Medical Insurance Billing & Coding Week 2: Quiz
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) credentialing committee review. peer review committee evaluation. utilization review. audit committee review.
utilization review. * A utilization review is a review of individual cases by a committee to make sure services are medically necessary and to study how providers use medical care resources.
A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called an individual policy. workers' compensation. unemployment insurance. disability insurance.
workers' compensation. * Workers' compensation is insurance against liability imposed on certain employers to pay benefits and furnish care to injured employees and to pay benefits to dependents of employees killed in the course of or because of circumstances arising from their employment.
Which of the following is not a disadvantage of managed care? Authorized services usually are covered. Physicians' choices in the treatment of patients can be limited. More paperwork may be necessary. Reimbursement is historically less than with traditional health insurance.
Authorized services usually are covered. * Coverage of authorized services is an advantage of managed care.
Most of today's health insurance policies cover which of the following? Preventive care Procedures deemed medically necessary Elective procedures All of the above Both A and B
Both A and B * Health insurance plans typically cover health services and procedures that are deemed medically necessary, or health services that are required to improve the patient's current health condition. Most of today's health insurance policies cover preventive care, which includes services provided to help prevent certain illnesses or that lead to an early diagnosis. Most insurance policies do not cover elective procedures, or medical procedures that will not improve the patient's current health, such as a facelift.
Which of the following plans require healthcare providers to become participating providers? All government-sponsored health plans Most privately sponsored health plans Indemnity health insurance plans Both A and B All of the above
Both A and B * With all government-sponsored health plans and most privately sponsored health plans, healthcare providers must become participating providers (PARs): providers that are contracted with the insurance plan. Indemnity plans are traditional health insurance plans that pay for all or a share of the cost of covered services, regardless of which physician, hospital, or other licensed healthcare provider is used.
Veterans of the U.S. armed forces may be covered by CHAMPVA. TRICARE. workers' compensation. Blue Cross/Blue Shield.
CHAMPVA. * CHAMPVA, which is similar to TRICARE, is a health benefits program for the spouses and dependent children of veterans suffering total, permanent, service-connected disabilities and for surviving spouses and dependent children of veterans who died as a result of service-related disabilities.
Which part of Medicare covers prescription drug services? A B C D
D * Part D offers Medicare recipients the option of choosing, at a reduced cost, a plan that pays for prescription drugs with just a small co-payment from the patient.
Which of the following expenses would be paid by Medicare Part B? Inpatient hospital charges Hospice services Physician's office visits Home healthcare charges
Physician's office visits * Medicare Part B covers physician's office visits, outpatient hospital care, medical equipment, and other medical services.
Which type of referral is usually processed immediately? Regular Urgent STAT All of the above
STAT
The maximum amount of money third-party payers will pay for a specific procedure or service is called the benefit. allowable amount. allowed service. incurred amount.
allowable amount. * An allowable amount is the maximum amount of money many third-party payers will pay for a specific procedure or service.
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. capitation self-insured managed care fee-for-service
capitation * A capitation plan is a payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for patients enrolled during a specific period, no matter what services are received or how many visits are made.
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? $3,809 $2,809 $3,980 $3,900
$3,809 * $4,359 - $500 deductible - $50 surgery co-pay = $3,809.
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? $3027.20 $3047.20 $3047.00 $3067.50
$3047.20 * $3,809 ´ 0.8 = $3,047.20.
Which of the following individuals would not normally be eligible for Medicare? A 66-year-old retired woman A blind teenager A 23-year-old recipient of AFDC A person on dialysis
A 23-year-old recipient of AFDC * A 23-year-old recipient of AFDC would be eligible for Medicaid, not Medicare.
Which of the following is not an advantage of managed care? Healthcare costs are usually contained. Access to specialized care and referrals is limited. Most preventive medical treatment is covered. 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 indemnity schedules. service benefit plans. relative value studies. All of the above
All of the above * Health insurance benefits can be determined by a number of sources.
Which of the following managed care plans require preauthorization for medical services such as surgery? HMOs PPOs EPOs Both A and B All of the above
All of the above * All managed care plans, including HMOs, PPOs, and EPOs, require preauthorization for medical services such as surgery, expensive medical tests, and medication therapy.
The medical assistant should always verify which of the following prior to the patient's appointment? Eligibility Benefits and exclusions Effective date of insurance All of the above
All of the above * The medical assistant should always verify the effective date, or date the insurance coverage began, and confirm that the patient is covered on the date the medical services will be rendered. The medical assistant should make it a practice to review the online insurance Web portal, which can verify insurance eligibility, benefits, and exclusions before the patient's appointment with the provider.
Which of the following are not reviewed by a utilization review committee? Physician referrals Cases of emergency department visits and urgent care Individual cases to ensure medical care services are medically necessary Fees for services provided
Fees for services provided * A utilization review committee reviews individual cases to make certain that medical care services are medically necessary (the specificity of diagnosis coding is critical) and to study how providers use medical care resources. This committee also reviews all physician referrals and cases of emergency department visits and urgent care.
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? Staff model Independent practice association Group model None of the above
Independent practice association * An independent practice association has general or family practice physicians or a physician group that practices independently and may contract with several IPAs.
Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium? Part A Part B Part C Part D
Part B * Part B is medical insurance for ambulatory care, including primary care and specialists for which patients are required to pay a monthly premium; Part B functions similar to a PPO in that patients can visit any specialist without a referral. Part A is hospital insurance for qualified Medicare participants and is financed with special contributions deducted from employed individuals' salaries, with matching contributions from their employers. Part C is an option for Medicare-qualified patients to turn their Part A and Part B benefits into a privately sponsored plan that can offer some additional benefits. Part D is a prescription drug program offered to Medicare-qualified individuals that requires an additional monthly premium.
Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department? Regular referral Urgent referral STAT referral All of the above
STAT referral * A STAT referral can be approved online when it is submitted to the utilization review department through the provider's Web portal. A STAT referral is used in an emergency situation as indicated by the physician. A regular referral usually takes 3 to 10 working days for review and approval. This type of referral is used when the physician believes that the patient must see a specialist to continue treatment. An urgent referral usually takes about 24 hours for approval. This type of referral is used when an urgent but not life-threatening situation occurs.
Dependents of military personnel are covered by which of the following government-sponsored health insurance plans? Medicaid Medicare TRICARE CHAMPVA Workers' compensation
TRICARE Dependents of military personnel are covered by TRICARE. A low-income patient may be eligible for Medicaid. Surviving spouses and dependent children of veterans who died in the line of duty are covered by the Civilian Health and Medical Program of the Veterans Administration (CHAMPVA). Some wage earners are protected against the loss of wages and the cost of medical care resulting from an occupational accident, disease, or disability through workers' compensation insurance.
Health insurance designed for military dependents and retired military personnel is called CHAMPVA. TRICARE. Medicare. Medicaid.
TRICARE. * TRICARE is the military's comprehensive healthcare program for family members of active duty personnel, military retirees and their eligible family members under age 65, and survivors of all uniformed services.
The "cafeteria-style" plan allows employers to choose the benefits they want for their respective employees. True False
True * The Cafeteria Style plan allows employers to choose the benefits they want for their respective employees.