Question 1

Under workers' compensation, a patient who has an industrial injury is billed:

Accepted Answer

Under workers' compensation laws, the cost of treatment for an industrial injury is typically covered by the employer's insurance, not the patient. However, if treatment was provided without proper authorization, the patient might be billed for those services.

Question 2

Physicians who treat patients under workers' compensation plans are usually required to register with the state Workers' Compensation Board:

Accepted Answer

C

Question 3

In a(n) _____ plan, patients are able to see specialists without having to obtain referrals from another physician.

Accepted Answer

D

Question 4

When a patient arrives at the medical office, you should copy _____ of the insurance card(s).

Accepted Answer

Both sides of the insurance card should be copied to ensure that all necessary information, including policy details and contact information, is captured.

Question 5

The term ____ refers to the discovery of the maximum amount of money that a carrier will pay for primary surgery, consultation services, an so on.

Accepted Answer

Predetermination refers to the process of discovering the maximum amount of money that an insurance carrier will pay for specific services like surgery or consultations before the services are provided.

Question 6

Ideally, a person in each medical office is designated as the ____ and is expected to maintain currency with insurers and insurance regulations.

Accepted Answer

The claims filer is typically responsible for staying updated with insurers and insurance regulations to ensure accurate and timely submission of insurance claims.

Question 7

Blue Cross was originally set up to pay for:

Accepted Answer

Blue Cross was originally set up in the 1920s to pay for hospital expenses, specifically to cover the cost of any hospital stays for patients.

Question 8

Part ___ of Medicare is for payment of medical expenses such as office visits and x-ray and laboratory services.

Accepted Answer

Part B of Medicare is for payment of medical expenses such as office visits and x-ray and laboratory services.

Question 9

When a provider does not accept assignment from Medicare, the most that can be charged to the patient is ___ of the Medicare-approved amount.

Accepted Answer

When a provider does not accept assignment from Medicare, they can charge the patient up to 115% of the Medicare-approved amount, which is known as the "limiting charge."

Question 10

A provider may not charge a patient for:

Accepted Answer

When a provider accepts assignment, they agree to accept the insurance company's approved amount as payment in full for their services. They cannot charge the patient for any balance beyond what the insurance company reimburses them. However, the patient is responsible for their deductible and coinsurance amounts. If a service is not covered by the patient's insurance, the provider may bill the patient for those services.

Question 11

Under the birthday rule, if the parents divorce and retain their plans, the parent with _____ is primary.

Accepted Answer

The birthday rule states that the insurance of the parent whose birthday comes first in a calendar year will be considered the primary insurance for any dependent children. This means that if the parents divorce and both retain their plans, the plan of the parent who has custody of the child will be considered primary.

Question 12

Medicaid cards are issued to recipients on a(n) ____ basis.

Accepted Answer

Medicaid cards are issued to recipients on a monthly basis.

Question 13

Once a patient is ready to leave the hospital, ____ is used to ensure that the patient is being discharged to the most appropriate setting.

Accepted Answer

Discharge planning is the process of determining the most appropriate setting for a patient to continue their care after leaving the hospital. This can include home health care, rehabilitation facilities, or nursing homes. The goal of discharge planning is to ensure that the patient receives the necessary care and support to continue their recovery outside of the hospital. Capitation refers to a payment model in which providers receive a fixed amount of money per patient, regardless of the services provided. Utilization review is the process of evaluating the medical necessity and appropriateness of healthcare services. Diagnostic planning refers to the process of determining the most appropriate diagnostic tests for a patient based on their symptoms and medical history. None of these options are directly related to ensuring appropriate patient discharge.

Question 14

Because a primary care physician (PCP) in an HMO makes referrals and approves additional care if needed, he or she is known as the:

Accepted Answer

A PCP in an HMO is referred to as a gatekeeper because they decide which specialist or additional care a patient may need and make referrals and approvals accordingly.

Question 15

Medicare pays ____ of the approved medical bill amount once the deductible is satisfied.

Accepted Answer

Medicare pays 80% of the approved medical bill amount once the deductible is satisfied.

Question 16

When patients without health insurance are seen in the medical practice, they are classified as ____ patients.

Accepted Answer

Patients without health insurance who pay for their medical expenses themselves are classified as self-pay patients. Pro bono refers to services provided free of charge, reimbursement refers to the payment a medical practice receives from an insurance company for services provided to a patient, and TRICARE is a health insurance program for military personnel and their families.

Question 17

Which type of HMO is composed of providers who practice in their own individual offices and retain their own staff and operations?

Accepted Answer

Independent practice association HMOs involve providers who retain their own staff and operations and practice in their own offices.

Question 18

Part ___ of Medicare was created to provide coverage for both generic and brand name drugs.

Accepted Answer

Part D of Medicare was specifically established to cover prescription drugs, including both generic and brand name medications.

Question 19

The only practitioners that can currently bill Medicare with the hard copy CMS-1500s are businesses with:

Accepted Answer

Businesses with less than 10 full-time employees, including physicians, are allowed to bill Medicare using hard-copy CMS-1500 forms. This exception is designed to accommodate smaller practices that may not have the resources to implement electronic billing systems.

Question 20

Health insurance offered by private companies to persons eligible for Medicare benefits and specifically designed to supplement such benefits is called:

Accepted Answer

Medigap insurance is designed to supplement Medicare benefits by covering some or all of the out-of-pocket costs that Medicare does not cover, such as deductibles, coinsurance, and copayments. Medicaid is a joint federal and state program that provides coverage for low-income individuals and families. TRICARE is a health insurance program for military members and their families, while CHAMPVA is a health care benefits program for certain eligible dependents and survivors of veterans.

Quiz 14: The Muscular System