Question 1

The 82-year-old patient presented in the physician's office for a routine physical examination. He gave the receptionist two cards, evidencing his primary, government-funded insurance plan that pays for most of the bill and an additional, private plan that covers the remaining charges. The patient's secondary insurance is called:

Accepted Answer

The secondary insurance that covers the remaining charges not covered by a primary, government-funded insurance plan (like Medicare) is known as supplemental insurance. This type of insurance helps to fill the "gaps" in coverage, such as copayments, coinsurance, and deductibles.

Question 2

The physician charged the patient $75 for an office visit. The patient paid the physician $15 and the patient's insurance company paid the physician $60. The patient's portion of the payment is called a:

Accepted Answer

The patient's portion of the payment, which is a fixed amount paid at the time of service, is called a copayment. Premiums are regular fees for insurance coverage, deductibles are amounts paid before insurance covers costs, and coinsurance is a percentage of costs shared between the patient and insurance after the deductible is met.

Question 3

Which is a way the Affordable Care Act aimed to lower health insurance premiums?

Accepted Answer

The Affordable Care Act aimed to lower health insurance premiums by increasing the number of healthier individuals in the risk pool, which helps to balance out the costs of covering sicker individuals.

Question 4

Some employers offer a ____________________ toward which employees can contribute money tax-free, which may then be used for health care and child care expenses.

Accepted Answer

A flexible spending account (FSA) allows employees to contribute money tax-free for use on eligible health care and child care expenses, distinguishing it from the other options which do not offer this specific benefit.

Question 5

Before his insurer will pay for a visit to a dermatologist, it requires Mr. Akers to visit his primary care provider (PCP) and obtain a referral to an in-network dermatologist. Mr. Akers' insurance plan is most likely a(n):

Accepted Answer

Health Maintenance Organizations (HMOs) typically require members to choose a Primary Care Provider (PCP) who acts as a gatekeeper for all non-emergency specialist visits, including dermatologists. This means a referral from the PCP is necessary for the visit to be covered.

Question 6

Which payment model features unlimited access to an independent primary care physician in exchange for a monthly fee?

Accepted Answer

Concierge medicine is a healthcare model where patients pay a monthly or annual fee to have unlimited access to their primary care physician, offering more personalized care and direct access.

Question 7

In the ________________, the organization owns the facilities, employs the physicians, and provides essentially all health care services.

Accepted Answer

In the staff model HMO, the organization indeed owns the facilities, employs the physicians directly, and provides a wide range of healthcare services to its members, making it a comprehensive form of managed care.

Question 8

Medicare claims are processed by:

Accepted Answer

Medicare claims are processed by Medicare Administrative Contractors (MACs), which are private health care insurers that have been awarded geographic jurisdictions by CMS to process Medicare Part A and Part B medical claims or durable medical equipment claims.

Question 9

Which of the following is NOT a way in which managed care organizations may influence and/or control the patient's choices in selecting health care services?

Accepted Answer

Managed care organizations influence patient choices through various mechanisms, such as requiring the selection of a primary care provider, reimbursing only for approved services, and deciding what services are "medically necessary." However, they do not limit their coverage exclusively to primary care services; they also cover specialist and hospital services as needed, within the framework of their managed care system.

Question 10

How did the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 change health care reimbursement?

Accepted Answer

TEFRA introduced a significant change in how hospitals were reimbursed for Medicare patients by implementing a prospective payment system (PPS) based on Diagnosis-Related Groups (DRGs), shifting from a cost-based reimbursement model to a fixed payment system.

Question 11

A contractor who manages health care claims for Medicare is a:

Accepted Answer

Medicare Administrative Contractors (MACs) are private health care insurers that have been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment claims for Medicare Fee-For-Service (FFS) beneficiaries. They are responsible for administering claims, enrolling healthcare providers in the Medicare program, and educating providers on Medicare billing requirements.

Question 12

What is the fixed amount a health insurance policyholder pays each month?

Accepted Answer

The fixed amount a health insurance policyholder pays each month is known as the premium.

Question 13

When is a claim usually submitted?

Accepted Answer

Claims are typically submitted after treatment to ensure that all services provided are accurately documented and billed.

Question 14

Which type of health insurance is obtained through an employer?

Accepted Answer

Group plans are typically offered through employers, providing health insurance coverage to employees as part of their benefits package.

Question 15

A family pays a monthly premium of $1,000 for a health insurance plan with a $2,000 deductible, a 10% coinsurance for inpatient stays, and a yearly out-of-pocket maximum for $6,000 per family member. The first medical event of the year was a family member having gallbladder surgery, which was a covered procedure. The charges from the hospital are $26,000, the charges from the surgeon are $1,500, and the charges from the anesthesiologist are $900. For what amount will the family pay out-of-pocket?

Accepted Answer

The answer of A family pays a monthly premium of...

Question 16

Which part of Medicare covers hospital, nursing home, and home health visits?

Accepted Answer

Part A of Medicare is specifically designed to cover inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care, which directly addresses the question's focus on hospital, nursing home, and home health visits.

Question 17

Which program pays for the care of a veteran's spouse and dependents?

Accepted Answer

CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) is designed to provide health care benefits to the spouse and dependents of veterans who meet specific eligibility criteria, such as veterans who are permanently and totally disabled due to a service-connected condition, among others.

Question 18

A health plan will have lower monthly premiums if

Accepted Answer

Higher deductibles and co-insurance mean that the insured will pay more out-of-pocket before the insurance starts to pay, which reduces the insurance company's risk and can lead to lower premiums.

Question 19

A woman visits her nurse practitioner (NP) for sciatic nerve pain, called sciatica. After an examination, the provider recommends stretching exercises and prescribes ibuprofen, an NSAID. A few weeks later the woman receives an EOB from her insurance company denying coverage of the visit. She subsequently received a bill from the NP in the amount of $146.00. What is this amount called?

Accepted Answer

This amount is called "the charges," which refers to the bill the patient receives for healthcare services when insurance does not cover the visit.

Question 20

A managed care insurer negotiates with a provider to pay 11% less than the provider's standard charge for a certain service. This reimbursement methodology is called:

Accepted Answer

Discounted fee-for-service is a payment model where the insurer pays the provider a fee for each service, but at a rate that is lower than the provider's usual charge. This is achieved through negotiation between the insurer and the provider.

Quiz 6: Financial Management