Deck 6: Payment Methods and Checkout Procedures

Question 1

Numerical values are assigned to medical services, based on nationwide research, in a(n)

A) relative value scale (RVS)
B) fee schedule
C) preferred-provider organization (PPO)
D) usual, customary, and reasonable (UCR)

Answer 1

relative value scale (RVS)

Question 2

The Centers for Medicare and Medicaid Services (CMS) Resource-Based Relative Value Scale (RBRVS) builds on the RVS method by adding factors for

A) patient expenses
B) hospital visits
C) health plan costs
D) provider expenses

Answer 2

provider expenses

Question 3

The comparison of the usual fee and individual physician charges for a service, the customary fee charged by most physicians in the community, and the reasonable fee for service is known as what approach?

A) usual, customary, and reasonable (UCR)
B) Resource-Based Relative Value Scale (RBRVS)
C) relative value scale (RVS)
D) None of these

Answer 3

usual, customary, and reasonable (UCR)

Question 4

If a patient makes a payment at the time of service, a medical billing program is used to print a(n)

A) invoice
B) walkout receipt
C) statement
D) superbill

Question 5

Whether a physician participates in a plan or not is decided by

A) the physician
B) the patient
C) the plan
D) the government

Question 6

Within a managed care organization, the gatekeeper is another name for a

A) health plan
B) primary care physician
C) provider
D) private plan

Question 7

Who makes referral for patients in an HMO?

A) the gatekeeper
B) the primary care physician
C) the specialist
D) both the gatekeeper and the primary care physician

Question 8

Which of the following do not usually file claims for patients?

A) PCP
B) non-participating physicians
C) health plans
D) hospitals

Question 9

The first step in calculating RBRVS is to determine the ____________.

A) diagnosis codes
B) HCPCS codes
C) UCR codes
D) procedure codes

Question 10

In some plans, a primary care physician (PCP) is assigned to

A) one provider
B) a health plan
C) each patient
D) All of these

Question 11

What should explain what is required of the patient financially when payment is due?

A) contract
B) financial policy
C) explanation of benefits
D) fee slip

Question 12

Positive or negative corrections to a patient's account, such as returned check fees, are called ______________.

A) charges
B) adjustments
C) capitation
D) payments

Question 13

Out-of-pocket medical expenses are paid by the

A) provider
B) physician
C) patient
D) health plan

Question 14

Under a point-of-service (POS) plan, an HMO patient who does not want to be limited to network providers might have to make

A) larger payments
B) out-of-state visits
C) hospital visits
D) None of these

Question 15

What document can the patient use to report the charges and payments to the insurance company?

A) explanation of benefits
B) encounter form
C) walkout receipt
D) superbill

Question 16

If a practice has not accepted assignment, and collects payment from the patient at the time of service and then sends a claim to the plan on behalf of the patient, what should the patient expect as the next course of action?

A) receive a bill for the remainder
B) receive a reimbursement check from the insurance company
C) if a practice has not accepted assignment, they wouldn't be able to send a claim
D) if a practice has not accepted assignment, they wouldn't be able to see the patient

Question 17

Which plan must meet a high deductible before the health plan can make a payment?

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

Question 18

For which type of insurance plan would the medical assistant verify the patient's deductible, the coverage benefits and the coinsurance or other financial information?

A) capitated plan
B) high deductible plan
C) managed care plan
D) None of these

Question 19

Which method does Medicare use to pay physicians in group practices?

A) Diagnosis-Related Group (DRG)
B) Usual, Customary, and Reasonable (UCR)
C) Resource-based relative value scale (RBRVS)
D) Relative Value Units (RVU)

Question 20

What percentage of the allowed charge does Medicare Part B Original Plan cover after the patient meets their annual deductible?

A) 10%
B) 20%
C) 50%
D) 80%

Question 21

What percentage of the allowed charge is the patient responsible for through the Original Medicare plan after the patient meets their annual deductible?

A) 10%
B) 20%
C) 50%
D) 80%

Question 22

Which of the following is not a typical time-of-service payment?

A) over-the-limit services
B) self-pay charges
C) registration fees
D) supplies and other services

Question 23

What is not a part of the real-time claims adjudication (RTCA)?

A) create the claim
B) note errors on the claim
C) receive real-time payment
D) receive real-time responses from payer

Question 24

After checkout, what is a next step in the billing cycle?

A) filing of charts
B) send claim for insurance payments
C) refer to a specialist
D) make next appointment

Question 25

In order, what are the next steps in the billing cycle after the patient checks out?

A) there is no particular order
B) patient is billed what they owe, send claim to insurance, and get reimbursement
C) refer to a specialist, make next appointment, and file away the chart
D) file claim, insurance payment, and patient billed for what they owe

Question 26

Which of the following is not taken into account when determining resource-based fee structures?

A) how many credentials the physician performing the procedure has
B) the relative risk that the procedure presents to the patient
C) how difficult it is for the provider to do the procedure
D) how much office overhead the procedure involves

Question 27

What does Real Time Claims Adjudication not generate?

A) "real-time" payment
B) patient financial responsibility
C) explanation of benefits
D) claim errors

Question 28

What is the goal of an effective patient checkout procedure?

A) the patient does not get aggravated over charges
B) the payment plan is set up according to UCR
C) the patient understands financial responsibility
D) to have the patient refer friends and family

Question 29

Which is not a part of the RBRVS fee?

A) RVU
B) GCPI
C) nationally uniform conversion factor
D) UCR

Question 30

Which should be paid at the time of service?

A) previous balances
B) balances from other family members
C) coinsurance
D) transaction fees

Question 31

Which type of payment is made during checkout based on an estimate?

A) copayment
B) partial payment
C) estimated expenses
D) allowable charges

Question 32

A preauthorization form is typically used with which type of transactions?

A) cash
B) check
C) credit card
D) wire transfer

Question 33

Which of the following is not a usually accepted form of payment?

A) cash
B) check
C) credit card
D) wire transfer

Question 34

What does it mean when a provider accepts assignment?

A) that they must collect payment and send a claim afterwards
B) that they do not bill the patient until a claim is processed
C) to accept the allowed charge as full payment
D) to accept patients of a particular health plan

Question 35

Under what condition of HIPAA is it permissible to bill a patient a reasonable charge?

A) it is not permissible to bill a patient under HIPAA
B) missed appointments
C) late fees
D) copies of medical records

Question 36

If patients have large bills that they must pay over time, what can be set up for them?

A) payment plan
B) tab
C) open account
D) financial spreadsheet

Question 37

What is one way a practice can help patients determine what they may owe?

A) previous patients can be used as a guideline
B) swipe card reader
C) there is no way to determine
D) the patient will know since it is their responsibility

Question 38

Which health plan has a rule that prohibits physicians from obtaining any patient payment except a copayment until after the claim is paid?

A) HMO
B) PPO
C) Medicaid
D) Medicare

Question 39

What might a contract between a health plan and a provider entail?

A) to prohibit balance billing
B) amount of visits a patient can incur
C) to prohibit all payment until after a claim is paid
D) a limited amount of referrals

Question 40

When are payments from the patient entered and the account updated?

A) when they check in
B) during the visit
C) after the patient's visit
D) after they are balance billed

Question 41

What does the Real-Time Claims Adjudication tool not provide?

A) exact payment due
B) errors on the claim
C) how much of the deductible the patient has met
D) patient's financial responsibility

Question 42

In what situation is the patient offered a walkout receipt?

A) a managed care patient has seen the doctor
B) the patient has made a payment at the end of a visit
C) a clearinghouse has sent a payment
D) the account balance has been written off completely

Question 43

What summarizes the services and charges for that day as well as any payment the patient made?

A) encounter summary
B) walkout receipt
C) superbill
D) fee slip

Question 44

All of the following procedures are completed at the end of a patient visit, except:

A) charges are calculated
B) payments are entered
C) case information is posted
D) insurance is verified

Question 45

What is the tool for calculating charges due at the time of service?

A) real-time claims adjudication (RTCA)
B) sliding fee schedule (SF)
C) service calculator
D) adjustable amount list

Question 46

To estimate charges the patient will pay, the medical assistant verifies:

A) UCR
B) deductible amount
C) discounted rate
D) adjustable amount

Question 47

What might a health plan require if the patient has more than one covered service in a single day?

A) bundled payment
B) write off
C) discounted rate
D) multiple copayments

Question 48

Which answer correctly lists the main methods(s) payers use to pay providers?

A) allowed charges
B) allowed charges, contracted fee schedule, and capitation
C) contracted fee schedule and capitation
D) capitation and retrospective payments

Question 49

If the provider's charge is lower than the allowed amount, the reimbursement is based on

A) the amount billed
B) the amount allowed
C) the difference
D) a percentage

Question 50

The deductibles, coinsurance, and copayments patients pay are called their

A) excluded services
B) out-of-pocket expenses
C) capitation rate
D) maximum benefit limit

Question 51

An option in an HMO that allows patients to use non-HMO providers is called

A) a preferred provider option
B) a point-of-service option
C) a physician-hospital option
D) a managed care option

Question 52

If a participating provider's usual charge is higher than the allowed amount, and balance billing is not permitted, what should the difference between the two charges become?

A) a write off
B) a deductible
C) a subtraction
D) a deduction

Question 53

Before the payer begins to pay benefits, what must a policyholder pay annually under a typical indemnity plan?

A) write off
B) copayment
C) deductible
D) stipend

Question 54

Under most managed care plans, what must patients pay to the provider at the time of service?

A) copayment
B) write off
C) deductible
D) coinsurance

Question 55

Medical insurance plans require patients to pay for all services that are

A) excluded
B) over-limit
C) both excluded and over-limit
D) hospital-related

Question 56

At what point in the billing process might a physician practice decide to have a policy to collect patients' payments?

A) claims processing
B) adjudication
C) both claims processing and adjudication
D) neither claims processing nor adjudication

Question 57

Collecting the difference between a provider's usual fee and a payer's lower allowed charge from the insured is called

A) claims processing
B) balance billing
C) collections
D) payment billing

Question 58

What term describes a physician who does not participate in a particular plan?

A) Non-PAR
B) PAR
C) non-allowed
D) out-of-PAR

Question 59

The amount of a copayment is determined by

A) the patient
B) the amount of the family deductible
C) the provider
D) the insurance carrier/health plan

Question 60

If the participating provider's charge is higher than the allowed amount, which amount is the basis for reimbursement?

A) allowed amount
B) copayment
C) deductible
D) customary amount

Question 61

When is a capitated payment made to a provider?

A) after services are given
B) before services are given
C) if the original payment is rejected
D) it is not given at all

Question 62

A capitation payment covers the services for a health plan member for

A) a visit to the office
B) the duration of their relationship
C) an unspecified period of time
D) a specific period of time

Question 63

The abbreviation CDHP stands for

A) consumer-driven health plan
B) company-driven health plan
C) coinsurance-driven health plan
D) copayment-driven health plan

Question 64

What are patients who do not have insurance coverage called?

A) indigent
B) self-pay
C) charity
D) write offs

Question 65

Discounted fee-for-service arrangements are also known as

A) capitation
B) the allowed amount
C) contracted fee schedules
D) None of these

Question 66

A list of charges for the procedures and services a physician performs is a

A) fee schedule
B) health plan
C) payment list
D) charge list

Question 67

What must be met before benefits from a payer begin?

A) deductible
B) health maintenance organization
C) fee schedule
D) coinsurance

Question 68

Which of the following is not a component of a network created by a PPO?

A) physicians
B) patients
C) hospitals
D) other health care providers

Question 69

A PPO plan will pay lower benefits if a patient sees a provider who is

A) in the network
B) out-of-network
C) both in the network and out-of-network
D) neither in the network nor out-of-network