Deck 46: Medical Insurance

Question 1

What insurance plan provides care for low-income individuals and children?

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

Answer 1

Medicaid

Question 2

Mary and Tom divorced after a few years. However, they both continued to work and share custody of their children (joint custody). However, the children reside with Mary. Neither parent has remarried. Tom is the "responsible party" for the children. Whose insurance is the primary insurance?

A) Both
B) Tom's
C) Mary's
D) The birthday rule applies

Answer 2

Tom's

Question 3

What term refers to the payments made to purchase health insurance?

A) Benefit
B) Funding
C) Premium
D) Deductible

Answer 3

Benefit

Question 4

Historically, how did health insurance become linked with an individual's employment?

A) One of the first insurance plans was arranged by a group of Dallas schoolteachers.
B) As an employee benefit, health insurance can increase functional income without affecting taxable income.
C) The insurance industry wanted to expand from accident insurance to more comprehensive health insurance.
D) The industrial revolution increased the likelihood of on-the-job injury, resulting in higher health costs for workers.

Question 5

Which federal insurance plan provides for services for the elderly and disabled?

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

Question 6

What insurance plan provides for care for patients who are suffering from end-stage kidney disease?

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

Question 7

When is the physician reimbursed directly for his services by the insurance company?

A) Never
B) Always
C) If the patient has signed a written consent for treatment
D) If the patient has signed an assignment of benefits form

Question 8

In what type of HMO model are the physicians employed by a managed care organization that provides services in its own offices?

A) Staff model HMO
B) Network model HMO
C) Group practice model HMO
D) Independent practice association

Question 9

Which type of insurance plan usually requires the patient to pay a higher percentage of out-of-network services?

A) Network HMO
B) Preferred provider organization
C) Exclusive provider organization
D) Independent physicians association

Question 10

What is the term for the amount of money that must be paid each year for services before the insurance company begins to pick up the payments?

A) Benefit
B) Premium
C) Deductible
D) Assignment

Question 11

When the insurance company pays 80% of the charge, and the patient pays the remaining 20%, what is the patient's portion called?

A) Benefit
B) Deductible
C) Copayment
D) Coinsurance

Question 12

Mary's insurance plan pays 100% of allowed charges and does not allow balance billing. She has a procedure done that is covered by her insurance. She is billed for $500 by the physician, but her insurance company only allows $350. How much will Mary have to pay?

A) Mary must pay $150
B) Mary has to pay only 20% of the $500 charge ($100)
C) Mary must pay only 20% of the allowed charge, which would come to $70
D) Nothing-the physician must accept the $350 from the insurance company as payment in full

Question 13

Mary and Tom Weatherly both work and participate in the family health insurance plan offered by their separate employers. What term relates to the rules used by their insurance companies relating to paying for services?

A) Coinsurance
B) Birthday rule
C) Double coverage
D) Coordination of benefits

Question 14

What type of payments do patients with HMO insurance usually make?

A) Deductible
B) Copayment
C) Coinsurance
D) Both deductible and coinsurance

Question 15

Tom's insurance plan is a traditional indemnity insurance plan. If Tom wants to make an appointment with a dermatologist to treat his acne, what must he do?

A) Simply make the appointment.
B) Obtain a referral from his primary care physician.
C) Visit the plan website and fill out a request for referral form.
D) Call the insurance company and obtain a preauthorization number.

Question 16

Which of the following plans was one of the first to offer prepaid health care paid for by capitation?

A) CHAMPUS
B) Kaiser Permanente
C) Harvard Medical Plan
D) Blue Cross Blue Shield

Question 17

What type of insurance plan usually covers full-time employees?

A) Group insurance
B) Individual insurance
C) Government insurance plans
D) Other types of insurance plans

Question 18

Tom Bloom is a disabled serviceman whose disability is caused by service-related injuries. What insurance plan covers his wife and children?

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

Question 19

Mary and Tom Weatherly are both covered by a family health insurance plan. Whose plan is the primary plan for their children?

A) Whoever earns the highest annual income
B) Whoever's birthday comes first in the year
C) Whoever has worked the longest
D) Whoever's birthday falls the closest to the child's

Question 20

If a patient has managed care insurance, who is the usual gatekeeper to authorize consultations with specialists?

A) The referral coordinator
B) The nurse practitioner
C) The primary care provider
D) An employee at the managed care insurance company

Question 21

A doctor who participates in Medicare performs a service for which he or she ordinarily charges $350. How much should the physician charge Medicare?

A) $350
B) $280
C) $250
D) $0

Question 22

How much is the copayment or coinsurance that a patient with Medicaid must pay?

A) 20% coinsurance
B) $10 copayment
C) 20% and a $100 deductible
D) The patient with Medicaid does not pay anything

Question 23

If a patient has Medicare insurance and a Medicare supplemental policy, which insurance is considered the primary insurance?

A) Medicare.
B) It depends on the birthday rule.
C) Medicare supplemental insurance.
D) It depends on the state in which the patient lives.

Question 24

What classification system forms the basis for payments for claims under Medicare Part A?

A) Title XIX (Title 19) fees
B) Diagnostic-related groups (DRGs)
C) Usual, customary, and reasonable charges (UCR)
D) A resource-based relative value system (RBRVS)

Question 25

Which of the following is NOT required for each charge on an insurance claim form?

A) Procedure code
B) Time of service
C) Place of service
D) Date(s) of service

Question 26

How does Medicare set allowable charges for services under Part B using resource-based relative value systems (RBRVS)?

A) Based on the usual, customary and reasonable charge in the geographic area
B) Using base units multiplied by time units and a factor to adjust for geographic location
C) Based on the education of the practitioner who performs the procedure with a geographic adjustment
D) Based on the amount of work for each procedure with adjustments for overhead and malpractice insurance

Question 27

In which of the following cases is a referral is required by most managed care organizations?

A) Hospitalization
B) Consultation by a specialist
C) Surgery to remove a tumor
D) Certain diagnostic tests, such as an MRI

Question 28

What type of number is usually used to identify the physician who provided each service on an insurance claim form?

A) NPI number
B) UPIN number
C) Social Security number
D) State medical license number

Question 29

If a patient with Medicare is admitted to a hospital for three days, what portion of the hospital costs must the patient pay?

A) Nothing
B) A deductible of $135.00
C) The cost of the first day of hospitalization
D) 20% of the amount charged by the hospital

Question 30

Under Medicare Part A, which of the following goods/services would be covered?

A) Hospital stay
B) Homemaker/health aide services
C) Canes and walkers purchased in a pharmacy
D) Medications administered in the medical office

Question 31

In which of the following types of insurance does the subscriber belong to both an HMO and an insurance plan?

A) Point of Service plan (POS)
B) Preferred Provider Organization (PPO)
C) Exclusive Provider Organization (EPO)
D) Independent Practice Association (IPA)

Question 32

What program provides benefits for the dependent spouses and children of veterans who suffered total, permanent service disabilities or who died as a result of those service-connected disabilities?

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

Question 33

With which of the following things having to do with each insurance plan accepted by the medical office need the medical assistant NOT be familiar?

A) The procedure to request a referral to a specialist
B) The specific procedures covered by each patient's insurance
C) The laboratories where patients may have laboratory tests performed
D) The medical facilities where patients may have procedures or diagnostic tests done

Question 34

What percentage of the allowed charges will Medicare pay a participating physician for office services if the patient has already met the annual deductible?

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

Question 35

Who processes Medicare claims?

A) The federal government
B) State insurance companies
C) The Department of Health and Human Services
D) Insurance companies that contract with the federal government

Question 36

What type of insurance covers long-term nursing home costs for eligible patients?

A) Medicaid
B) Medicare
C) CHIP plans
D) None of the above

Question 37

Under Medicare Part B, which of the following goods/services are covered?

A) Cosmetic surgery
B) Over-the-counter drugs
C) Services in the hospital on an inpatient basis
D) Medications administered in the medical office

Question 38

The Health Insurance Association of America has sought to have all medical claims filed on a common form. What form is accepted for most office visits?

A) UB-04
B) UB-92
C) CMS-1450
D) CMS-1500

Question 39

Which of the following applies to patients who are injured at work and covered under workers' compensation?

A) They should be treated as ordinary patients.
B) They should have separate medical and financial records.
C) They should have all of their previous medical records sent to the employer's insurance company.
D) They should be aware that they can be charged for services not covered by the insurance company.

Question 40

Which of the following insurance plans is not one of the choices available for spouses and dependents of active military personnel?

A) TRICARE Basic
B) TRICARE Extra
C) TRICARE Prime
D) TRICARE Standard

Question 41

Which of the following information must always be completed on the insurance claim?

A) The referring physician name
B) The employer's name or school name
C) The date of onset of the illness or condition
D) If the physician accepts assignment of benefits

Question 42

When an insurance form has been completed and is ready to be submitted to the insurance company, where should a record be made?

A) In the patient's medical record
B) In the insurance claims register
C) On the patient's financial ledger card
D) None of the above-no record is necessary until reimbursement is received

Question 43

The physician must always approve a referral or get approval from a managed care organization.

Question 44

Diagnosis-related groups (DRGs) are used to classify patients by diagnosis in order to gather statistics for National Center for Health Statistics

Question 45

What does the abbreviation SOF indicate on an insurance claim?

A) The physician will accept any payment by the insurance company as payment in full.
B) The office has verified that the patient is eligible for benefits for the services billed on the claim.
C) The office maintains a document signed by the patient that authorizes submission insurance claims.
D) The physician promises that all information on the claim form is correct to the best of his or her knowledge.

Question 46

An independent practice association (IPA) is a type of model of managed care insurance.

Question 47

Resource-based relative value scales (RBRVS) are used to set fee schedules for procedures in outpatient settings.

Question 48

On an insurance claim form, when should the box asking whether the patient had been charged for outside laboratory work be checked "yes"?

A) Whenever any laboratory tests were done
B) Only if blood was collected from the patient in the office
C) Whenever the office sent specimens to a hospital laboratory
D) Whenever the office charged the patient for laboratory work done outside the office

Question 49

Unlike ordinary health insurance, workers' compensation also covers wages lost due to illness or accident.

Question 50

A participating provider (PAR) in the Medicare program is allowed to bill a patient for the portion of the bill that Medicare did not allow.

Question 51

What is a frequent reason for an insurance claim to be rejected?

A) The claim was not filed in a timely manner.
B) A two-digit modifier was used with the procedure code.
C) The procedures are not medically justified by the diagnosis.
D) The secondary insurance company is billed after the primary insurance has paid on the claim.

Question 52

Which method is most commonly used to submit insurance forms?

A) Typed paper forms
B) Handwritten paper forms
C) Electronically submitted forms
D) Computer-generated paper forms

Question 53

When managed care organizations include a prescription drug benefit, they often publish a list of approved medications called a formulary.

Question 54

Where should the name and address of the insurance company appear on the insurance form submitted by the medical office?

A) It is not necessary to include this information.
B) The information should be placed in the top section of the form.
C) The information should be placed in Box 7, in the patient and insured information section.
D) The information should be placed in Box 33, in the physician information section.

Question 55

In order to obtain authorization for many procedures under managed care, the physician's proposed referral or procedure is subject to utilization review.

Question 56

What can the medical assistant use to determine the patient's identification or policy group number?

A) The patient's insurance card
B) The patient's driver's license
C) The patient's Social Security number
D) A telephone call to the patient's insurance company

Question 57

Managed care companies often negotiate a fee schedule that is lower than traditional indemnity insurance plans.

Question 58

If a claim is rejected by an insurance company, what should the medical assistant do first?

A) Immediately resubmit the claim exactly as it before.
B) Resubmit the claim with corrections and/or additional information.
C) Mark in the insurance claims register that the claim will not be paid.
D) Prepare a bill for the patient, since he or she is now completely responsible.

Question 59

If a person must pay a fixed amount of money every time he or she receives medical services, that amount is called a copayment.