MA Chapter 17: Insurance and billing

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1

Of the federal programs providing healthcare, the largest is? Which provides health insurance for citizens aged 65 and older?

MEDICARE

2

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

MEDICAL ASSISTANT

3

What is the authorization called that directs an insurance carrier to pay the medical provider or medical practice directly?

ASSIGNMENT OF BENEFITS

4

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

SUBSCRIBER

5

When the insured person pays an annual cost for healthcare insurance, it is called?

PREMIUM

6

Patients who belong to 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?

COPAYMENT

7

In a typical medical practice, insurance claims are filled?

A FEW DAYS AFTER THE DATE OF SERVICE

8

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

DENIED BECAUSE THE TREATMENT WAS NOT MEDICALLY NECESSARY BASED ON THE DIAGNOSIS

9

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

REVIEW FOR ALLOWABLE BENEFITS

10

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

PATIENT LIABILITY

11

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

LIABILITY

12

To be covered under Medicare Part B, patients must

ENROLL BECAUSE COVERAGE IS NOT AUTOMATIC

13

Which insurance covers a patient who has been hospitalized up to 90 days for each benefit period?

MEDICARE PART A

14

Which of the following is a characteristic of Medicaid?

IT IS A HEALTH COST ASSISTANCE PROGRAM

15

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?

KIDNEY FAILURE

16

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

THE TERMINALLY ILL PATIENT WILL BE MOVED TO A RESPITE CARE FACILITY

17

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

HOSPICE

18

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

THE PHYSICIAN CAN BILL THE PATIENT FOR WHAT MEDICAID DOES NOT COVER

19

What percent of the allowable fee does Medicare pay the healthcare provider after the annual deductible is met?

80%

20

Which of the following is NOT part of Medicare’s resource-based relative value scale

MEDIGAP TO REDUCE THE GAP IN COVERAGE

21

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

TREAT THE PATIENT AS IF HE OR SHE HAS PRIVATE INSURANCE

22

Which statement is true about TRICARE?

TRICARE FOR LIFE ACTS AS A SECONDARY PAYER TO MEDICAID

23

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?

TRICARE FOR LIFE

24

Which of the following is included in Worker’s Compensation insurance in most states?

REHABILITATION SERVICES ARE COVERED TO RETURN AN EMPLOYEE TO WORK

25

One advantage of submitting claims electronically is?

ELECTRONIC SUBMISSIONS IS COST-EFFECTIVE

26

Which statement is TRUE regarding health maintenance organizations

PHYSICIANS WITH HMO CONTRACTS ARE OFTEN PAID A CAPITATED RATE

27

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?

THE INSURANCE PLAN OF THE PERSON WHO'S BIRTHDAY COMES FIRST IN THE CALENDER YEAR

28

Using a clearinghouse to transmit electronic media claims?

INCLUDES ALL DATA ELEMENTS THAT ARE TRANSMITTED IN A COMPUTER FILE

29

Which of the following is correct regarding electronic claim submission?

CLAIMS ARE PREPARED FOR TRANSMISSION AFTER ALL REQUIRED DATA ELEMENTS HAVE BEEN ENTERED

30

An appropriate approach to maintaining patient confidentiality on the computer is to?

CHANGE YOUR PASSWORD EVERY 90 DAYS

31

Under a contracted of fixed prepayment called ? physicians are paid a fixed amount of money to provided needed care?

CAPITATION

32

Which of the following groups are not covered by TRICARE or CHAMPVA

FAMILIES OF ALL MILITARY PERSONNEL

33

The payment system used by Medicare is based on?

RESOURCES

34

How should data in medical billing programs be entered

ENTER ALL INFORMATION IN CAPITAL LETTERS

35

The process of deciding the amount of money that will be paid by a third-party payer for a procedure is?

PREDETERMINATION

36

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

PREAUTHORIZATION

37

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

WILL ACCEPT THE AMOUNT OF MONEY MEDICARE PAYS AS PAYMENT IN FULL

38

Eligibility for Medicaid is?

BASED ON THE PATIENTS REPORTED INCOME AND ASSETS FROM THE PREVIOUS MONTH

39

Which of the following is NOT part of the process for verifying worker’s compensation coverage?

GETTING THE NAME AND POLICY NUMBER OF THE PATIENTS PERSONAL HEALTH INSURANCE

40

What is the birthday rule?

THE INSURANCE POLICY OF THE POLICYHOLDER WHOSE BIRTHDAY COMES FIRST IN THE CALENDER YEAR IS THE PRIMARY PAYER FOR ALL DEPENDENTS

41

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

CHARGED TO MOST OF THEIR PATIENTS MOST OF THE TIME UNDER TYPICAL CONDITIONS

42

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

NATIONAL IDENTIFIER

43

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

A BN

44

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

UNDERPAYMENT

45

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. 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?

CONTACT MEDICAID TO VERIFY HER ELIGIBILITY

46

Mr. Johnson came to the office today complaining of headaches and upset stomach. He has the traditional Medicaid fee-for-service plan. Your offices 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?

$25

47

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 5/23/1978. Who is the primary payer in this case?

GREG'S INSURANCE BECAUSE HE WAS BORN 5 YEARS EARLIER THAN HIS WIFE