Ch.17 Insurance And Billing Test Bank Docx Wyma

Student name:__________

1) Expenses that are not covered by an insurance plan are called __________.

2) The __________ is a fixed percentage payable by the patient after the deductible is met.

3) The health plan that pays for medical services is known as a __________ payer.

4) The list of drugs approved by an insurance company is called a(n) __________.

5) The __________ is the annual payment made to an insurance company by the patient to keep the insurance policy in effect.

6) Payments made by a health plan for medical services provided to the patient are known as __________.

7) The __________ is a fixed amount that must be paid by the policyholder each year before a third-party payer begins to cover medical expenses.

8) A small fee that is collected at the time of service is called a(n) __________.

9) The __________ fee is considered the maximum charge that the health plan will pay a provider for a particular procedure or service.

10) A fixed prepayment is made under contract to a medical provider for each plan member in the __________ payment method.

11) The provider should have the patient sign a(n) __________ of benefits statement under which the provider agrees to prepare healthcare claims for the patient and to receive payments directly from the payer.

12) Billing the patient for the difference between a higher usual fee and a lower allowed charge is called __________ billing.

13) Three major methods are used to transmit claims electronically: direct transmission to the payer, __________ use, and direct data entry.

14) Legal clauses in insurance policies that prevent duplication of payment are called __________ of benefits clauses.

15) Because Medicare pays 80% of approved charges and the patient is responsible for the remaining 20%, individuals enrolled in the Original Medicare Part B plan often buy additional insurance called a(n) __________ plan.

16) A(n) __________ procedure is a medical procedure that is not required to sustain life and that is planned in advance to be done at the convenience of the provider or surgeon and the patient.

17) Billing programs used to exchange health information about the practice's patients with health plans use an electronic data __________ to send information quickly and securely.

18) Insurers include either an explanation of payment or a(n) __________ advice along with payment to the practice or to the patient, depending on whether an assignment of benefits was signed.

19) Under a Medicare managed care plan, the primary care physician (PCP) provides treatment and manages the patient’s medical care through __________ and authorizations to specialists when additional care is required.

20) The oldest and most expensive type of healthcare plans repay policyholders for costs of healthcare due to illness and accidents and are called __________ plans.

21) The payment system used by __________ is called the resource-based relative value scale (RBRVS).

22) The electronic claim transaction preferred by Medicare is the X12 837 Health Care Claim, commonly referred to as the "__________ claim."

23) Federal law requires employers to purchase and maintain a certain minimum amount of workers' __________ insurance for their employees.

24) CHIP allows states to provide health coverage to uninsured __________ in families that do not qualify for Medicaid but cannot afford private health insurance.

25) Some payers offer an Internet-based service called __________ data entry, or DDE, that allows medical offices to enter data without EDI formatting.

26) A(n) "__________" healthcare claim is one that is error-free and is accepted for processing by the payer.

27) If your office submits paper claims, you should create and maintain a claims __________ to track the progress of submitted claims.

28) Insurance carriers perform a review for medical __________ on each claim to determine whether the treatment is needed for the diagnosis listed.

29) The main goal of the __________ model is to change the organization and delivery of primary health care in America.

30) When the medical assistant confirms with the insurance company that the patient has coverage for a procedure before scheduling, the process is called __________.

31) Of the federal programs providing healthcare, the largest is __________, which provides health insurance for citizens aged 65 and older.

A) Medicaid
B) Medicare
C) disability insurance
D) liability insurance
E) CHAMPVA

32) Who most frequently files insurance claims and handles insurers' payments for a medical practice?

A) Patient
B) Nurse
C) Medical assistant
D) Provider
E) Physician assistant

33) What is the authorization called that directs an insurance carrier to pay the medical provider or the medical practice directly?

A) copayment
B) provider of medical services
C) assignment of benefits
D) health insurance provider
E) preauthorization

34) The person whose name the insurance is carried under is called the __________.

A) carrier
B) subscriber
C) coinsurer
D) provider
E) third party

35) When the insured person pays an annual cost for healthcare insurance, it is called a __________.

A) coinsurance
B) premium
C) copayment
D) capitation
E) benefit

36) The fixed dollar amount a subscriber must pay or "meet" each year before the insurer begins to cover expenses is the __________.

A) copayment
B) premium
C) coinsurance
D) capitation
E) deductible

37) Patients who belong to a managed care health plan, such as an HMO, are responsible for a small per-visit fee collected either prior to seeing the practitioner or at the time the patient is leaving the office. This fee is commonly called a(n) __________.

A) copayment
B) premium
C) coinsurance
D) capitation
E) deductible

38) In a typical medical practice, insurance claims are filed __________.

A) the day before the filing limit is reached
B) the day before the date of service
C) a few business days after the date of service
D) 9 months after the service is rendered
E) 1 year from the date of service

39) The most likely outcome of an insurance claim submitted with a diagnosis code of a sore throat and a treatment code indicating a cast for a broken leg would be __________.

A) coverage at 100 percent for both the sore throat and the broken leg
B) the fee for service would be applied toward the patient's deductible
C) denied because the treatment was not medically necessary based on the diagnosis
D) a reprimand to the provider for not treating the sore throat
E) the patient may have to pay a coinsurance after the deductible is met

40) An insurance claims department compares the fee the doctor charges with the benefits provided by the patient's health plan. This is called the __________.

A) payment of benefits
B) review of medical necessity
C) explanation of benefits
D) review for allowable benefits
E) payment and remittance advice

41) Which of the following is what the patient owes after the insurance company has paid?

A) premium
B) exclusion
C) patient liability
D) comorbidity
E) capitation

42) Which of the following types of insurance covers injuries that are caused by the insured or that occurred on the insured's property?

A) medical
B) liability
C) disability
D) medicare
E) medicaid

43) To be covered under Medicare Part B, patients must __________.

A) remain in the hospital for more than 90 days
B) receive medical care at home
C) purchase private insurance
D) enroll, because coverage is not automatic
E) be terminally ill

44) Which insurance covers a patient who has been hospitalized up to 90 days for each benefit period?

A) Medicare Part A
B) CHAMPVA
C) Medicare Part B
D) Medicaid
E) TRICARE Prime

45) Which of the following is a characteristic of Medicaid?

A) It is a health cost assistance program.
B) It provides health benefits to people aged 65 and older.
C) Patients are enrolled automatically.
D) Rules are the same from state to state.
E) It is an insurance program for low-income, blind, and disabled patients.

46) Patients 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) kidney failure
C) pneumonia
D) stomach ulcers
E) gallstones

47) Which of the following is included in Medicare benefits for respite care?

A) The patient must be terminally ill with 2 years or less to live.
B) Medicare has no respite care benefits.
C) The terminally ill patient is moved to a care facility for the respite.
D) Medicare provides a respite for the terminally ill patient.
E) The terminally ill patient's caregiver is admitted to the respite facility.

48) An organization that provides pain relief to terminally ill patients and supports these patients and their families is a __________.

A) respite
B) hospital
C) outpatient clinic
D) rehabilitation center
E) hospice

49) Which of the following statements applies to a provider who agrees to accept Medicaid patients?

A) The provider can bill the patient for services that Medicaid does not cover.
B) The provider may see Medicaid patients as a last resort when he does not have enough patients with insurance.
C) If the provider fee is higher than the Medicaid payment, the patient is billed for the difference.
D) The provider does not have to agree to accept the established Medicaid payment for covered services.
E) The provider can bill Medicare for any services not covered by Medicaid.

50) What percent of the allowable fee does Medicare pay the healthcare provider after the annual deductible is met?

A) 20%
B) 50%
C) 75%
D) 80%
E) 100%

51) 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
E) adjustments according to the cost-of-living index

52) Which of the following guidelines is applicable when filing a Medicaid claim and interacting with Medicaid patients?

A) Allow a 2-year time limit on all claim submissions.
B) Submit claims without proving patient eligibility for benefits.
C) Treat the patient as if he or she has private insurance.
D) Submit claims without proving Medicaid membership.
E) Send claims to the national claims center.

53) Which statement is true about TRICARE?

A) TRICARE Extra can be used only after enrollment in the program.
B) TRICARE is a health insurance plan.
C) Providers must accept all TRICARE patients.
D) TRICARE for Life acts as a secondary payer to Medicare.
E) TRICARE Standard is a health maintenance organization.

54) 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 Standard
B) TRICARE for Life
C) TRICARE Prime
D) TRICARE Extra
E) CHAMPVA

55) Which of the following is included under Workers' Compensation insurance in most states?

A) Rehabilitation costs are covered to return an employee to work.
B) A monthly amount is paid to the patient for a temporary disability.
C) There are no death benefits.
D) Only selected medical expenses are covered, and no inpatient expenses are covered.
E) It covers workers who are injured while they are on vacation.

56) One advantage of submitting claims electronically is __________.

A) it increases the time between submission and payment
B) patients can submit their own claims easily
C) electronic claims cannot be rejected
D) the practice can receive larger payments
E) electronic submissions are cost-efficient

57) Which statement is true regarding health maintenance organizations?

A) They focus on medical procedures and services rather than on wellness and preventive care.
B) They require subscribers to complete paperwork and file claims for routine procedures.
C) Providers with HMO contracts are often paid a capitated rate.
D) Routine annual physical examinations are discouraged.
E) Patients generally do not have to make copayments.

58) A husband and wife are both employed and have work-sponsored insurance plans that cover each other and their three children. Which insurance plan is the primary payer?

A) the husband's insurance plan, because he makes more money
B) the insurance plan of the person whose birthday comes first in the calendar year
C) the wife's insurance plan, because it has the most comprehensive coverage
D) whichever the husband and wife want to declare as primary
E) the insurance plan of the person whose policy went into effect first

59) Using a clearinghouse to transmit electronic media claims __________.

A) makes more paperwork than paper claims
B) requires a greater amount of time to process claims
C) includes data elements that are transmitted in a computer file
D) enables a 30-day turnaround time from submission to payment
E) requires a translator and technology to conduct electronic data interchange

60) Which of the following is correct regarding electronic claim submissions?

A) Claims cannot be transmitted directly by electronic data interchange (EDI).
B) Claims cannot be entered into the health plan's computer system.
C) Clearinghouses will modify data as necessary to ensure a standard format.
D) Claims are prepared for transmission after all required data elements have been entered.
E) Claim submissions cannot be integrated with EHR systems.

61) An appropriate approach to maintaining patient confidentiality on the computer is to __________.

A) make sure a coworker knows your password in case you are sick
B) allow former employees to keep their passwords
C) change your password every 90 days
D) provide each patient with a unique password
E) send confidential information only by fax, never by computer

62) Under a contracted or fixed prepayment called __________, providers are paid a fixed amount of money to provide needed care.

A) preauthorization
B) copayment
C) managed care
D) capitation
E) dual coverage

63) Which of the following groups are not covered by TRICARE or CHAMPVA?

A) active military personnel
B) veterans who served in active combat
C) non-military government employees
D) families of all military personnel
E) disabled veterans

64) The payment system used by Medicare is based on __________.

A) prevailing rates in the region
B) resources
C) the price of medical equipment used
D) fee-for-service agreements
E) the providers’ minimum charges

65) 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) include invalid data only if necessary
D) use "see above" for repeated data
E) use hyphens, commas, and apostrophes as appropriate

66) The process of deciding the amount of money that will be paid by a third-party payer for a procedure is __________.

A) preauthorization
B) copayment
C) precertification
D) deductible
E) predetermination

67) The request for approval for payment from a third-party payer prior to a procedure is the __________.

A) coinsurance
B) elective procedure
C) preauthorization
D) predetermination
E) explanation of payment

68) When a provider agrees to accept assignment for a Medicare patient, this means the provider __________.

A) bills Medicare for the cost of service not covered by Medicaid
B) will accept Medicare but not Medicaid patients
C) will accept the amount of money Medicare pays as payment in full
D) will accept only emergency patients covered by Medicaid
E) bills the patient for the cost of service not covered by Medicare

69) Eligibility for Medicaid is __________.

A) automatic for patients aged 65 and older
B) based on the patient's reported income and assets from the previous month
C) based on the patient's reported income and assets from the previous year
D) based on the patient's reported income and assets for the previous three months
E) based on the patient's reported income and assets for the previous six months

70) Which of the following is not part of the process for verifying workers' compensation coverage?

A) getting the name and policy number of the patient's personal health insurance policy
B) obtaining the employer's verification that the accident was work-related
C) asking the verifier at the patient's company for the original date of the injury
D) getting the name of the verifier at the patient's company
E) asking if the company has opened a workers’ compensation case with the insurance company

71) What is the birthday rule?

A) Coverage for the year begins on the policyholder's birthday.
B) Dependent children lose coverage on their 18th birthday.
C) The policyholder's primary insurance coverage ends on his 80th birthday.
D) The insurance policy of the policyholder whose birthday comes first in the calendar year is the primary payer for all dependents.
E) Insurance coverage for all dependents ends on the policyholder's 65th birthday.

72) The usual fees that are listed on the medical office's fee schedule are fees __________.

A) paid by the third-party provider
B) charged over what most third-party payers will pay
C) charged to most of their patients most of the time under typical conditions
D) charged as a professional courtesy
E) charged only to patients who have private insurance

73) What is the term for the 10-digit number that identifies the provider’s medical specialty?

A) taxonomy code
B) national identifier
C) capitation
D) provider code
E) DEA number

74) 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) RBRVS
D) ABN
E) GAF

75) If providers submit a claim for a simple procedure when in fact a more complicated procedure was documented in the medical record, __________ may occur.

A) no payment
B) underpayment
C) overpayment
D) denial of claim
E) recovery audit

76) Mrs. Lawrence is an elderly diabetic patient 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 last week to have the provider examine and treat the ulcers. At that time, you checked, and she qualified for Medicaid as well as Medicare. She has come to the office today for follow-up care and treatment. Which of the following should you do first?

A) Ensure that the provider signs the Medicaid claim.
B) Contact Medicare for preauthorization.
C) Contact Medicaid to verify her eligibility.
D) Send the claim to Medicaid.
E) Notify Mrs. Lawrence that she will not have to pay anything.

77) Mr. Johnson came to the office today complaining of headache and upset stomach. He has the traditional Medicare fee-for-service (or indemnity) plan. Your office's usual fee for an established patient visit is $125. Medicare's allowable charge is $100. If Mr. Johnson does not have Medigap insurance, how much will he have to pay for this visit?

A) $20
B) $25
C) $80
D) $100
E) $125

78) Greg Owen 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 7/19/1973 and his wife's DOB is 5/23/1978. Who is the primary payer in this case?

A) Greg's insurance, because he was born 5 years earlier than his wife
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
E) Workers' Compensation, since Greg is employed full-time

79) A managed care plan that establishes a network of providers to perform services for plan members is known as which of the following?

A) PCP
B) MCO
C) HMO
D) PPO
E) PCMH

80) Which Medicare plan covers prescription medications?

A) Part A
B) Part B
C) SSI
D) Part C
E) Part D