Chapter 17
Insurance and Billing
Multiple Choice Questions
1. | Of the federal programs providing healthcare, the largest is ____, which provides health insurance for citizens aged 65 and older.
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2. | Who most frequently files insurance claims and handles insurers' payments for a medical practice?
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3. | What is the authorization called that directs an insurance carrier to pay the medical provider or the medical practice directly?
B. | Provider of medical services |
C. | Assignment of benefits |
D. | Health insurance provider |
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4. | The person whose name the insurance is carried under is called the ____.
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5. | When the insured person pays an annual cost for healthcare insurance, it is called a ________.
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6. | The fixed dollar amount a subscriber must pay or "meet" each year before the insurer begins to cover expenses is the ____.
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7. | Patients who belong to a managed care health plan, such as an HMO, are responsible for a small per-visit fee collected at the time of the visit. This fee is commonly called a(n) ____.
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8. | 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 |
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9. | 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 physician for not treating the sore throat |
E. | the patient may have to pay a coinsurance after the deductible is met |
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10. | An insurance claims department compares the fee the doctor charges with the benefits provided by the patient's health plan. This is called the ____.
B. | review of medical necessity |
C. | explanation of benefits |
D. | review for allowable benefits |
E. | payment and remittance advice |
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11. | Which of the following is what the patient owes after the insurance company has paid?
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12. | Which of the following types of insurance covers injuries that are caused by the insured or that occurred on the insured's property?
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13. | 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 |
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14. | Which insurance covers a patient who has been hospitalized up to 90 days for each benefit period?
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15. | 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. |
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16. | 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.
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17. | 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. |
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18. | An organization that provides pain relief to terminally ill patients and supports these patients and their families is a ____.
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19. | Which of the following statements applies to a physician who agrees to accept Medicaid patients?
A. | The physician can bill the patient for services that Medicaid does not cover. |
B. | The physician may see Medicaid patients as a last resort when he does not have enough patients with insurance. |
C. | If the physician's fee is higher than the Medicaid payment, the patient is billed for the difference. |
D. | The physician does not have to agree to accept the established Medicaid payment for covered services. |
E. | The physician can bill Medicare for any services not covered by Medicaid. |
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20. | What percent of the allowable fee does Medicare pay the healthcare provider after the annual deductible is met?
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21. | 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 |
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22. | 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 |
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23. | 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. | Physicians must accept all TRICARE patients. |
D. | TRICARE for Life acts as a secondary payer to Medicare. |
E. | TRICARE Standard is a health maintenance organization. |
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24. | 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?
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25. | 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. |
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26. | 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 |
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27. | 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. | Physicians 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. |
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28. | 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 |
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29. | 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 |
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30. | 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. |
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31. | 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 |
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32. | Under a contracted or fixed prepayment called ____, physicians are paid a fixed amount of money to provide needed care.
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33. | 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 |
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34. | The payment system used by Medicare is based on ____.
A. | prevailing rates in the region |
C. | the price of medical equipment used |
D. | fee-for-service agreements |
E. | the physicians' minimum charges |
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35. | 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 |
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36. | The process of deciding the amount of money that will be paid by a third-party payer for a procedure is ____.
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37. | The request for approval for payment from a third-party payer prior to a procedure is the ____.
E. | explanation of payment |
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38. | When a physician agrees to accept assignment for a Medicare patient, this means the physician ____.
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 |
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39. | 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 |
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40. | 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 worker's compensation case with the insurance company |
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41. | 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. |
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42. | 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 |
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43. | What is the term for the 10-digit number that identifies the physician's medical specialty?
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44. | Which of the following must be verbally discussed with a Medicare beneficiary to enable the beneficiary to consider options and make informed choices?
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45. | If providers submit a claim for a simple procedure when in fact a more complicated procedure was documented in the medical record, ____ may occur.
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46. | 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 physician 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 physician 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 |
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47. | Mr. Johnson came to the office today complaining of headache and upset stomach. He has the traditional Medicare fee-for-service 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?
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48. | 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 is also 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 |
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Fill in the Blank Questions
49. | Expenses that are not covered by an insurance plan are called ________.
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50. | The ________ is a fixed percentage payable by the patient after the deductible is met.
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51. | The health plan that pays for medical services is known as a __________ payer.
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52. | The list of drugs approved by an insurance company is called a(n) ________.
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53. | The ________ is the annual payment made to an insurance company by the patient to keep the insurance policy in effect.
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54. | Payments made by a health plan for medical services provided to the patient are known as ________.
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55. | The ________ is a fixed amount that must be paid by the policyholder each year before a third-party payer begins to cover medical expenses.
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56. | A small fee that is collected at the time of service is called a(n) _______.
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57. | The ________ fee is considered the maximum charge that the health plan will pay a provider for a particular procedure or service.
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58. | A fixed prepayment is made under contract to a medical provider for each plan member in the ________ payment method.
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59. | 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.
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60. | Billing the patient for the difference between a higher usual fee and a lower allowed charge is called ________ billing.
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61. | Three major methods are used to transmit claims electronically: direct transmission to the payer, ________ use, and direct data entry.
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62. | Legal clauses in insurance policies that prevent duplication of payment are called ________ of benefits clauses.
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63. | 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.
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64. | 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 physician or surgeon and the patient.
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65. | 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.
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66. | 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.
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67. | Under a Medicare managed care plan, the primary care physician (PCP) provides treatment and manages the patient’s medical care through ________ to specialists when additional care is required.
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68. | The oldest and most expensive type of healthcare plans repay policyholders for costs of healthcare due to illness and accidents and are called ________ plans.
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69. | The payment system used by ________ is called the resource-based relative value scale (RBRVS).
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70. | The electronic claim transaction preferred by Medicare is the X12 837 Health Care Claim, commonly referred to as the "________ claim."
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71. | Federal law requires employers to purchase and maintain a certain minimum amount of workers' ________ insurance for their employees.
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72. | CHIP allows states to provide health coverage to uninsured ________ in families that do not qualify for Medicaid but cannot afford private health insurance.
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73. | Some payers offer an Internet-based service called ________ data entry, or DDE, that allows medical offices to enter data without EDI formatting.
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74. | A(n) "________" healthcare claim is one that is error-free and is accepted for processing by the payer.
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75. | If your office submits paper claims, you should create and maintain a claims ________ to track the progress of submitted claims.
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76. | Insurance carriers perform a review for medical ________ on each claim to determine whether the treatment is needed for the diagnosis listed.
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Multiple Choice Questions
77. | A managed care plan that establishes a network of providers to perform services for plan members is known as which of the following?
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78. | Which Medicare plan covers prescription medications?
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Fill in the Blank Questions
79. | The main goal of the _________ model is to change the organization and delivery of primary health care in America.
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80. | When the medical assistant confirms with the insurance company that the patient has coverage for a procedure before scheduling, the process is called ____________.
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