Chapter 14: The Basics of Health Insurance (M.O.M)

A review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called a(n) a.) utilization review. b.) credentialing committee review. c.) audit committee review. d.) peer review committee evaluation.

a

Employee-sponsored group policies usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected. However, these employee-sponsored group health insurance plans offer limited benefits, and healthcare access is limited to healthcare providers that are contracted with them. a.) The first statement is true; the second is false. b.) Both statements are true. c.) The first statement is false; the second is true. d.) Both statements are false.

a

The amount of money paid to keep an insurance policy in force is the a.) premium b.) deductible c.) co-pay d.) co-insurance

a

The physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ______ provider. a.) participating b.) paying c.) physician d.) None of the above

a

This is the healthcare program for the Department of Defense. a.) Tricare b.) Blue Cross Blue Shield c.) Worker's Compensation d.) Medicaid

a

Who is the first party? a.) The patient b.) The doctor c.) The insurance company d.) None of the above

a

A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called a.) an individual policy b.) unemployment insurance c.) workers' compensation d.) disability insurance

c

America's oldest and largest system of privately sponsored insurers is.. a.) AETNA b.) Harvard Health c.) Blue Cross/Blue Shield d.) Mass Health

c

Dependents of military personnel are covered by which of the following government-sponsored health insurance plans? a.) Medicare b.) CHAMPVA c.) TRICARE d.) Workers' compensation e.) Medicaid

c

Entities that make payment on an obligation or debt but are not parties of the contract that created the debt are called a.) capitation b.) riders c.) third-party payers d.) service benefit plans

c

The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage is called the a.) premium b.) co-pay c.) benefits d.) deductible

c

The federal- and state-sponsored health insurance program for the medically indigent is called a.) Medigap b.) MediCal c.) Medicaid d.) Medicare

c

Which type of referral is usually processed immediately? a.) Regular b.) Urgent c.) STAT d.) All of the above

c

Most of today's health insurance policies cover which of the following? a.) Preventive care b.) Procedures deemed medically necessary c.) Elective procedures d.) All of the above e.) Both A and B

e

Which of the following managed care plans require preauthorization for medical services such as surgery? a.) HMOs b.) PPOs c.) EPOs d.) Both A and B e.) All of the above

e

A physician can choose whether to accept Medicaid patients. True or False

true

The "cafeteria-style" plan allows employers to choose the benefits they want for their respective employees. True or False

true

A payment method in which providers are paid for each individual enrolled in a plan, regardless of whether the person sees the provider that month, is called a ______ plan. a.) self-insured b.) managed care c.) fee-for-service d.) capitation

d

A program that pays the medical bills for people with job-related injuries or illnesses is called... a.) PPO b.) Medicaid c.) Medicare d.) Worker's Compensation

d

Health insurance benefits are determined by a.) indemnity schedules b.) service benefit plans c.) relative value studies d.) All of the above

d

If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay, how much will his insurance pay on his bill of $4,359? a.) $2.809 b.) $3,980 c.) $3,900 d.) $3,809

d

In class, you were asked to read an article after you took your quiz on insurance terms. What was that article about? a.) TRICARE b.) CHAMPVA c.) Medicaid d.) Managed Care Plans

d

Medigap polices cover which of the following? a.) Any services not covered under Medicare b.) Any services not covered under Major medical c.) Difference between major medical reimbursement and patient financial responsibilities d.) Difference between Medicare reimbursement and patient financial responsibilities

d

Organizations that fund their own insurance programs offer their employees a.) individual coverage. b.) government plans. c.) group coverage. d.) self-funded plans.

d

The maximum amount of money third-party payers will pay for a specific procedure or service is called the a.) benefit b.) incurred amount c.) allowed service d.) allowable amount

d

The medical assistant should always verify which of the following prior to the patient's appointment? a.) Eligibility b.) Benefits and exclusions c.) Effective date of insurance d.) All of the above

d

This type of referral takes hours. a.) urgent b.) regular c.) emergency d.) stat

d

Which of the following pays the hospital surgical room fee? a.) Disability b.) Basic medical c.) Surgical d.) Hospital e.) Both C and D

d

Which of the following plans require healthcare providers to become participating providers? a.) All government-sponsored health plans b.) Most privately sponsored health plans c.) Indemnity health insurance plans d.) Both A and B e.) All of the above

d

Which part of Medicare covers prescription drug services? a.) A b.) C c.) B d.) D

d

Who is the third party? a.) patient b.) guarantor c.) provider d.) insurance company

d

We spoke in class about "real life" office situations. What happens if the insurance company denies a claim? a.) you can appeal it b.) then the patient pays for it c.) the second party absorbs the cost d.) none of the above

a

When a claim is denied after an appeal, what happens? a.) it goes into a peer to peer with the doctor b.) a written request must be sent to the third party c.) the patient must absorb the cost d.) the second party must absorb the cost

a

Which of the following are not reviewed by a utilization review committee? a.) Fees for services provided b.) Physician referrals c.) Cases of emergency department visits and urgent care d.) Individual cases to ensure medical care services are medically necessary

a

Which of the following individuals would not normally be eligible for Medicare? a.) A 23-year-old recipient of AFDC b.) A person on dialysis c.) A 66-year-old retired woman d.) A blind teenager

a

Most insurance policies also cover "elective" procedures, such as certain cosmetic surgeries, that are not considered medically necessary. True or False

False

TRICARE is a form of government insurance for veterans of the U.S. armed forces. True or False

False

Nearly all of the physician's income is derived from the insurance payments received for services rendered. True or False

True

Which of the following is not an advantage of managed care? a.) Access to specialized care and referrals is limited. b.) Most preventive medical treatment is covered. c.) Out-of-pocket expenses tend to be less than traditional insurance. d.) Healthcare costs are usually contained.

a

Health insurance designed for military dependents and retired military personnel is called a.) Medicaid b.) TRICARE c.) CHAMPVA d.) Medicare

b

If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay and then pays 80% of the charges, how much will his policy pay on his bill of $4,359? a.) $3047.00 b.) $3047.20 c.) $3067.50 d.) $3027.20

b

The amount of money the policyholder pays per claim or per accident toward the total amount of an insured loss before the company will pay on the claim is known as the a.) exclusion b.) deductibile c.) remittance d.) premium

b

This process includes notifying the insurance company for approval prior to a procedure. a.) allowable charge b.) preauthorization c.) reimbursement d.) obtaining a deductible

b

Which type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own offices? a.) Staff model b.) Independent practice association c.) Group model d.) None of the above

b

Who is the second party? a.) the patient b.) the doctor, hospital or clinic c.) the insurance carrier d.) none of the above

b

A policy that covers a number of people under a single master contract issued to the employer or to an association with which they are affiliated and that is not self-funded is usually called a.) individual policy b.) government plan c.) group policy d.) self-insured plan

c

Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium? a.) Part C b.) Part A c.) Part B d.) Part D

c

Veterans of the U.S. armed forces may be covered by a.) TRICARE b.) Blue Cross/ Blue Shield c.) CHAMPVA d.) workers' compensation

c

What increased the quality, availability, and affordability of private and public health insurance for more than 44 million uninsured Americans? a.) HIPAA b.) The Privacy Rule c.) The Affordable Care Act d.) The Security Rule

c

Which of the following HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network? a.) Group model b.) IPA c.) Staff model d.) PPO

c

Which of the following expenses would be paid by Medicare Part B? a.) Home healthcare charges b.) Inpatient hospital charges c.) Physician's office visits d.) Hospice services

c

Which of the following is not a disadvantage of managed care? a.) More paperwork may be necessary. b.) Physicians' choices in the treatment of patients can be limited. c.) Authorized services usually are covered. d.) Reimbursement is historically less than with traditional health insurance.

c

Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department? a.) Regular referral b.) Urgent referral c.) STAT referral d.) All of the above

c