

Explanation of benefits

300

A medical office submits a claim, but it is rejected due to missing information. What steps should the office take to correct the issue and ensure the claim is processed?

The office should review the claim for errors, correct the missing information, and resubmit the claim electronically or by mail as required by the payer.

300
  1. The process of discovering the maximum amount of money an insurance carrier will pay for a specific service is called __________________ .

Predetermination

300
  1. The amount paid periodically to an insurance company for health coverage is known as the __________________ .

Premium

300
  1. The spouse of a veteran who dies from a service-connected condition may be eligible for __________________ coverage.

CHAMPVA

400
  1. When a claim contains errors, the insurance company may __________________ the claim and request corrections.

reject

400
  1. A patient receives an Explanation of Benefits (EOB) form listing the amount billed, the amount covered by insurance, and the remaining patient responsibility. What should the patient do if they believe the EOB contains an error?

The patient should contact the insurance company to verify the details and request a correction if an error is found. They may also need to contact the provider's office for clarification.

400
  1. __________________ adjudication allows providers to determine what a patient owes and what insurance will pay at the time of service.

Real-time

400
  1. A healthcare provider who participates in an insurance network is referred to as a __________________ provider.

Participating provider (PAR)

400
  1. Medicare Part A primarily covers __________________ services, such as hospital stays and skilled nursing care.

inpatient

500
  1. An advance __________________ notice (ABN) informs a patient that a service may not be covered by Medicare and that they may be responsible for the cost.

beneficiary

500

A healthcare provider unknowingly bills for services that were not medically necessary. Would this situation be classified as fraud, abuse, or both? Explain your reasoning.

This situation would be classified as abuse because the provider did not intentionally commit fraud. Fraud involves knowingly and intentionally billing improperly, while abuse involves practices that result in unnecessary costs but lack intent to deceive.

500
  1. When a patient has both Medicare and Medicaid, __________________ acts as the primary payer.

medicare

500
  1. __________________ is when a provider knowingly bills for services not provided or medically unnecessary.

Fruad

500
  1. Medicare Part B primarily covers __________________ services, such as doctor visits and outpatient care.

Outpatient

M
e
n
u