Deck 17: Insurance and Billing

Question 1

The most likely outcome of an insurance claim submitted with a diagnosis code of a sore throat and a treatment code indicating a cast for a broken leg would be ____.

A) coverage at 100 percent for both the sore throat and the broken leg
B) the fee for service would be applied toward the patient's deductible
C) denied because the treatment was not medically necessary based on the diagnosis
D) a reprimand to the physician for not treating the sore throat
E) the patient may have to pay a coinsurance after the deductible is met

Answer 1

denied because the treatment was not medically necessary based on the diagnosis

Question 2

Who most frequently files insurance claims and handles insurers' payments for a medical practice?

A) Patient
B) Nurse
C) Medical assistant
D) Physician
E) Physician assistant

Answer 2

Medical assistant

Question 3

Patients under the age of 65 who are blind or widowed or who have serious long-term disabilities, such as ____, may be entitled to Medicare.

A) asthma
B) kidney failure
C) pneumonia
D) stomach ulcers
E) gallstones

Answer 3

kidney failure

Question 4

A patient who has been hospitalized up to 90 days for each benefit period is covered under ____.

A) Medicare Part A
B) CHAMPVA
C) Medicare Part B
D) Medicaid
E) TRICARE Prime

Question 5

The fixed dollar amount a subscriber must pay or "meet" each year before the insurer begins to cover expenses is the ____.

A) copayment
B) premium
C) coinsurance
D) capitation
E) deductible

Question 6

An organization that provides pain relief to terminally ill patients and supports these patients and their families is a ____.

A) respite
B) hospital
C) outpatient clinic
D) rehabilitation center
E) hospice

Question 7

To be covered under Medicare Part B, patients must ____.

A) remain in the hospital for more than 90 days
B) receive medical care at home
C) purchase private insurance
D) enroll, because coverage is not automatic
E) be terminally ill

Question 8

An insurance claims department compares the fee the doctor charges with the benefits provided by the patient's health plan. This is called the ____.

A) payment of benefits
B) review of medical necessity
C) explanation of benefits
D) review for allowable benefits
E) payment and remittance advice

Question 9

Patients who belong to a managed care health plan, such as an HMO, are responsible for a small per-visit fee collected at the time of the visit. This fee is commonly called a(n) ____.

A) copayment
B) premium
C) coinsurance
D) capitation
E) deductible

Question 10

In a typical medical practice, insurance claims are filed ____.

A) the day before the filing limit is reached
B) the day before the date of service
C) a few business days after the date of service
D) 9 months after the service is rendered
E) 1 year from the date of service

Question 11

Which of the following types of insurance covers injuries that are caused by the insured or that occurred on the insured's property?

A) Medical
B) Liability
C) Disability
D) Medicare
E) Medicaid

Question 12

Which of the following is included in Medicare benefits for respite care?

A) The patient must be terminally ill with 2 years or less to live.
B) Medicare has no respite care benefits.
C) The terminally ill patient is moved to a care facility for the respite.
D) Medicare provides a respite for the terminally ill patient.
E) The terminally ill patient's caregiver is admitted to the respite facility.

Question 13

The authorization for an insurance carrier to pay the physician or the medical practice directly is the ____.

A) copayment
B) provider of medical services
C) assignment of benefits
D) health insurance provider
E) preauthorization

Question 14

In most cases, the insured person pays an annual cost or ____ for healthcare insurance.

A) coinsurance
B) premium
C) copayment
D) capitation
E) benefit

Question 15

The person whose name the insurance is carried under is called the ____.

A) carrier
B) subscriber
C) coinsurer
D) provider
E) third party

Question 16

Of the federal programs providing healthcare, the largest is ____, which provides health insurance for citizens aged 65 and older.

A) Medicaid
B) Medicare
C) disability insurance
D) liability insurance
E) CHAMPVA

Question 17

Which of the following statements applies to a physician who agrees to accept Medicaid patients?

A) The physician can bill the patient for services that Medicaid does not cover.
B) The physician may see Medicaid patients as a last resort when he does not have enough patients with insurance.
C) If the physician's fee is higher than the Medicaid payment, the patient is billed for the difference.
D) The physician does not have to agree to accept the established Medicaid payment for covered services.
E) The physician can bill Medicare for any services not covered by Medicaid.

Question 18

Which of the following is what the patient owes after the insurance company has paid?

A) Premium
B) Exclusion
C) Patient liability
D) Comorbidity
E) Capitation

Question 19

Which of the following is a characteristic of Medicaid?

A) It is a health cost assistance program.
B) It provides health benefits to people aged 65 and older.
C) Patients are enrolled automatically.
D) Rules are the same from state to state.
E) It is an insurance program for low-income, blind, and disabled patients.

Question 20

The benefit period for Medicare begins the day a patient goes into the hospital and ends when that patient has not been hospitalized for ____ days.

A) 10
B) 30
C) 60
D) 90
E) 120

Question 21

When a physician agrees to accept assignment for a Medicare patient, this means the physician ____.

A) bills Medicare for the cost of service not covered by Medicaid
B) will accept Medicare but not Medicaid patients
C) will accept the amount of money Medicaid pays as payment in full
D) will accept only emergency patients covered by Medicaid
E) bills the patient for the cost of service not covered by Medicare

Question 22

Which of the following is not part of Medicare's resource-based relative value scale?

A) The nationally uniform relative value
B) A nationally uniform conversion factor
C) Medigap, to reduce the gap in coverage
D) A geographic adjustment factor
E) Adjustments according to the cost-of-living index

Question 23

The payment system used by Medicare is based on ____.

A) prevailing rates in the region
B) resources
C) the price of medical equipment used
D) fee-for-service agreements
E) the physicians' minimum charges

Question 24

A husband and wife are both employed and have work-sponsored insurance plans that cover each other and their three children. Which insurance plan is the primary payer?

A) The husband's insurance plan, because he makes more money
B) The insurance plan of the person whose birthday comes first in the calendar year
C) The wife's insurance plan, because it has the most comprehensive coverage
D) Whichever the husband and wife want to declare as primary
E) The insurance plan of the person whose policy went into effect first

Question 25

TRICARE and CHAMPVA cover ____.

A) active military personnel
B) veterans who served in active combat
C) non-military government employees
D) families of all military personnel
E) disabled veterans

Question 26

An appropriate approach to maintaining patient confidentiality on the computer is to ____.

A) make sure a coworker knows your password in case you are sick
B) allow former employees to keep their passwords
C) change your password every 90 days
D) provide each patient with a unique password
E) send confidential information only by fax, never by computer

Question 27

The request for approval for payment from a third-party payer prior to a procedure is the ____.

A) coinsurance
B) elective procedure
C) preauthorization
D) predetermination
E) explanation of payment

Question 28

A feature of Blue Cross/Blue Shield (BCBS) is ____.

A) routine cancellation of a patient's policy because of poor health
B) there is no provision for conversion to individual coverage
C) specific plans for BCBS can vary greatly
D) denial of transfer of benefits from one state to another
E) it is a national nonprofit service organization

Question 29

The determination of the amount of money paid by a third-party payer for a procedure is ____.

A) preauthorization
B) copayment
C) precertification
D) deductible
E) predetermination

Question 30

One advantage of submitting claims electronically is ____.

A) it increases the time between submission and payment
B) patients can submit their own claims easily
C) electronic claims cannot be rejected
D) the practice can receive larger payments
E) electronic submissions are cost-efficient

Question 31

In which program can enrollees who are aged 65 and older continue to obtain medical services at military hospitals and clinics as they did before they turned 65?

A) TRICARE Standard
B) TRICARE for Life
C) TRICARE Prime
D) TRICARE Extra
E) CHAMPVA

Question 32

Which of the following is correct regarding electronic claim submissions?

A) Claims cannot be transmitted directly by electronic data interchange (EDI).
B) Claims cannot be entered into the health plan's computer system.
C) Clearinghouses will modify data as necessary to ensure a standard format.
D) Claims are prepared for transmission after all required data elements have been entered.
E) Claim submissions cannot be integrated with EHR systems.

Question 33

Which statement is true regarding health maintenance organizations?

A) They focus on medical procedures and services rather than on wellness and preventive care.
B) They require subscribers to complete paperwork and file claims for routine procedures.
C) Physicians with HMO contracts are often paid a capitated rate.
D) Routine annual physical examinations are discouraged.
E) Patients generally do not have to make copayments.

Question 34

Which of the following guidelines is applicable when filing a Medicaid claim and interacting with Medicaid patients?

A) Allow a 2-year time limit on all claim submissions
B) Submit claims without proving patient eligibility for benefits
C) Treat the patient as if he or she has private insurance
D) Submit claims without proving Medicaid membership
E) Send claims to the national claims center

Question 35

When entering data in medical billing programs, you should ____.

A) use prefixes such as Mr., Mrs., or Ms.
B) enter information using capital letters
C) include invalid data only if necessary
D) use "see above" for repeated data
E) use hyphens, commas, and apostrophes as appropriate

Question 36

Which statement is true about TRICARE?

A) TRICARE Extra can be used only after enrollment in the program.
B) TRICARE is a health insurance plan.
C) Physicians must accept all TRICARE patients.
D) TRICARE for Life acts as a secondary payer to Medicare.
E) TRICARE Standard is a health maintenance organization.

Question 37

Under a contracted or fixed prepayment called ____, physicians are paid a fixed amount of money to provide needed care.

A) preauthorization
B) copayment
C) managed care
D) capitation
E) dual coverage

Question 38

The amount Medicare pays the physician or healthcare provider after the annual deductible is met is ____.

A) 20%
B) 50%
C) 75%
D) 80%
E) 100%

Question 39

Using a clearinghouse to transmit electronic media claims ____.

A) makes more paperwork than paper claims
B) requires a greater amount of time to process claims
C) includes data elements that are transmitted in a computer file.
D) enables a 30-day turnaround time from submission to payment
E) requires a translator and technology to conduct electronic data interchange

Question 40

Which of the following is included under Workers' Compensation insurance in most states?

A) Rehabilitation costs are covered to return an employee to work.
B) A monthly amount is paid to the patient for a temporary disability.
C) There are no death benefits.
D) Only selected medical expenses are covered, and no inpatient expenses are covered.
E) It covers workers who are injured while they are on vacation.

Question 41

Some payers, particularly PPOs, establish fixed fee schedules with their participating physicians, which are also called ________ fee schedules.

Question 42

A small fee that is collected at the time of service is called a(n) _______.

Question 43

The usual fees that are listed on the medical office's fee schedule are fees ____.

A) paid by the third-party provider
B) charged over what most third-party payers will pay
C) charged to most of their patients most of the time under typical conditions
D) charged as a professional courtesy
E) charged only to patients who have private insurance

Question 44

Mrs. Lawrence is an elderly diabetic patient who is on Medicare. She recently injured her lower left leg, and since then has had trouble with open sores or ulcers on that leg. She came to the office last week to have the physician examine and treat the ulcers. At that time, you checked, and she qualified for Medicaid as well as Medicare. She has come to the office today for follow-up care and treatment. Which of the following should you do first?

A) Ensure that the physician signs the Medicaid claim
B) Contact Medicare for preauthorization
C) Contact Medicaid to verify her eligibility
D) Send the claim to Medicaid
E) Notify Mrs. Lawrence that she will not have to pay anything

Question 45

The ________ is a fixed amount that must be paid by the policyholder each year before a third-party payer begins to cover medical expenses.

Question 46

The ________ is a fixed percentage payable by the patient after the deductible is met.

Question 47

The ________ charge is the maximum charge that the payer will pay a provider for a particular procedure or service.

Question 48

What is the term for the 10-digit number that identifies the physician's medical specialty?

A) Taxonomy code
B) National identifier
C) Capitation
D) Physician code
E) DEA number

Question 49

If providers submit a claim for a simple procedure when in fact a more complicated procedure was documented in the medical record, ____ may occur.

A) no payment
B) underpayment
C) overpayment
D) denial of claim
E) recovery audit

Question 50

The ________ is the annual payment made to an insurance company by the patient to keep the insurance policy in effect.

Question 51

Expenses that are not covered by an insurance plan are called ________.

Question 52

Which of the following is not part of the process for verifying workers' compensation coverage?

A) Getting the name and policy number of the patient's personal health insurance policy
B) Obtaining the employer's verification that the accident was work-related
C) Asking the verifier at the patient's company for the original date of the injury
D) Getting the name of the verifier at the patient's company
E) Asking if the company has opened a worker's compensation case with the insurance company

Question 53

Which of the following must be verbally discussed with a Medicare beneficiary to enable the beneficiary to consider options and make informed choices?

A) CHIP
B) DRG
C) RBRVS
D) ABN
E) GAF

Question 54

Mr. Johnson came to the office today complaining of headache and upset stomach. He has the traditional Medicare fee-for-service plan. Your office's usual fee for an established patient visit is $125. Medicare's allowable charge is $100. If Mr. Johnson does not have Medigap insurance, how much will he have to pay for this visit?

A) $20
B) $25
C) $80
D) $100
E) $125

Question 55

Eligibility for Medicaid is ____.

A) automatic for patients aged 65 and older
B) based on the patient's reported income and assets from the previous month
C) based on the patient's reported income and assets from the previous year
D) based on the patient's reported income and assets for the previous three months
E) based on the patient's reported income and assets for the previous six months

Question 56

Greg Owen is in the office today for treatment of a small but deep cut he received while cutting laminate for the new floor in his kitchen. He has employer-provided insurance and is also listed as a dependent on his wife's insurance. His DOB is 7/19/1973 and his wife's DOB is 5/23/1978. Which plan will be the primary payer for the children?

A) Greg's insurance, because he was born 5 years earlier than his wife
B) Greg's wife's insurance, because her birthday occurs earlier in the calendar year
C) Medicare, because Greg is over 65
D) Medicaid, because Greg does not think he can afford to have sutures
E) Workers' Compensation, since Greg is employed full-time

Question 57

A health plan provides ________, which are the payments for medical services provided to the patient.

Question 58

What is the birthday rule?

A) Coverage for the year begins on the policyholder's birthday.
B) Dependent children lose coverage on their 18th birthday.
C) The policyholder's primary insurance coverage ends on his 80th birthday.
D) The insurance policy of the policyholder whose birthday comes first in the calendar year is the primary payer for all dependents.
E) Insurance coverage for all dependents ends on the policyholder's 65th birthday.

Question 59

The list of drugs approved by an insurance company is called a(n) ________.

Question 60

The ________ payer is the health plan that pays for medical services.

Question 61

The provider should have the patient sign a(n) ________ of benefits statement under which the provider agrees to prepare healthcare claims for the patient and to receive payments directly from the payer.

Question 62

CHIP allows states to provide health coverage to uninsured ________ in families that do not qualify for Medicaid but cannot afford private health insurance.

Question 63

The payment system used by ________ is called the resource-based relative value scale (RBRVS).

Question 64

Legal clauses in insurance policies that prevent duplication of payment are called ________ of benefits clauses.

Question 65

Billing the patient for the difference between a higher usual fee and a lower allowed charge is called ________ billing.

Question 66

A fixed prepayment is made to a physician for each plan member in the ________ payment method.

Question 67

Because Medicare pays 80% of approved charges and the patient is responsible for the remaining 20%, individuals enrolled in the Original Medicare Part B plan often buy additional insurance called a(n) ________ plan.

Question 68

If your office submits paper claims, you should create and maintain a claims ________ to track the progress of submitted claims.

Question 69

The oldest and most expensive type of healthcare plans repay policyholders for costs of healthcare due to illness and accidents and are called ________ plans.

Question 70

Three major methods are used to transmit claims electronically: direct transmission to the payer, ________ use, and direct data entry.

Question 71

The electronic claim transaction preferred by Medicare is the X12 837 Health Care Claim, commonly referred to as the "________ claim."

Question 72

Federal law requires employers to purchase and maintain a certain minimum amount of workers' ________ insurance for their employees.

Question 73

Some payers offer an Internet-based service called ________ data entry, or DDE, that allows medical offices to enter data without EDI formatting.

Question 74

Insurance carriers perform a review for medical ________ on each claim to determine whether the treatment is needed for the diagnosis listed.

Question 75

Insurers include either an explanation of payment or a(n) ________ advice along with payment to the practice or to the patient, depending on whether an assignment of benefits was signed.

Question 76

A(n) ________ procedure is a medical procedure that is not required to sustain life and that is planned in advance to be done at the convenience of the physician or surgeon and the patient.

Question 77

A(n) "________" healthcare claim is one that is error-free and is accepted for processing by the payer.

Question 78

The total sum that the health plan will pay out over the patient's life is the lifetime ________ benefit.

Question 79

Billing programs used to exchange health information about the practice's patients with health plans use an electronic data ________ to send information quickly and securely.

Question 80

Under a Medicare Managed Care Plan, the PCP provides treatment and manages the patient's medical care through ________ to specialists when additional care is required.