Question 1

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

Accepted Answer

A consumer-driven health plan typically consists of a health insurance plan paired with a special savings account, such as a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA), which consumers can use to pay for healthcare expenses.

Question 2

Describe the process of adjudication.

Accepted Answer

Adjudication in the context of healthcare insurance refers to the payer's process of evaluating a submitted claim to determine its validity and decide on the extent of payment. This involves a series of steps including verification of coverage, checking for necessary documentation, and ensuring the claim complies with the terms of the policy.

Question 3

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

Accepted Answer

The third party in an insurance contract is the insurance plan or company that pays for the healthcare services on behalf of the patient.

Question 4

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

Accepted Answer

Insurance companies are examples of private-sector payers, as they are privately owned entities that provide health insurance coverage, unlike Medicaid and Medicare, which are government-run programs, and workers' compensation insurance, which is a form of government-mandated insurance.

Question 5

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.

Accepted Answer

Medical assistants often serve as the first point of contact for patients, requiring them to have a high level of proficiency in dealing with the public professionally and pleasantly. They perform both administrative and clinical tasks in healthcare settings, making their role crucial in ensuring a positive patient experience.

Question 6

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

Accepted Answer

Under a capitated rate, the provider shares risk with the third-party payer. This is because the provider is paid a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.

Question 7

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

Accepted Answer

When a POS (Point of Service) HMO member chooses to receive medical services from out-of-network providers, they typically incur additional costs beyond what they would pay for in-network services. This can include higher copayments, deductibles, or coinsurance.

Question 8

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

Accepted Answer

Outpatient surgery is not considered a preventive medical service because it is typically performed to address an existing health issue rather than to prevent one.

Question 9

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.

Accepted Answer

Employment-related injuries are typically covered by workers' compensation insurance rather than standard health insurance policies. Therefore, they are often considered noncovered services at a primary care medical office for billing purposes, as they require billing through the employer's workers' compensation plan rather than through traditional health insurance or out-of-pocket payments by the patient.

Question 10

Collecting copayments is part of which revenue cycle step?

Accepted Answer

Collecting copayments is typically done during the patient check-in process, which is part of Step 3 in the revenue cycle. This step involves verifying patient information and collecting any necessary payments before services are rendered.

Question 11

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

Accepted Answer

Medical insurance companies summarize the payments they may make for medically necessary medical services in the schedule of benefits document. This document outlines the coverage details, including what services are covered and to what extent.

Question 12

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

Accepted Answer

An Electronic Health Record (EHR) is a digital version of a patient's paper chart and more. It's a real-time, patient-centered record that makes information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, it goes beyond the standard clinical data collected in a provider's office and can be inclusive of a broader view of a patient's care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other health care providers, such as laboratories and specialists, so they contain information from all clinicians involved in a patient's care.

Question 13

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

Accepted Answer

Providers participating in a Preferred Provider Organization (PPO) generally agree to accept lower fees in exchange for a higher volume of patients or more patient visits. This arrangement benefits providers by increasing their patient base, even though the payment per service is reduced.

Question 14

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

Accepted Answer

Medical insurance is a written agreement between a policyholder and a health plan, detailing the terms and conditions of the coverage provided.

Question 15

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

Accepted Answer

In an 80-20 coinsurance arrangement, the insurance company (payer) pays 80% of the covered expenses, while the insured (policyholder) pays the remaining 20%.

Question 16

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

Accepted Answer

Consumer-driven health plans often include a health savings account (HSA) or similar account that is used to pay for medical bills before the deductible is met. This allows individuals to pay for eligible healthcare expenses with pre-tax dollars.

Question 17

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

Accepted Answer

Health plans typically do not pay for noncovered services, as these are explicitly excluded from the plan's benefits. Covered services, hospitalization, and preventive medical services are usually included in the scope of services for which a health plan will pay.

Question 18

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

Accepted Answer

Disability insurance is specifically designed to provide income in the event that a person is unable to work due to a disability.

Question 19

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

Accepted Answer

The titles of Certified Coding Specialist (CCS) and Certified Coding Specialist-Physician-based (CCS-P) are awarded by the American Health Information Management Association (AHIMA).

Question 20

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

Accepted Answer

Step 5, review billing compliance, is the step where the medical insurance specialist verifies that charges are in compliance with insurance guidelines. This involves ensuring that the billing for services provided is accurate and adheres to the specific rules and regulations set by the insurance companies.

Quiz 1: Introduction to the Medical Billing Cycle

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