Full Test Bank Reimbursement Safian Ch.39

Let’s Code It!, 1e (Safian)

Chapter 39 Reimbursement

1) ________ is a type of health insurance coverage that controls the care of each subscriber by using a primary care provider as a central health care supervisor.

A) HMO

B) Gatekeeper

C) Managed Care

D) FFS

2) Agreements between a physician and a managed care organization that pay the physician a predetermined amount of money each month for each member of the plan who identifies that provider as his or her primary care physician are known as ________.

A) FFS Plans

B) Capitation Plans

C) Point-of-service Plans

D) HMO plans

3) Individuals who are supported, either financially or with regard to insurance coverage, by others are known as ________.

A) disabled

B) dependents

C) inactive

D) wards

4) ________ is a policy that covers loss or injury to a third party caused by the insured or something belonging to the insured.

A) Automobile insurance

B) HMO insurance

C) Insurance premium

D) Liability insurance

5) The total management of an individual's well-being by a health care professional is known as ________.

A) Health care

B) Managed care

C) Episodic care

D) Survival care

6) The ________ is the amount of money, often paid monthly, by a policyholder or insured, to an insurance company to obtain coverage.

A) co-pay

B) insurance premium

C) insurance plan

D) co-insurance

7) An insurance company pays a provider one flat fee to cover the entire course of treatment for an individual's condition. This is known as ________.

A) Health care

B) Managed care

C) Episodic care

D) Survival care

8) ________ is a plan that reimburses a covered individual a portion of his or her income that is lost as a result of being unable to work due to illness or injury.

A) TriCare

B) Capitation

C) Workers' Compensation

D) Disability Compensation

9) Payment agreements that outline, in a written fee schedule, exactly how much money the insurance carrier will pay the physician for each treatment and/or service provided, are known as ________.

A) FFS pans

B) capitation plans

C) point-of-service plans

D) HMO plans

10) A physician who serves as the primary care physician for an individual, and is responsible for evaluating and determining the course of treatment or services, as well as for deciding whether or not a specialist should be involved in care, is called a ________.

A) HMO

B) Gatekeeper

C) Managed Care

D) FFS

11) What does ERA stand for?

A) Electronic Research Administration

B) Electronic Remittance Advice

C) Electronic Representative Association

D) Earned Run Average

12) UCR stands for ________.

A) Uniform Case Records

B) Urinary Creatinine

C) Usual, Customary and Reasonable

D) Usual and Customary Rates

13) Which two abbreviations are similar and can be interchangeable by some in the industry?

A) UCR and EOB

B) PPO and RA

C) RA and HMO

D) EOB and RA

14) ________ is an individual or organization that is not directly involved in an encounter but has a connection because of its obligation to pay, in full or part, for that encounter.

A) Third-party payer

B) Electronic Media Claim

C) Preferred Provider Organization

D) Point-of-Service

15) The process of confirming with the insurance carrier that an individual is qualified for benefits that would pay for services provided by your health care professional on a particular day is known as ________.

A) Eligibility Verification

B) Employment Authorization

C) Document Establishment

D) Verify Connection

16) ________ is a health care claim form that is transmitted electronically.

A) ERA

B) EOB

C) EMC

D) PPO

17) As the coders transfer information from patient registration forms and other documents, they must be certain to:

A) Double-check their work to make sure it is accurate.

B) Confirm that the form is completely filled out, with no necessary information missing.

C) Verify the spelling of every name and the accuracy of every number.

D) All of these

E) None of these

18) Most third-party payers, including Medicare, prefer claim forms to be submitted ________.

A) manually

B) electronically

C) by text

D) by fax

19) With electronic claims, payment is usually received within ________ weeks.

A) 1 to 2

B) 2 to 3

C) 3 to 4

D) 5 to 6

20) Essentially, there are ________ participants in each health care encounter.

A) two

B) three

C) four

D) five

21) In the health care encounter, party 1 is considered the ________.

A) patient

B) insurance carrier

C) health care provider

D) facility

22) In the health care encounter, party 2 is considered the ________.

A) insurance carrier

B) health care provider

C) patient

D) facility

23) In the health care encounter, party 3 is considered the ________.

A) patient

B) health care provider

C) facility

D) insurance carrier

24) HMO stands for ________.

A) High-performance Medical Operations

B) Health Maintenance Organizations

C) Habitat Module Outfitting

D) Health Members Only

25) Which of the following uses a gatekeeper?

A) CMS

B) POS

C) HMO

D) PPO

26) All of the following are types of insurance plans except a(n) ________.

A) HMO

B) PPO

C) POS

D) PCP

27) ________ is a national health insurance program that pays, or reimburses, for health care services provided to those over the age of 65.

A) Medicaid

B) Medicare

C) TriCare

D) Blue Cross Blue Shield

28) ________ is a plan that pays for, or reimburses, medical assistance and health care services for people who are indigent.

A) Medicaid

B) Medicare

C) Tricare

D) Blue Cross Blue Shield

29) ________ offers the most common health care plans you will encounter when caring for individuals in the military and their families.

A) Aetna

B) Medicaid

C) TriCare

D) Medicare

30) TriCare covers which of the following groups?

A) ADSM

B) ADSMs dependents

C) Surviving spouses and children of deceased retired members

D) All of these

E) None of these

31) ________ is an insurance program designed to pay the medical costs for treating those injured, or made ill, at their place of work or by their job.

A) Disability compensation

B) Capitation

C) Workers' compensation

D) CHAMPUS

32) Which of the following types of insurance have physicians, hospitals, and other health care providers join together and agree to offer services to members of a group at a lower cost or discount?

A) HMO

B) PPO

C) POS

D) CMS

33) Which of the following is a method of compensation?

A) FFS

B) Capitation

C) Episodic care

D) All of these

E) None of these

34) ________ is an extra reduction in the rate charged to an insurer for services provided by the physician to the plan's members.

A) Fee-for-Service Plan

B) Capitation Plans

C) Discounted FFS

D) HMO

35) ________ are a type of episodic care payment plan used by Medicare to pay for treatments and services provided to beneficiaries who have been admitted into an acute care hospital.

A) APCs

B) DRGs

C) POS

D) PPO

36) DRG stands for ________.

A) Digital-related graphs

B) Defense research groups

C) Diagnosis-related groups

D) Direct resources groups

37) A ________ is usually a fixed amount of money that the individual will pay each time he or she goes to a health care provider.

A) deductible

B) co-insurance

C) co-payment

D) premium

38) A ________ is based on a percentage of the total charge rather than a fixed amount.

A) deductible

B) co-insurance

C) co-payment

D) premium

39) ________ is the amount of money that patients must pay, out of their own pockets, before the insurance benefits begin.

A) Deductible

B) Co-insurance

C) Co-payment

D) Premium

40) The Quality Payment Program includes which of the following paths?

A) Advanced Alternative Payment Models (APMs)

B) Merit-Based Incentive Payment System (MIPs)

C) Home-Based Replacement System (HBRs)

D) APMs and MIPs

E) None of these

41) ________ reinforces accurate and proper coding in addition to preventing reimbursement of inaccurate amounts as the result of noncompliance coding methods in Part B claims.

A) NSD

B) LCD

C) NCCI

D) PTP

42) ________ is/are to prevent improper payments when services are reported with incorrect units of service.

A) Medical Use Equipment

B) Medically Unlikely Edits

C) Multi-User Equipment

D) Medically Unique Electronics

43) CMS computers evaluate submitted claims to look for pairs of codes being reported that are known to be mutually exclusive procedures, also known as ________ edits.

A) MUE

B) PTP

C) NCD

D) LCD

44) ________ codes are used on professional claims to identify the specific location where procedures, services, and treatments were provided to the patient.

A) PPO

B) POS

C) TOS

D) FFS

45) The Place of Service name is Telehealth. What is the POS code?

A) 01

B) 02

C) 05

D) 09

46) The Place of Service name is Assisted Living Facility. What is the POS code?

A) 10

B) 13

C) 17

D) 19

47) The Place of Service name is Public Health Clinic. What is the POS code?

A) 61

B) 65

C) 71

D) 99

48) ________ codes are also used to ensure that procedures, services, and treatments, along with the Place-of-Service codes, are used to determine appropriateness of location and service.

A) PPO

B) POS

C) TOS

D) FFS

49) The Type of Service Indicator for Monthly Capitation Payment for Dialysis is ________.

A) D

B) J

C) M

D) Q

50) Which of the following are reasons for claim denials?

A) Preexisting Condition

B) Lack of Medical Necessity

C) Benefit Limitation on Treatment by an Assistant

D) Office Personnel Error

E) All of these

F) None of these

51) When a coder is following-up on submitted claims the coder should separate the claims into ________ piles.

A) two

B) three

C) four

D) five