Deck 1: Introduction to the Medical Billing Cycle

Question 1

A physician has a contract to receive a $2,000 monthly capitation fee, based on a fee of $50 for 40 patients who are in the plan. If only 10 patients visited the practice in the last month, the capitation payment will be

A) $500.
B) $2,000.
C) $4,000.
D) $1,000.

Answer 1

$2,000.

Question 2

Identify the type of HMO cost-containment method that limits members to receiving services from the HMO's physician network.

A) cost-sharing
B) restricting patients' choice of providers
C) controlling drug costs
D) requiring preauthorization for services

Answer 2

restricting patients' choice of providers

Question 3

Determine which method a self-funded health plan most often uses in setting up its provider network.

A) buy the use of existing networks from managed care organizations
B) hire a PCP to provide a network
C) are not required to set up a network
D) set up their own provider network

Answer 3

buy the use of existing networks from managed care organizations

Question 4

Choose the entity(ies) that may form agreements with an MCO.

A) the patient and provider
B) the provider
C) the health plan
D) the provider and health plan

Question 5

PPO members who use out-of-network providers may be subjected to

A) lower copayments.
B) decreased deductibles.
C) lower insurance rates.
D) higher copayments.

Question 6

Calculate the amount of money a patient would owe for a noncovered service costing $900 if their indemnity policy has a coinsurance rate of 80-20, and they have already met their deductible.

A) $0
B) $180
C) $900
D) $720

Question 7

A patient ledger records

A) the patient's financial transactions.
B) the day's appointments and payments.
C) the patient's illnesses.
D) the patient's relatives.

Question 8

When medical insurance specialists work with patient billing programs, they need

A) communication skills.
B) knowledge of anatomy.
C) flexibility.
D) computer skills.

Question 9

Which of the following conditions must be met before payment is made under an indemnity plan?

A) payment of the deductible
B) payment of the premium and coinsurance
C) payment of the copayment
D) payment of premium, deductible, and coinsurance

Question 10

What adds up to form a practice's accounts receivable?

A) money due from health plans
B) money due from both health plans and patients
C) money due from patients
D) money owed to patients

Question 11

Which of the following programs covers people who cannot otherwise afford medical care?

A) TRICARE
B) Medicaid
C) Medicare
D) CHAMPUS

Question 12

Patients who enroll in a point-of-service type of HMO may use the services of

A) any affiliated provider.
B) only out-of-network providers.
C) HMO network or out-of-network providers.
D) only HMO network providers.

Question 13

Which of the following is required when an HMO patient is admitted to the hospital for nonemergency treatment?

A) preauthorization
B) referral
C) utilization
D) coinsurance

Question 14

Pick the most accurate definition of certification.

A) recognition of higher level of degree of schooling
B) recognition of professionalism
C) recognition of a superior level of skill by an official organization
D) recognition of a successful career

Question 15

Identify another name for a point-of-service (POS) plan.

A) restricted HMO
B) open HMO
C) closed HMO
D) free HMO

Question 16

Which term best describes medical services that meet professional medical standards?

A) medical ethics.
B) medical necessity.
C) medical etiquette.
D) medical networks.

Question 17

What is the formula for calculating an insurance company payment in an indemnity plan?

A) charge ? deductible ? coinsurance
B) deductible ? coinsurance
C) deductible + coinsurance
D) charge ? deductible

Question 18

Compare the choices below to determine which type of provider service would most likely NOT be covered by a health plan.

A) a surgery performed on an outpatient basis
B) an illness that started after the insurance coverage began
C) a medical procedure that is not included in a plan's benefits
D) all elective procedures performed in the hospital

Question 19

Out-of-pocket expenses must be paid by

A) the insurance company.
B) the insured.
C) the health plan.
D) the provider.

Question 20

The statement that "coding professionals should not change codes. . .to increase billings" is an example of

A) professional ethics.
B) professional etiquette.
C) professional services.
D) personal ethics.

Question 21

How is coinsurance defined?

A) the periodic payment the insured is required to make to keep a policy in effect
B) the amount that the insured pays on covered services before benefits begin
C) the percentage of each claim that the insured pays
D) a prepayment covering provider's services for a plan member for a specified period

Question 22

What is typically required of professional organizations?

A) there are no requirements
B) good attendance
C) continuing education sessions
D) membership in more than one organization

Question 23

Medical insurance specialists ensure financial success of the medical practice by

A) using health information technology.
B) failing to communicate effectively.
C) setting their own rules and regulations.
D) recording only cash payments.

Question 24

A capitated payment amount is called a

A) prospective payment.
B) retroactive payment.
C) copayment.
D) coinsurance payment.

Question 25

One of the advantages of an HMO for patients who face difficult treatments is Disease/Case Management by assigning a

A) referral.
B) copayment.
C) case manager.
D) PCP.

Question 26

The key to receiving coverage and payment from a payer is the payer's definition of

A) policyholder.
B) provider.
C) medical necessity.
D) medical insurance.

Question 27

Practice management programs may be used for

A) scheduling appointments and financial record keeping.
B) financial record keeping and billing.
C) scheduling appointments, financial record keeping, and billing.
D) billing only.

Question 28

Another term used for a primary care physician (PCP) is

A) gatekeeper.
B) specialist.
C) controller.
D) practitioner.

Question 29

Calculate the amount of money the insurance company would owe on a covered service costing $850 if there is a $500 deductible (which has not yet been met) and no coinsurance.

A) $0
B) $500
C) $350
D) $150

Question 30

In what ways can insurance policies be written?

A) only individual
B) only workers
C) an individual or group
D) only group

Question 31

Identify the type of HMO cost-containment method that requires patients to obtain approval for services before they receive the treatment.

A) restricting patients' choice of providers
B) requiring preauthorization for services
C) controlling drug costs
D) cost-sharing

Question 32

Professional organizations generally have a(n) __________ that its members should follow/possess.

A) employee policy and procedure manual
B) code of ethics
C) financial policy
D) list of attributes

Question 33

Identify the advantages offered to patients in managed care plans, as compared to indemnity insurance.

A) higher deductibles
B) higher premiums
C) lower premiums and charges
D) lower premiums, charges, and deductibles

Question 34

In general, how do the cost of policies written for groups compare to those written for individuals?

A) Policies written for individuals are cheaper.
B) Policies written for groups are cheaper.
C) Policies written for individuals and groups cost the same.
D) Policies written for groups are more expensive.

Question 35

What skills are required for successful mastery of the tasks of a medical insurance specialist?

A) courtesy and good attendance
B) professional appearance and attention to detail
C) initiative and communication skills
D) attention to detail and ability to work as a team member

Question 36

When is a deductible paid?

A) at the end of the year
B) never
C) after benefits begin
D) before benefits begin

Question 37

On what is the PMPM rate usually based?

A) health-related characteristics of the enrollees
B) fee for service
C) a restricted choice of providers
D) the health plan's formulary

Question 38

In a medical practice, cash flow is required to

A) pay for hospital supplies.
B) pay for office expenses.
C) pay for the staff of an insurance company.
D) pay for nursing home employees.

Question 39

Courteous treatment of patients who visit the medical practice is an example of medical

A) ethics.
B) insurance.
C) etiquette.
D) coding.

Question 40

The designation of Registered Medical Assistant (RMA) is awarded by

A) AAMA.
B) AAPC.
C) AMT.
D) AHIMA.

Question 41

Name the two components of a consumer-driven health plan (CDHP).

A) a health plan and a special "savings account"
B) a health plan and a gatekeeper
C) a gatekeeper and a formulary
D) a gatekeeper and a special "savings account"

Question 42

Describe the process of adjudication.

A) the process of appealing a rejected claim
B) the practice's monitoring of the money that is needed to run the practice
C) the practice's comparison of each payment sent with a claim
D) the payer's process of putting a claim through a series of steps designed to judge whether it should be paid

Question 43

Under an insurance contract, the patient is the first party and the physician is the second party. Who is the third party?

A) insurance plan
B) provider
C) federal government
D) PCP

Question 44

Which of the following is an example of a private-sector payer?

A) Medicaid
B) workers' compensation insurance
C) insurance company
D) Medicare

Question 45

According to the textbook, pick the rising occupation in the health care industry that requires the employee to have the highest level of proficiency in dealing with the public professionally and pleasantly.

A) medical assistant
B) lab technician
C) health information technician
D) radiology technician

Question 46

Under a capitated rate for each plan member, which of the following does a provider share with the third-party payer?

A) the premium
B) risk
C) services
D) payments

Question 47

If a POS HMO member elects to receive medical services from out-of-network providers they usually

A) pay an additional cost.
B) pay less than in-network benefits.
C) will receive inferior treatment.
D) need only pay the standard copayment.

Question 48

Identify the type of service that is not considered to be a preventive medical service.

A) prenatal care
B) outpatient surgery
C) pediatric and adolescent immunizations
D) routine screening procedures

Question 49

Examine the list of services in the answer choices below and determine which one would most likely be considered a noncovered service at a primary care medical office.

A) employment-related injuries
B) emergency medical care
C) annual physical examinations
D) surgical procedures

Question 50

Collecting copayments is part of which revenue cycle step?

A) Step 3, check in patients.
B) Step 10, follow up payments and collections
C) Step 8, monitor patient adjudication.
D) Step 5, review billing compliance

Question 51

Where do medical insurance companies summarize the payments they may make for medically necessary medical services?

A) encounter form
B) medical necessity document
C) workers' compensation document
D) schedule of benefits document

Question 52

A computerized lifelong health care record for an individual that incorporates data from all sources is known as a(n)

A) electronic health record (EHR).
B) lifelong health care record (LHR).
C) practice management program (PMP).
D) computerized health record (CHR).

Question 53

What do providers participating in a PPO generally receive in exchange for accepting lower fees?

A) capitation payments
B) less patient visits
C) more patient visits
D) increased hospitalization rates

Question 54

Medical insurance is a(n) __________ between a policyholder and a health plan.

A) written agreement
B) verbal agreement
C) informal agreement
D) exchange of money

Question 55

An indemnity policy states that the coinsurance rate is 80-20. Which of the following is the payer's portion?

A) 100
B) 80
C) 60
D) 20

Question 56

Consumer-driven health plans combine a health plan with a special "savings account" that is used to pay what before the deductible is met?

A) medical bills
B) excluded services
C) coinsurance
D) non-medically necessary services

Question 57

Determine which of the following types of services a health plan will not pay for.

A) covered services
B) hospitalization
C) preventive medical services
D) noncovered services

Question 58

What type of insurance reimburses income lost because of a person's inability to work?

A) self-insured coverage
B) medical necessity coverage
C) standard medical insurance
D) disability insurance

Question 59

The titles of Certified Coding Specialist (CCS) and Certified Coding Specialist-Physician-based (CCS-P) are awarded by

A) ABC.
B) AMA.
C) AHIMA.
D) CNN.

Question 60

In what step does the medical insurance specialist verify that charges are in compliance with insurance guidelines?

A) Step 5, review billing compliance.
B) Step 2, establish financial responsibility for the visit.
C) Step 10, follow up patient payments.
D) Step 3, check in patients.

Question 61

Under an indemnity plan, typically a patient may use the services of

A) only HMO network providers.
B) only out-of-network providers.
C) any provider.
D) any affiliated provider.

Question 62

Dependents of a policyholder may include his/her

A) only children.
B) physician.
C) only spouse.
D) spouse and children.

Question 63

What is the definition of revenue cycle?

A) all administrative and clinical functions which ensure that sufficient monies flow into the practice to pay bills
B) clinical care provided for patients, from appointment to discharge
C) all coding and billing steps involved in preparing correct claims
D) complete documentation that is submitted to third-party payers

Question 64

Which of the following covers patients who are age 65 and over?

A) CHAMPUS
B) TRICARE
C) Medicare
D) Medicaid

Question 65

To be fully covered, patients who enroll in an HMO may use the services of

A) only HMO network providers.
B) only out-of-network providers.
C) any provider within 50 miles.
D) any provider.

Question 66

Which of the following characteristics should medical insurance specialists use when working with patients' records and handling finances?

A) knowledge of medical terms
B) communication skills
C) honesty and integrity
D) able to work as a team member

Question 67

In what format are health care claims sent?

A) electronic or hard copy
B) claims do not need to be sent
C) only hard copy
D) only electronic

Question 68

Name a benefit a provider usually gets from participation with a health plan.

A) no contractual duties
B) more contractual duties
C) a decreased number of patients
D) an increased number of patients

Question 69

The capitated rate per member per month covers

A) services listed on the schedule of benefits.
B) the episode of care.
C) all members' premiums.
D) all medical services.

Question 70

Scheduling appointments is part of which revenue cycle step?

A) Step 5, review coding compliance.
B) Step 1, preregister patients.
C) Step 10, follow up on patient payments.
D) Step 8, monitor patient adjudication.

Question 71

The most important characteristic for a medical insurance specialist to possess is

A) punctuality.
B) quickness.
C) professionalism.
D) friendliness.

Question 72

Medical insurance specialists use practice management programs to

A) schedule patients.
B) collect data on patients' diagnoses and services.
C) record payments from insurance companies.
D) All of these are correct.

Question 73

The employment forecast for well-trained medical insurance and coding specialists is/are

A) increasing opportunities.
B) decreasing opportunities.
C) staying the same as today.
D) remaining stagnant.

Question 74

Imagine you are a patient who wants to regulate your health care expenses on your own; what type of insurance plan would you use?

A) consumer-driven health plan
B) health maintenance organization
C) preferred provider organization
D) point-of-service plan

Question 75

Under a written insurance contract, the policyholder pays a premium, and the insurance company provides

A) payments for covered medical services.
B) preventive medical services.
C) surgery.
D) copayments.

Question 76

Calculate the amount of money a patient would owe for a covered service costing $1,800 if their indemnity policy has a $400 deductible (which has not been met) and their coinsurance rate is 80-20.

A) $680
B) $1,800
C) $1,400
D) $280

Question 77

In how many managed care plans may a physician participate?

A) one
B) two
C) many
D) zero

Question 78

For a patient insured by an HMO, the phrase "out-of-network" means providers who are

A) only acting as a specialist.
B) not under contract with the payer.
C) licensed by the state.
D) whose offices are more than 50 miles from the patient.

Question 79

Higher copayments may be charged for patient visits to/for

A) the office of a specialist.
B) their primary care physician.
C) preventive services.
D) medical necessary services.

Question 80

Health care claims report data to payers about __________ and __________.

A) the physician; the services provided by the physician
B) the patient; the services provided by the physician
C) the patient; the physician's income taxes
D) the service; the deductible