BOT2673- Medical Insurance Billing

The Veterans Healthcare Expansion Act of 1973 authorized Veterans Affairs to establish __________ to provide health care benefits for dependents of veterans rated as 100 percent permanently and totally disabled as a result of service-connected conditions, veterans who died as a result of service-connected conditions, and veterans who died on duty with less than 30 days of active service.

CHAMPVA

Medicare requires providers to submit the __________ claim for payment of outpatient and office services.

CMS-1500

The Health Care and Education Reconciliation Act (HCERA) amended the PPACA to implement health care reform initiatives, which included __________.

closing the Medicare "donut hole"

The National Committee for Quality Assurance (NCQA) reviews managed care plans and develops report cards to __________.

allow health care consumers to make informed decisions when selecting a plan

Which has a more narrow focus because it is the patient record created for a single medical practice using a computer, keyboard, mouse, optical pen device, voice recognition system, scanner, and/or touch screen?

electronic medical record

Managed health care was developed as a way to provide affordable, comprehensive, prepaid health care services to __________.

enrollees

Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.

establishes a utilization management program and performs external utilization review services

Which term describes the principles of right or good conduct and includes rules that govern the conduct of members of a profession?

ethics

The Resource-Based Relative Value Scale (RBRVS) system reimburses physicians' practice expenses using a __________.

fee schedule

Which consumer-directed health plan allows participants to enroll in a relatively inexpensive high-deductible insurance plan and open a tax-deductible savings account to cover current and future medical expenses? Money deposited (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax-free. Money can be withdrawn for purposes other than health care expenses after payment of income tax plus a 15 percent penalty. Unused balances "roll over" from year to year, and if an employee changes jobs, he or she can continue to use the fund to pay for qualified health care expenses.

health savings account

Which would be found on a remittance advice?

payment information about a claim

A health maintenance organization (HMO) is an alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a __________ basis.

prepaid

Conduct or qualities that characterize a professional person are called __________.

professionalism

Which is an insurance agreement that protects business contents against fire, theft, and other risks?

property insurance

Clinical Laboratory Improvement Act (CLIA) legislation established __________ for alllaboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed.

quality standards

The Patient Protection and Affordable Care Act (PPACA) was signed into federal law on March 23, 2010, and resulted in the creation of a Health Insurance Marketplace to:

​allow Americans to purchase health coverage that fits their budget and meets their needs.

With managed care's capitation financing method, if the physician provides services that cost less than the capitation amount, there is a profit, which the physician ___________.

keeps to reinvest in the medical practice

When a health insurance plan's preauthorization requirements are not met by providers,

payment of the claim is denied.

The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) includes a patient classification system that reflects differences in patient __________.

resource use and costs

Which defines a profession, delineates qualifications and responsibilities, and clarifies supervision requirements?

scope of practice

Which is a centralized health care system adopted by some Western nations (e.g., Canada, Great Britain) and funded by taxes?

single-payer plan

Which is a type of single-payer system in which the government owns and operates health care facilities and providers (e.g., physicians) receive salaries?

socialized medicine

The word embezzle means to _____.

steal

The primary care provider (PCP) is responsible for __________.

supervising and coordinating health care services for enrollees

Which type of insurance covers employees and their dependents against injury and death that occurs during the course of employment?

workers' compensation

The Healthcare Common Procedure Coding System (HCPCS) consists of __________ codes.

CPT and national

The Centers for Medicare and Medicaid Services (CMS) agency is located in the __________.

DHHS

Which coding system is used to report procedures and services on inpatient hospital claims?

ICD-10-PCS

The Outpatient Prospective Payment System (OPPS), which uses __________ to calculate reimbursement, is implemented for billing of hospital-based Medicare outpatient claims.

ambulatory payment classifications

The Financial Services Modernization Act (FSMA) (or Gramm-Leach-Bliley Act) prohibits sharing of medical information among health insurers and other financial institutions for use in making __________ decisions.

credit

Which is the amount for which the patient is financially responsible before an insurance policy provides payment?

deductible

A claims examiner employed by a third-party payer reviews health-related claims to determine whether the charges are reasonable, in addition to

determining medical necessity of services/procedures.

The process of reporting __________ as numeric and alphanumeric characters on the insurance claim is called coding.

diagnoses and procedures/services

Which is associated with contracted health care services that are delivered to subscribers by individual physicians in the community?

direct contract model HMO

A managed care organization (MCO) is responsible for the health of a group of __________ and can be a health plan, hospital, physician group, or health system

enrollees

One result of the Patient Protection and Affordable Care Act (PPACA) was establishment of state health insurance __________ that Americans will use to purchase health coverage that fits their budget and meets their needs.

exchanges or marketplaces

Which consumer-directed health plan provides tax-exempt accounts offered by employers to any number of employees, which individuals use to pay health care bills? The employees contribute funds through a salary reduction agreement and withdraw funds to pay medical bills. Funds are exempt from both income tax and Social Security tax (and employers may also contribute). By law, employees forfeit unspent funds at the end of the year.

flexible spending account

The Investing in Innovations (i2) Initiative is designed to spur innovations in health information technology (health IT) by promoting research and development to enhance competitiveness in the United States. An example of this type of an initiative includes _____.

generating results by providing patients, caregivers, and clinicians with access to rigorous and relevant information that can support real needs and immediate decisions

Which type of health insurance coverage is subsidized by employers and other organizations?

group health insurance

The National Correct Coding Initiative (NCCI) was created to promote national correct codingmethodologies and to eliminate __________ coding.

improper

The organization that hires a(n) __________ is not liable for the acts or omissions of that individual.

independent contractor

Which type of HMO contracts health services that are delivered to subscribers by physicians who remain in their own office settings?

independent practice association

Which type of health insurance coverage is purchased by families who do not have access to employer-subsidized coverage?

individual health insurance

A management service organization (MSO) is usually owned by physicians or a hospital and provides practice management (administrative and support) services to __________.

individual physician practices

Managed care plans that are "federally qualified" and those that must comply with state quality review mandates, or __________, are required to establish quality assurance programs.

laws

Medical malpractice insurance is which type of insurance?

liability

Prior to implementation of a prospective payment system for acute care hospital inpatient stays, reimbursement was generated on a __________ basis, which issued payment based on daily rates.

per diem

Which party signs a contract with a health insurance company and thus, owns the health insurance policy?

policyholder

The Home Health Prospective Payment System (HH PPS) reimburses home health agencies at a __________ rate for health care services provided to patients.

predetermined

A managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee is called a(n) __________.

preferred provider organization

Which may specifically result in the early detection of health problems, allowing less drastic and less expensive treatment options?

preventive examination

Which is a systematic method of documentation that consists of four components: database, problem list, initial plan, and progress notes?

problem-oriented record

Reviewing the appropriateness and necessity of care provided to patients prior to the administration of care is called __________ review, and such review after care has been provided is called __________ review.

prospective; retrospective

Which type of health insurance coverage includes federal and state government health programs (e.g., Medicare, Medicaid, SCHIP, TRICARE) that are available to eligible individuals?

public health insurance

The Skilled Nursing Facility Prospective Payment System (SNF PPS) was implemented to cover all costs (routine, ancillary, and capital) related to services furnished to Medicare Part A beneficiaries. SNF PPS generates per diem payments for each admission. These payments are case-mix adjusted using a resident classification system called __________.

resource utilization groups

Which is Latin for "let the master answer," which means that the employer is liable for the actions and omissions of employees as performed and committed within the scope of their employment?

respondeat superior

An integrated provider organization (IPO) manages the delivery of health care services offered by hospitals, physicians, and other health care organizations. Physicians associated with an IPO are considered __________.

employees

Which type of health insurance coverage has costs that are typically less per person and provides broader coverage?

group health insurance

Which is submitted to the payer requesting reimbursement?

health insurance claim

Prior to scheduling elective surgery, managed care plans often require a __________ during which another physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery.

second surgical opinion

Large employers who assume the financial risk for providing health care benefits to employees do not pay a fixed premium to a health insurance payer, but establish a trust fund (of employer and employee contributions) out of which claims are paid. This concept is called __________.

self-insurance

Accreditation organizations develop standards that are reviewed during an evaluation process that is conducted both offsite and onsite. The evaluation process is called a(n) __________.

survey

Sally Simmons is a patient of Dr. Tyler's. She received preventive services for her annual physical examination on May 17. The third-party payer determined the allowed charge for preventive services to be $100, for which the payer reimbursed the physician 80 percent of that amount. Sally is responsible for paying the remaining 20 percent directly to the physician. Thus, the physician will receive a check in the amount of __________ from the payer, and the patient will pay __________ to the physician.

$80; $20

Medicare __________ is a type of Medigap insurance that requires enrollees to use a network of providers to receive full benefits, which may result in lower premiums for enrollees.

SELECT

Which code set is copyrighted by the American Dental Association?

CDT

Which program assesses and measures improper Medicare fee-for-service payments (based on reviewing selected claims and associated medical record documentation)?

CERT

Which is a comprehensive health care program for which the Department of Veterans Affairs shares costs of covered health care services and supplies with eligible beneficiaries?

CHAMPVA

Which insurance claim is submitted to receive reimbursement under Medicare Part B?

CMS-1500

Which insurance claim is submitted to receive reimbursement under Medicare Part C?

CMS-1500 or UB-04

Private fee-for-service (PFFS) plans are offered by private insurance companies in some regions of the country, and Medicare pays a pre-established amount of money each month to the insurance company, which decides how much it will pay for services. Such plans reimburse providers on a fee-for-service basis and are authorized to charge enrollees up to __________ percent of the plan's payment schedule.

115

ICD-10-CM diagnosis codes are entered in Block 21 of the CMS-1500 claim. A maximum of __________ ICD-10-CM codes may be entered on a single claim.

12

The Balanced Budget Act of 1997 allows certain health care providers to withdraw from Medicare and enter into private contracts with their Medicare patients, which requires "opting out" of Medicare for at least __________ years for all covered items and services furnished to Medicare beneficiaries.

2

When entering a fee in Blocks 24F, 28, or 29, enter __________ in the cents column.

2 zeros

Secondary diagnoses codes are entered in Blocks __________ of the CMS-1500 claim.

21B - 24L

A Medicare benefit period begins with the first day of hospitalization and ends when the patient has been out of the hospital for __________ consecutive days.

60

An initial enrollment period (IEP) that provides an opportunity for the individual to enroll in Medicare Part A and/or Part B is for a period of __________ months.

7

The Office of Workers' Compensation Programs (OWCP) administers programs that provide wage-replacement benefits, medical treatment, vocational rehabilitation, and other benefits to federal workers (or eligible dependents) who are injured at work or acquire an occupational disease. In which federal department is the OWCP located?

Department of Labor

The U.S. Labor Department's Mine Safety and Health Administration (MSHA) helps reduce deaths, injuries, and illnesses in U.S. mines through a variety of activities and programs. Which is an example of such an activity or program?

Develops and enforces safety and health rules that apply to all U.S. mines

Covered entities are required to use mandated national standards when conducting any of the defined transactions covered under HIPAA. Which is an example of a covered entity?

ERISA-covered health benefit plans

To qualify for workers' compensation benefits, an employee must be injured while working within the scope of the job description, be injured while performing a service required by the employer, or develop a disorder that can be directly linked to employment, such as asbestosis or mercury poisoning. The worker does not have to be physically on company property to qualify for workers' compensation. Which is an example of an on-the-job injury that would qualify the employee for workers' compensation benefits?

Employee is injured when picking up reports for the office at the local hospital.

Which prohibits discrimination on the basis of race, color, religion, national origin, sex, marital status, age, receipt of public assistance, or good-faith exercise of any rights under the Consumer Credit Protection Act?

Equal Credit Opportunity Act

Which is a hospital payment monitoring program data analysis tool that provides administrative hospital and state-specific data for specific CMS target areas?

FATHOM

Which regulates fraud associated with military contractors selling supplies and equipment to the Union Army?

False Claims Act

Which is the physician self-referral law that protects patients and federal health care programs from fraud and abuse by curtailing the corrupting influence of money on health care decisions?

Federal Anti-Kickback Law

Which is an Office of Workers' Compensation Programs (OWCP) program?

Federal Black Lung Program

Which requires Medicare administrative contractors to attempt the collection of overpayments received by a provider or beneficiary?

Federal Claims Collection Act

Which legislation provides civilian employees of the federal government with medical care, survivors' benefits, and compensation for lost wages?

Federal Employees' Compensation Act

Which legislation protects and compensates railroad workers who are injured on the job?

Federal Employers' Liability Act

Which is a legal newspaper published every business day by the National Archives and Records Administration (NARA), and is available in paper form, on microfiche, and online?

Federal Register

Which is a variable-length file format used to bill institutional, professional, dental, and drug claims?

ANSI ASC X12N 837

Which is the abbreviation for the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 that required implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, required faster Medicare appeals decisions, and more?

BIPA

FEP cards contain the phrase __________ under the BCBS trademark.

Government-Wide Service Benefit Plan

Which program provides consumers with quality of care information so they can make more informed decisions about health care options?

Hospital Inpatient Quality Reporting (Hospital IQR)

Diagnosis pointer letters A-L are preprinted in Block 21 of the CMS-1500 claim to allow for entry of __________ codes, and they are reported in Block 24E.

ICD-10-CM

Which established the CERT, FATHOM, HPMP, PEPPER, and PERM programs?

Improper Payments Information Act of 2002

The State Children's Health Insurance Program (SCHIP) was established to provide health assistance to uninsured, low-income children, either through separate programs or through expanded eligibility under state __________ programs.

Medicaid

The State Children's Health Insurance Program (SCHIP) was implemented in accordance with the Balanced Budget Act (BBA) to allow states to create or expand existing insurance programs, providing more federal funds to states for the purpose of expanding __________ eligibility to include a greater number of currently uninsured children.

Medicaid

The federal name for the Title 19 medical assistance program is __________.

Medicaid

Title XIX of the Social Security Amendments of 1965 is a cost-sharing program between the federal and state governments to provide health care services to low-income Americans. It is a government plan known as __________.

Medicaid

Which program pays for inpatient hospital critical care access, skilled nursing facility stays, hospice care, and some home health care?

Medicare Part A

Which program pays for physician services, outpatient hospital care, and durable medical equipment?

Medicare Part B

Which program includes managed care and private fee-for-service plans that provide contracted care to Medicare patients?

Medicare Part C

Which established the Hospital IQR, RAC, and ZPIC programs?

Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003

The Health Maintenance Organization (HMO) Assistance Act of 1973 authorized grants and loans to develop HMOs under private sponsorship. It defines a federally qualified HMO as being certified to provide health care services to __________ enrollees.

Medicare and Medicaid

BCBS corporations offer several federally designed and regulated Medicare supplemental plans that augment the Medicare program by paying for Medicare deductibles and copayments. These plans are usually identified by the word __________ on the patient's plan ID card.

Medigap

Medicare beneficiaries can also obtain supplemental insurance to help cover costs not reimbursed by the original Medicare plan. This type of coverage is called __________.

Medigap

Supplemental plans usually cover the deductible and copay or coinsurance of a primary health insurance policy. Which is the best known supplemental plan?

Medigap

Which is maintained by the Food and Drug Administration (FDA) and identifies prescription drugs and some over-the-counter products?

NDC

Which was created by the Centers for Medicare and Medicaid Services for the purpose of assigning unique identifiers to health care providers and health plans?

NPPES

Which was developed by the Centers for Medicare and Medicaid Services to assign the unique health care provider and health plan identifiers and to serve as a database from which to extract data?

NPPES

Which flat file is used to bill physician and noninstitutional services, such as services reported by a general practitioner, on the CMS-1500?

NSF

Which is responsible for the surveillance of fraud and abuse activities worldwide involving purchased care for beneficiaries in the Military Health Care System?

Program Integrity Office

Which prohibits physicians from referring Medicare patients to clinical laboratory services in which the physicians or their family members have a financial ownership/investment interest and/or compensation arrangement?

Stark I

Which allows TRICARE Standard users to save 5 percent of their TRICARE Standard cost-shares by using health care providers in the TRICARE network?

TRICARE Extra

Which is the TRICARE managed care option similar to a civilian health maintenance organization?

TRICARE Prime

Which act resulted in a prospective payment system (PPS) that issues a predetermined payment for inpatient services?

Tax Equity and Fiscal Responsibility Act of 1982

Which created the Physician Quality Reporting System that established a financial incentive for eligible professionals who participate in a voluntary quality reporting program?

Tax Relief and Health Care Act of 2006

Which is the current program that makes cash assistance available, for a limited time, for children deprived of support because of a parent's absence, death, incapacity, or unemployment?

Temporary Assistance for Needy Families

Hospital inpatient charges are reported on the __________ claim.

UB-04

Which flat file is a series of fixed-length records that is currently used to bill institutional services, such as services performed in hospitals?

UB-04

BCBS Healthcare Anywhere coverage allows members of the independently owned and operated BCBS plans to have access to health care benefits throughout the __________, depending on their home plan benefits.

United States and world

Postoperative complications requiring a return to the operating room for surgery related to the original procedure are billed as an additional procedure, and the additional procedure is linked to __________.

a new diagnosis that describes the complication

When the YES box in Block 27 of the CMS-1500 claims contains an X, the provider agrees to receive as payment in full whatever the payer reimburses. This concept is called __________.

accept assignment

Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?

accept assignment

Which are the amounts owed to a business for services or goods provided?

accounts receivable

Which best assists providers in the overall collection of appropriate reimbursement for services rendered?

accounts receivable management

The BCBS coordinated home health and hospice care program allows patients with this option to elect an alternative to __________ or long-term care settings.

acute

When a workers' compensation claim is denied, the employee (or eligible dependents) can appeal the denial to the state workers' compensation board and undergo a process called __________, which is a judicial dispute resolution process in which an appeals board makes a final determination.

adjudication

A(n) __________ claim has a payment correction, resulting in additional payment(s) to the provider.

adjusted

Triple option plans are intended to prevent the problem of covering members who are sicker than the general population, which is called __________ selection.

adverse

Claims adjudication involves making a determination about __________ charges, which is the maximum amount the payer will permit for each procedure or service, according to the patient's policy.

allowed

A participating provider (PAR) contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. This means that PARs __________ allowed to bill patients for the difference between the contracted rate and their normal fee.

are not

A quality assurance program includes activities that __________ the quality of care provided in a health care setting.

assess

Patients sign Block 13 of the CMS-1500 claim to instruct the payer to directly reimburse the provider. This concept is called __________.

assignment of benefits

Which is offered to members and marketed to small business owners as a way to provide coverage to employees?

association health insurance

Survivor benefits claims provide death benefits to eligible dependents. These benefit amounts are calculated according to the employee's earning capacity __________.

at the time of the illness or injury

Which type of insurance is a contract between an individual and an insurance company whereby the individual pays a premium and, in exchange, the insurance company agrees to pay for specific vehicle-related financial losses during the term of the policy?

automobile

BCBS fee-for-service __________ coverage includes minimum benefits, such as inpatient hospitalizations and diagnostic laboratory services.

basic

A pre-existing condition is any medical condition that was diagnosed and/or treated within a specified period of time __________ the enrollee's effective date of coverage.

before

Which include sponsors and dependents of sponsors?

beneficiaries

A policyholder or __________ is the person in whose name the insurance policy is issued.

beneficiary

A TRICARE __________ provides information about using TRICARE and assists with other matters affecting access to health care (e.g., appointment scheduling).

beneficiary services representative

Which of the following is an example of abuse?

billing noncovered services/procedures as covered services/procedures

Workers' compensation insurance provides weekly cash payments and reimburses health care costs for covered employees who develop a work-related illness or sustain an injury while on the job. It also provides payments to qualified dependents of a worker who dies from a compensable illness or injury. Each state establishes a workers' compensation __________, which is responsible for administering workers' compensation laws and handling appeals for denied claims or cases in which a worker feels compensation was too low.

board

The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) resulted in implementation of risk contracts, which are arrangements among providers to provide __________ health care services to Medicare beneficiaries.

capitated

Which involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner?

case management

The TRICARE benefit that protects beneficiaries from devastating financial loss due to serious illness or long-term treatment by establishing limits over which payment is not required is called the __________ cap benefit.

catastrophic

Which is the financial record source document used by health care providers and other personnel in a hospital outpatient setting to select codes for treated diagnoses and services rendered to the patient during the current visit?

chargemaster

OSHA has special significance for those employed in health care because employers are required to obtain and retain manufacturers' Material Safety Data Sheets (MSDS), which contain information about __________ used on site. Training employees in the safe handling of these substances is also required.

chemical and hazardous substances

Which involves comparing the claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures performed or services provided are covered benefits?

claims adjudication

Which involves sorting claims upon submission to collect and verify information about the patient and provider?

claims processing

Which is the electronic or manual transmission of claims data to payers or clearinghouses for processing?

claims submission

Electronic claims are submitted directly to the payer after being checked for accuracy by billing software or a health care clearinghouse, which results in a __________ claim that contains all required data elements needed to process and pay the claim.

clean

Which claims are filed according to year and insurance company and include those for which all processing, including appeals, has been completed?

closed claims

Which type of automobile insurance pays for damage to a covered vehicle caused by hitting an object or being hit during an automobile accident?

collision

Which type of health insurance covers the medical expenses of individuals (e.g., private health insurance) and groups (e.g., employer group health insurance)?

commercial

TRICARE enrollees use their uniformed services __________, which can be scanned each time they receive health care services.

common access card

The claim is also checked against the __________, which is an abstract of all recent claims filed on each patient and helps determine whether the patient is receiving concurrent care for the same condition by more than one provider.

common data file

The Medicare Catastrophic Coverage Act of 1988 implemented Spousal Impoverishment Protection Legislation in 1989 to prevent married couples from being required to spend down income and other liquid assets (cash and property) before one of the partners could be declared eligible for Medicaid coverage for nursing facility care. The spouse residing at home is called the __________ spouse.

community

Which is a review for medical necessity of tests and procedures ordered during an inpatient hospitalization?

concurrent review

The base period of a disability policy usually covers 12 months and is divided into four __________ quarters.

consecutive

The Patient Protection and Affordable Care Act established a Medicare shared savings program to facilitate the __________ to improve the quality of care for Medicare fee-for-service beneficiaries and to reduce unnecessary costs.

coordination and cooperation among health care providers

Which is the fixed amount the patient pays each time he or she receives health care services?

copayment

Group health insurance is available through employers and other organizations, and allor part of the premium costs are paid by employers. Employer-based group health insurance __________.

covers all employees, regardless of health status, and cannot be canceled if an employee becomes ill

Civil law deals with all areas of the law that are not classified as __________ law.

criminal

Which is the sequence of activities that can normally be expected to result in the most cost-effective clinical course of treatment?

critical pathway

Which consumer-directed health plan funds health care expenses with insurance coverage and the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium?

customized sub-capitation plan

The computer-to-computer transfer of data between providers and third-party payers (or providers and health care clearinghouses) in a data format agreed upon by sending and receiving parties is called electronic __________.

data interchange

The manual daily accounts receivable journal is also known as the __________, and it is a chronologic summary of all transactions posted to individual patient ledgers/accounts on a specific date.

day sheet

Which are located at military treatment facilities to assist beneficiaries in resolving health care collection-related issues?

debt collection assistance officers

Which tests and establishes the feasibility of implementing a new program during a trial period, after which the program is evaluated, modified, and/or abandoned?

demonstration project

Any procedure or service reported on the claim that is not included on the master benefit list is a noncovered benefit and will result in claims __________.

denial

Which is testimony under oath taken outside of court, such as at the physician's office?

deposition

Which is filed with the workers' compensation board to document any significant change in the worker's medical or disability status?

detailed narrative progress/supplemental report

The MUE project was implemented by CMS as part of the NCCI to improve the accuracy of Medicare payments by __________.

detecting and denying unlikely Medicare claims on a prepayment basis

Permanent disability refers to an ill or injured employee's __________ capacity to return to work.

diminished

Which occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department?

direct admission

Which type of insurance is defined as reimbursement for income lost as a result of a temporary or permanent illness or injury?

disability

Which involves arranging appropriate health care services for the patient who is being released from an inpatient hospitalization?

discharge planning

Breach of confidentiality involves the unauthorized release of patient information to a third party, such as health care employees who __________.

discuss patient information outside an exam room where other patients are present

When a person uses a title such as Sr., Jr., II, or III, __________.

do not enter it on the claim unless printed on the patient's insurance ID card

Which is the assignment of lower-level codes than documented in the record?

downcoding

Which consists of routine pediatric checkups provided to all children enrolled in Medicaid, including dental, hearing, vision, and other screening services to detect potential problems?

early and periodic screening, diagnostic, and treatment

The Preferred Provider Health Care Act of 1985 __________ restrictions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO.

eased

HIPAA regulations require all payers to accept __________ attachments.

electronic

Providers have the option of arranging for __________, which means that payers deposit reimbursement for health care services to the provider's account electronically.

electronic funds transfer

Clearinghouses process claims in an electronic flat file format, which requires conversion of CMS-1500 claims data to a standard format. Providers can also use software to convert claims to an electronic flat file format, also known as a(n) __________, which is a series of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers as a bill for health care services.

electronic media claim

The HIPAA Security Rule adopts standards and safeguards to protect health information that is collected, maintained, used, or transmitted __________.

electronically

The BlueCross BlueShield Federal Employee Program (FEP) is a(n) __________ health benefits program established by an Act of Congress in 1959.

employer-sponsored

Which is considered a financial source document from which an insurance claim is generated?

encounter form

Which is the financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current visit?

encounter form

Physician incentives include payments made directly or indirectly to health care providers to __________ so as to save money for the managed care plan. Managed care plans that contract with Medicare or Medicaid must disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.

encourage them to reduce or limit patient services

Encoding or __________ a computer file makes it safe for electronic transmission so that unauthorized parties cannot read it.

encrypting

Many states have enacted legislation requiring a(n) __________ to review health care provided by managed care organizations.

external quality review organization

Which of the following is an example of fraud?

falsifying certificates of medical necessity plans of treatment

Which describes annual income guidelines established by the federal government?

federal poverty level

A competitive medical plan (CMP) is an HMO that meets __________ eligibility requirements for a Medicare risk contract, but is not licensed as abut is not licensed as a __________ qualified plan.

federal; federally

The code reported in Block 21A of the CMS-1500 claim is the major reason the patient was treated by the health care provider. It is called the __________ diagnosis.

first-listed

TRICARE deductibles are applied to the government's __________ year, which runs from October 1 of one year to September 30 of the next.

fiscal

By 1932 some plans modified the prepaid plan concept and organized community-wide programs that allowed the subscriber to be hospitalized in one of several member hospitals in accordance with signed contracts to provide services __________.

for negotiated special rates

BCBS indemnity coverage offers choice and flexibility to subscribers who want to receive a full range of benefits along with the __________.

freedom to use any licensed health care provider

CPT includes a section called Evaluation and Management (E/M), which describes patient encounters with providers for the purpose of the evaluation and management of __________.

general health status

When reporting procedures and services on the CMS-1500, list one procedure per line, starting with line one of Block 24. To report more than six procedures or services for the same date of service, __________.

generate a new claim to enter more procedures/services

Coordination of benefits (COB) is a provision in __________ health insurance policies intended to keep multiple insurers from paying benefits covered by other policies.

group

Which is associated with contracted health care services that are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice?

group model HMO

Which person is responsible for paying the charges?

guarantor

A TRICARE __________ assists primary care providers with preauthorizations and referrals to health care services in a military treatment facility or civilian provider network.

health care finder

The Away From Home Care Program allows participating BCBS plan members who are temporarily residing outside of their home HMO service area for at least 90 days to temporarily enroll with a local __________.

health maintenance organization

Which consumer-directed health plan allows tax-exempt accounts to be offered by employers with 50 or more employees, which individuals then use to pay health care bills? Funds must be used for qualified health care expenses, and unspent money can be accumulated for future years. If an employee changes jobs, he or she can continue to use the funds to pay for qualified health care expenses.

health reimbursement arrangement

Which is associated with "last resort" health insurance for individuals who cannot obtain coverage due to a serious medical condition?

high-risk pool

Which is an autonomous, centrally administered program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients and their families?

hospice

BCBS has a mandatory second surgical opinion (SSO) requirement necessary when a patient is considering elective, nonemergency surgical care. The initial surgical recommendation must be made by a physician qualified to perform the anticipated surgery. If a second surgical opinion is not obtained prior to surgery, the patient's out-of-pocket expenses may be __________.

increased

Which is traditional fee-for-service health insurance that covers a portion of services, such as inpatient hospitalizations or physician office visits, with the patient paying the remaining costs?

indemnity insurance

The Longshore and Harbor Workers' Compensation Program, administered by the U.S.Department of Labor, provides medical benefits, compensation for lost wages, and rehabilitation services to longshoremen, harbor workers, and other maritime workers who are __________.

injured from or suffer diseases during employment

HIPAA defines fraud as an __________ deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.

intentional

Which is a legal document containing a list of questions that must be answered in writing?

interrogatory

A nonparticipating provider (nonPAR) is an out-of-network provider who does not contract with the insurance plan, and patients who elect to receive care from non-PARs will incur higher out-of-pocket expenses. The patient __________ expected to pay the difference between the insurance payment and the provider's fee.

is usually

A remittance advice submitted to the provider electronically is called an electronic remittance advice (ERA), and __________.

it contains identical information to the information on a paper-based remittance advice

When the patient is covered by other medical or liability policies, Medicaid reimburses providers __________.

last

Block 33 of the CMS-1500 claim requires entry of the name, address, and telephone number of the billing entity, which is the __________.

legal business name of the practice

An appeal is documented as a(n) __________ why a claim should be reconsidered for payment.

letter signed by the provider explaining

Which type of automobile insurance pays for accidental bodily injury and property damage to others, including medical expenses, pain and suffering, lost wages, and other special damages?

liability

Which type of insurance covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured?

liability

The Medicare Integrity Program includes medical review, which is defined by CMS as a review of claims to determine whether services provided are __________, as well as to followup on the effectiveness of previous corrective actions.

medically reasonable and necessary

The BCBS PPO plan is sometimes described as a subscriber-driven program, and BCBS substitutes the term subscriber or __________ for policyholder.

member

An electronic signature will result in a unique bit string (or computer code) called a(n) __________, which is encrypted and appended to the electronic document.

message digest

Health Affairs (HA) refers to the Office of the Assistant Secretary of Defense for Health Affairs, which is responsible for __________.

military readiness and peacetime health care

When a child lives with both parents, and each parent subscribes to a different health insurance plan, the primary and secondary policies are determined by applying the birthday rule. The individual who holds the primary policy for dependent children is the spouse whose birth __________.

month and day occur earlier in the calendar year

Any time patients state that they receive Medicaid, they must present a valid Medicaid identification card because eligibility, in many cases, will depend on the patient's __________ income.

monthly

A mother/baby claim is submitted for services provided to a baby under the __________ Medicaid identification number.

mother's

The CHAMPUS Reform Initiative (CRI) demonstration project offered military families a choice of how their health care benefits could be used. The DoD noted its successful operation and high levels of patient satisfaction, and determined that its concepts should be expanded to a __________ program.

nationwide uniform

The Merchant Marine Act (or Jones Act) provides seamen with the same protection from employer __________ as the Federal Employment Liability Act (FELA) provides railroad workers.

negligence

A clearinghouse that involves value-added vendors, such as banks, in the processing of claims is called a value-added __________ to improve efficiency and reduce expenses.

network

Which of the following health care professionals is permitted to bill a physician when that physician provides direct supervision of procedures/services?

nonphysician practitioner

TRICARE __________ are available 24/7 for advice and assistance with treatment alternatives and to discuss whether a sponsor should see a provider based on a discussion of symptoms, and they will also discuss preventive care and ways to improve a family's health.

nurse advisors

Programs of All-inclusive Care for the Elderly (PACE) use a capitated payment system to provide a comprehensive package of community-based services as an alternative to institutional care for persons age 55 or older who require a(n) __________ level of care.

nursing facility

The Amendment to the HMO Act of 1973 allowed federally qualified HMOs to permit members to __________.

occasionally use non-HMO physicians and be partially reimbursed

Surgeon's charges for inpatient and outpatient surgery are billed according to a global fee, which means that __________ cover(s) presurgical evaluation and management, initial and subsequent hospital visits, surgical procedure, the discharge visit, and uncomplicated postoperative follow-up care in the surgeon's office.

one charge

When the same payer issues the primary, secondary, or supplemental policies, the correct procedure for submitting the claim would be to submit __________.

one claim for all policies

Which claims are organized by month and insurance company after submission to the payer, but for which processing is not complete?

open claims

Which is associated with health care that is provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO?

open-panel HMO

Health insurance plans may include a(n) __________ provision, which means that when the patient has reached that limit for the year, appropriate patient reimbursement to the provider is determined.

out-of-pocket payment

Many physician practices contract out or __________ the delinquent accounts to a full-service collections agency that utilizes collection tactics, including written contacts and multiple calls from professional collectors.

outsource

Some BCBS contracts also include one or more riders, which are special clauses that stipulate additional coverage __________ the standard contract.

over and above

Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work related. Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contacting the provider, who is liable for the __________ because of the provider's failure to disclose that the injury was work-related.

overpayment

The CMS-1500 paper claim was designed to accommodate optical scanning of __________ claims.

paper

Any information communicated by the __________ is considered privileged communication, and HIPAA provisions address the privacy and security of protected health information.

patient to a health care provider

Which is considered a nonphysician practitioner?

physician assistant

First Report of Injury forms are completed by the __________ when treatment for a work-related illness or injury is sought.

physician or other health care provider

Who is required to personally sign the original and all photocopies of reports submitted to the workers' compensation board?

physician or other health care provider

To create flexibility in managed care plans, some HMOs and preferred provider organizations have implemented a(n) __________, under which patients have freedom to use the managed care panel of providers or to self-refer to out-of-network providers.

point-of-service plan

Which are decision-making tools used by providers to determine appropriate health care for specific clinical circumstances?

practice guidelines

Which is a review for medical necessity of inpatient care prior to the patient's admission?

preadmission certification

Which is a review that grants prior approval for reimbursement of a health care service?

preauthorization

Court decisions establish standard use legal decisions that serve as authoritative rules or patterns in future similar cases. The legal term for standard is __________.

precedent

The forerunner of what is known today as the BlueCross plan began in 1929 when Baylor University Hospital in Dallas, Texas, approached teachers in the Dallas school district with a plan that would guarantee up to 21 days of hospitalization per year for subscribers and each of their dependents, in exchange for a $6 annual premium. This was considered a __________ plan.

prepaid

Which is assigned to a TRICARE Prime sponsor and is part of the TRICARE provider network?

primary care manager

Which is the insurance plan responsible for paying health care insurance claims first?

primary insurance

The optical scanning process uses a device that converts __________ characters into text that can be viewed by an optical character reader (OCR).

printed

An advance beneficiary notice of noncoverage (ABN) is a written document provided to a Medicare beneficiary by a supplier, physician, or provider, and the ABN must be presented to the patient __________.

prior to providing the service or treatment

Which is the right of individuals to keep their information from being disclosed to others?

privacy

The BCBS outpatient pretreatment authorization plan (OPAP) requires preauthorization of outpatient physical, occupational, and speech therapy services. Other terms for OPAP include precertification and __________ authorization.

prospective

Medicare calls its remittance advice a(n) __________.

provider remittance notice

Which is the special group that requires states to pay Medicare premiums, deductibles, and coinsurance amounts for individuals whose income is at or below 100 percent of the federal poverty level and whose resources are at or below twice the standard allowed under SSI?

qualified Medicare beneficiaries

Which program helps individuals whose assets are not low enough to qualify them for Medicaid by requiring states to pay their Medicare Part A and B premiums, deductibles, and coinsurance amounts?

qualified Medicare beneficiary program

Which program helps individuals who received Social Security and Medicare because of disability, but who lost their Social Security benefits and free Medicare Part A because they returned to work and their earnings exceed the limit allowed, by requiring states to pay their Medicare Part A premiums?

qualified disabled working individual

Which is the special group that requires states to pay Medicare Part A premiums for certain disabled individuals who lose Medicare coverage because of work?

qualified working disabled individuals

Which is the special group that requires states to pay Medicare Part B premiums for individuals with incomes between 120 percent and 175 percent of the federal poverty level?

qualifying individuals

The TRICARE Management Activity (TMA) coordinates and administers the TRICARE program and is accountable for __________ health care provided to members of the uniformed services and their families.

quality

Which program resulted from the Balanced Budget Act of 1997 (BBA) and requires that quality assurance activities are performed to improve the functioning of Medicare Advantage (Medicare Part C) organizations?

quality assessment and performance improvement (QAPI)

Which is an abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, meaning "who as well for the king as for himself sues in this matter"?

qui tam

A Medicare medical necessity denial is a denial of otherwise covered services that were found to be not __________.

reasonable and necessary

Laws that are implemented as guidelines written by administrative agencies, such as CMS, are called __________.

regulations

Which is another name for a health insurance specialist?

reimbursement specialist

Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider's office has received a(n) __________ from the primary payer.

remittance advice

The Federal Black Lung Program provides medical treatment and other benefits for __________ conditions related to former employment in the nation's coal mines.

respiratory

Which is the term for short-term care provided by another caregiver, so the usual caregiver can rest?

respite care

Nonprofit corporations are charitable, educational, civic, or humanitarian organizations whose profits are __________.

returned to the nonprofit corporation

Which is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees' health status, age, sex, and occupation?

risk pool

Third-party recovery standards for investigation of liability coverage and the process for filing a lien in a potential liability case vary on a federal and state basis. A lien is defined as __________.

securing a debtor's property as security or payment for a debt

Which involves the safekeeping of patient information by controlling access to records, protecting patient information from alteration/destruction/tampering/loss, and providing employee training in HIPAA requirements, which includes the consequences of improper disclosure of patient information?

security

TRICARE regions are served by one or more __________ who assist TRICARE sponsors with health care needs and answer questions about the program.

service centers

BlueCross plans originally covered only hospital bills, and BlueShield plans covered fees for physician services, and there was close cooperation between the plans that resulted in joint ventures where the two corporations were housed in one building. In these joint ventures, BlueCross BlueShield (BCBS) __________.

shared one building and computer services but maintained separate corporate identities

For-profit corporations pay taxes on profits generated by the corporation's enterprises and pay dividends to __________ on after-tax profits.

shareholders

When completing the CMS-1500, enter a __________ for the dollar sign or decimal in all charges or totals and parentheses surrounding the area code in a telephone number.

space

Mary Smith is working full time and enrolled in Medicare Part A at age 65. She decided not to enroll in Medicare Part B at that time because her employer group health insurance coverage reimburses for physician and other outpatient encounters. Mary is eligible to enroll in Medicare Part B anytime during a(n) __________ enrollment period, which is a set time when individuals can sign up for Medicare Part B if they did not enroll when they applied for Medicare Part A.

special

Which is the special group that requires states to pay Medicare Part B premiums for individuals with incomes between 100 and 120 percent of the federal poverty level?

specified low-income Medicare beneficiaries

Which program helps low-income individuals by requiring states to pay their Medicare Part B premiums?

specified low-income Medicare beneficiary

Health care services provided to subscribers by physicians employed by the HMO are associated with a __________. Premiums and other revenue are paid to the HMO, and usually all ambulatory services are provided within HMO corporate buildings.

staff model HMO

The Occupational Safety and Health Act of 1970 created the Occupational Safety and Health Administration (OSHA) to protect employees against injuries from occupational hazards in the workplace. OSHA and its state partners (of approximately 2,100 inspectors) establish protective __________, which are enforced. OSHA also reaches out to employers and employees by providing technical assistance and consultation programs.

standards

In 1965 Congress passed Title 19 of the Social Security Act, establishing a federally mandated, __________-administered medical assistance program for individuals with incomes below the federal poverty level.

state

The portion of the Medicaid program paid by the federal government is called the Federal Medical Assistance Percentage (FMAP) and is determined annually for each state using a formula that compares __________ average per capita income level with the national average.

state

Which is a quasi-public agency that provides workers' compensation insurance coverage to private and public employers and acts as an agent in state workers' compensation cases involving state employees?

state insurance fund

Federal and state __________ are laws passed by legislative bodies, such as federal Congress and state legislatures.

statutes

Record retention is the __________ of documentation for an established period of time, usually mandated by federal and/or state law.

storage

Which is an order of the court that requires a witness to appear at a particular time and place to testify?

subpoena

Which requires documents, such as a patient record, to be produced in court?

subpoena duces tecum

Which refers to the contractual right of a third-party payer to recover health care expenses from a liable party?

subrogation

Which is the financial record source document used by health care providers and other personnel in a physician's office setting to record treated diagnoses and services rendered to the patient during the current visit?

superbill

Which is a licensed physician in good standing who, according to state regulations, engages in the direct management of nonphysician practitioners whose duties are encompassed by that physician's scope of practice?

supervising physician

Federal regulations require Medicaid to establish and maintain a(n) __________ program, which safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services.

surveillance and utilization review

When dealing with delinquent claims, it is important to review records to determine whether the claim was paid, was denied, or is pending. A pending claim is considered in __________.

suspense

If a patient is covered by two different policies, the usual procedure for submitting a claim would be __________.

to submit to the primary payer first, followed by submitting to the secondary after primary payment is received

Which is the official document that contains new and changed Medicare policies and/or procedures that are to be incorporated into a specific CMS program manual?

transmittals

Which is usually offered either by a single insurance plan or as a joint venture among two or more insurance payers and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans?

triple option plan

An account receivable that cannot be collected by the provider or a collection agency is called a bad debt. To deduct a bad debt, the amount must have been __________.

turned over to a collections agency for processing

Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization, are called __________ services.

unauthorized

Which is the practice of submitting multiple CPT codes when just one code should have been submitted?

unbundling

Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment), some hospitals engage in a practice called __________, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the purpose of illegally increasing reimbursement.

upcoding

Which is a method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care or after care has been provided?

utilization management

A(n) __________ claim is one that Medicaid should not have originally paid, and results in a deduction from the lump-sum payment made to the provider.

voided

BlueShield plans were created as the result of a resolution passed by the House of Delegates at an American Medical Association meeting in 1938. This resolution supported the concept of __________ health insurance that would encourage physicians to cooperate with prepaid health care plans.

voluntary

The Health Information Technology for Economic and Clinical Health Act was included in the American Recovery and Reinvestment Act of 2009 and amended the Public Health Service Act to establish the __________.

Office of National Coordinator for HIT

Effective July 31, 2001, the Energy Employees Occupational Illness Compensation Program (EEOICP) started providing benefits to eligible employees and former employees of the Department of Energy, its contractors and subcontractors, or to certain survivors of such individuals, and to certain beneficiaries of the Radiation Exposure Compensation Act. Which is responsible for adjudicating and administering claims filed by employees, former employees, or certain qualified survivors?

Office of Workers' Compensation Programs (OWCP)

Which increased resources available to CMS to combat abuse, fraud, and waste in the Medicaid program, creating the Medicare Improvement Program (MIP)?

Deficit Reduction Act of 2005

Which amended the Truth in Lending Act and requires prompt written acknowledgment of consumer billing complaints and investigation of billing errors by creditors?

Fair Credit Billing Act

Which protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services?

Fair Credit Reporting Act

Which amended the Truth in Lending Act and requires credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-ended credit and charge accounts and under other circumstances?

Fair Credit and Charge Card Disclosure Act

Which states that third-party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred for personal, family, or household purposes?

Fair Debt Collection Practices Act

Which unique identifier is assigned to third-party payers and has 10 numeric positions, including a check digit as the tenth position?

HPID

Which program measures, monitors, and reduces the incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals?

HPMP

Which organization offers the CMBS exam?

MAB

Which allows providers to electronically access the state's eligibility file to verify Medicaid eligibility?

MEVS

Which authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program?

MIP

Which is a private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for consideration when selecting a managed care plan?

National Committee for Quality Assurance

Which consists of audits implemented by DHHS that examines the billing practices of physicians at teaching hospitals with the focus on compliance with the Medicare rule affecting payment for physician services provided by residents and whether the level of the physician service was coded and billed properly?

PATH

Which program measures improper payments in the Medicaid program and the State Children's Health Insurance Program (SCHIP)?

PERM

A simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass __________ programs offered by public health clinics and other entities that bill Medicare payers.

PPV and influenza virus vaccination

Which program was implemented to find and correct improper Medicare payments paid to health care providers participating in fee-for-service Medicare?

Recovery Audit Contractor (RAC)

Which is a legal action that can be used to recover a debt and is usually a last resort for a medical practice?

litigation

When applying the birthday rule, if policyholders have identical birthdays, the policy in effect the __________ is considered primary.

longest

Temporary disability claims cover health care treatment for illness and injuries as well as payment for __________.

lost wages

A physician-hospital organization (PHO) is owned by hospital(s) and physician groups that obtain managed care plan contracts. The physicians __________ and provide health care services to plan members.

maintain their own practices

BCBS fee-for-service __________ coverage includes additional benefits, such as office visits, physical and occupational therapy, and mental health encounters.

major medical

The American Recovery and Reinvestment Act of 2009 (ARRA) protects whistleblowers, who are individuals that __________ covered by the Act.

make specified disclosures relating to funds

Participating providers contract to participate in a BCBS plan's preferred provider network (PPN), which is a program that requires providers to adhere to __________ care provisions.

managed

Vocational rehabilitation claims cover expenses for vocational retraining for both temporary and permanent disability cases. Vocational rehabilitation retrains an ill or injured employee so he or she can return to the workforce. The employee __________ of resuming the position held prior to the illness or injury.

may be incapable

Diagnoses must be entered in the patient's record to validate __________ of procedures or services billed.

medical necessity

Which act allows employees to continue health care coverage beyond the benefit termination date?

Consolidated Omnibus Budget Reconciliation Act of 1985

Which act governs privacy, security, and electronic transactions standards for health care information and was implemented to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs?

HIPAA

Which act provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the Great Depression and World War II (1929 to 1945)?

Hill-Burton Act

Which classification system was developed by the World Health Organization and used to collect data for statistical purposes?

International Classification of Diseases

The Medicare Contracting Reform initiative (MCR) was established to integrate the administration of Medicare Parts A and B fee-for-service benefits with new entities called __________.

Medicare administrative contractors

The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the __________ and created standards to assess managed care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators.

National Committee for Quality Assurance (NCQA)

An integrated delivery system (IDS) is an organization of __________ that offer joint health care services to subscribers.

affiliated providers' sites

POR progress notes are documented for each problem assigned to the patient, using the SOAP format. When the patient states, "I have had a stuffy nose and sore throat for about one week," the provider documents the statement in the __________ portion of the progress note.

Subjective

Which is a voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law?

accreditation

A medical foundation is a nonprofit organization that contracts with and __________ the clinical and business assets of physician practices.

acquires

Total practice management software is used to generate the electronic medical record, automating which of the following medical practice functions?

appointment scheduling

Which guarantees repayment for financial losses resulting from an employee's act or failure to act?

bonding insurance

A triple option plan is also called a __________ or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator.

cafeteria plan

Which is associated with health care that is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO?

closed-panel HMO

Which was introduced in 2000 as a way to encourage individuals to locate the best health care at the lowest possible price with the goal of holding down health care costs?

consumer-driven health plans

The primary purpose of the patient record is to provide for __________ of care, which involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment.

continuity

Which provides coverage for catastrophic or prolonged illnesses and injuries?

major medical insurance

Which involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity of performing that procedure or service?

medical necessity

The CHAMPUS Reform Initiative (CRI) of 1988 resulted in a new program called TRICARE, which includes __________.

multiple options

Which are published by CMS and used to report procedures, services, and supplies not classified in CPT?

national codes

If the insurance plan has a hold harmless clause, it means that the patient is

not responsible for paying what the insurance plan denies.

The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) utilizes information from a __________ to classify patients into distinct groups based on clinical characteristics and expected resource needs.

patient assessment instrument

During completion of a student internship, the facility will likely require students to sign a nondisclosure agreement to protect __________.

patient confidentiality

Which documents health care services provided to a patient and includes patient demographic (or identification) data, documentation to support diagnoses and justify treatment provided, and the results of treatment provided?

patient record

Which serves as a system of checks and balances for labor and management?

third-party administrator

A claims examiner is employed by a

third-party payer to review claims.

Which type of insurance has as its goal providing every individual with access to health coverage, regardless of the system implemented to achieve that goal?

universal health insurance