Insurance Review (Red Mod- Fortis)

Health insurance typically covers services and procedures considered medically necessary. Most insurance policies also cover elective procedures, such as certain cosmetic surgeries, that are not considered medically necessary True or False

False

Which type of HMO meodel 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 (IPA) c. group model d. none of the above

independent practice association (IPA)

Which type of protection, formerly called catastrophic insurance, provides coverage for especially large medical bills resulting from a prolonged illness? a. disability protection b. basic medical c. hospitalization d. major medical

major medical

Insurance that protects a person in the event of a certain type of accident, such as an automobile or plane crash, is called ____ insurance. a. liability b. life c. special risk d. long-term

special risk

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

third-party payers

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. credentialing committee review b. peer review committee evaluation c. utilization review d. audit committee review

utilization review

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. $3,809 b. $2,809 c. $3,980 d. $3,900

$3,809

If Mr. Jones's insurance has a $500 deductible, 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. $3027.20 b. $3047.20 c. $3047.00 d. $3067.50

$3047.20

Veterans of the U.S. Armed Forces may be covered by: a. CHAMPVA b. TRICARE c. worker's compensation d. Blue Cross-Blue Shield

CHAMPVA

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

D

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

Medicaid

Which type of referral is usually processed immediately? a. regular b. urgent c. STAT d. all of the above

STAT

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

True

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

True

The purpose of health insurance is to help individuals and families offset the costs of medical care True or False

True

The so-called cafeteria style plan is one in which the employer can choose the benefits that the employer wants for their respective employees True or False

True

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

a 23-year-old recipient of Aid to Families with Dependent Children (AFDC)

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

a participating

Which of the following is not an advantage of managed care? a. healthcare costs are usually contained b. access to specialized care and referrals is limited c. most preventive medical treatment is covered d. out of pocket expenses tend to be less than traditional insurance

access to specialized care and referrals is limited

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

all of the above

Which of the following is a type of insurance verification method? a. asking about the patient's insurance during the initial appointment telephone call b. copying the insurance card when the patient arrives for an appointment c. calling the carrier to verify benefits and eligibility d. all of the above

all of the above

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

allowed charge

Which of the following is not an advantage of managed care? a. authorized services usually are covered b. physicians' choices in the treatment of patients can be limited c. more paperwork may be necessary d. reimbursement is historically less than with traditional health insurance

authorized services usually are covered

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

TRICARE

The individual entitled to receive benefits from an insurance policy or program is called the: a. beneficiary b. insured c. payer d. carrier

beneficiary

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. benefit b. deductible c. premium d. co-pay

benefits

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. capitation b. self-insured c. managed care d. fee-for-service

capitation

The amount of money that 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. premium c. deductible d. remittance

deductible

The TRICARE option that is similar to a preferred provider network is TRICARE: a. prime b. extra c. standard d. basic

extra

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. group coverage b. individual coverage c. a government plan d. a self-insured plan

group coverage

Which of the following expenses would be paid by Medicare Part B? a. inpatient hospital charges b. hospice services c. physician's office visits d. home healthcare charges

physician's office visits

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

premium

A document that explains what expenses were paid after submission to Medicaid and sent to the physician's office is called a(n): a. remittance advice b., estimate benefits c. explanation of benefits d. utilization review

remittance advice

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

self-insured plans

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. workers' compensation c. unemployment insurance d. disability insurance

workers' compensation