322- Chapter 12- Health Insurance Essentials

A review of individual cases by a committee to make sure that services are medically necessary 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 document sent by the insurance company to the provider and the patient explaining the allowed charge, the amount reimbursed for services, and the patient's financial responsibilities is: -explanation of benefits. -fee schedule. -claim. -policy.

explanation of benefits.- An explanation of benefits (EOB) is a document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient's financial responsibilities.

A list of the fixed fees for services is a: -explanation of benefits. -fee schedule. -claim. -policy.

fee schedule.- A fee schedule is a list of fixed fees for services.

In some managed care plans referrals to a specialist must be approved by the: -beneficiary. -gatekeeper. -third-party administrator. -policyholder.

gatekeeper.- Patients are required to select a PCP, who acts as the gatekeeper to more specialized care with health maintenance organizations.

The Affordable Care Act includes which of the following categories of essential health benefits? -Emergency services -Laboratory services -Prescription drugs -All are correct

All are correct- The Affordable Care Act (ACA) requires all health plans to cover essential health benefits. There are 10 categories of essential health benefits:· Ambulatory patient services· Emergency services· Hospitalization· Maternity and newborn care· Mental health and substance use disorder services· Rehabilitative and habilitative services and devices· Prescription drugs· Laboratory services· Preventive and wellness services and chronic disease management· Pediatric services, including oral and vision care

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

Medicaid.- Medicaid is a federal- and state-sponsored health insurance program for the medically indigent.

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 are correct

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 provider. A regular referral usually takes 3 to 10 working days for review and approval. This type of referral is used when the provider 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.

Which type of referral is usually processed immediately? -Regular -Urgent -STAT -All are correct

STAT- A STAT referral can be approved by telephone immediately after it is faxed to the utilization review department. A STAT referral is used in an emergency situation as indicated by the provider.

A provider can choose whether to accept Medicaid patients.

True- A provider may accept or decline to treat Medicaid patients. The provider who accepts Medicaid patients automatically agrees to accept Medicaid payment as payment in full for covered services.

A formal request for payment from an insurance company for services provided is: -explanation of benefits. -fee schedule. -claim. -policy.

claim.- In order for the insurance carrier to pay for services, a claim must be submitted. The claim is reviewed by the insurance company to determine if the services provided are covered under the policy.

The amount of money the policyholder pays per claim before the insurance company will pay on the claim is known as the: -exclusion. -premium. -deductible. -remittance.

deductible.- A deductible is a specific amount of money a patient must pay out of pocket before the insurance carrier begins paying. The deductible amount is met on a yearly or per-incident basis.

Someone who is poor, needy, or impoverished is considered: -uninsurable. -a cash only patient. -indigent. -None are correct

indigent.- Indigent refers to someone who is poor, needy, impoverished.

The provider who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ______ provider. -participating -paying -provider -None are correct

participating- A participating provider is a physician or other healthcare provider who enters into a contract with a specific insurance company or program and by doing so agrees to abide by certain rules and regulations set forth by that particular third-party payer.

A written agreement between two parties, where one party agrees to pay another party if certain specified circumstances occur is a: -policy. -preauthorization. -referral. -fee schedule.

policy.- A policy is a written agreement between two parties, in which one party (the insurance company) agrees to pay another party (the patient) if certain specified circumstances occur.

A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services is: -preauthorization. -referral. -precertification -None are correct

preauthorization.- Preauthorization is a process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services.

The amount of money paid to keep an insurance policy in force is the: -premium. -deductible. -copayment. -co-insurance.

premium.- A premium is the periodic (monthly, quarterly, or annual) payment of a specific sum of money to an insurance company, for which the insurer in return agrees to provide certain benefits.

Service provided to stop certain conditions from occurring or to lead to an early diagnosis are considered: -elective. -preventive. -medically necessary. -provider network.

preventive.- Preventive care includes services provided to help prevent certain illnesses or that lead to an early diagnosis.

An order from a primary care provider for the patient to see a specialist is a(n): -preauthorization. -policy. -referral. -health insurance exchange.

referral.- A referral is an order from a primary care provider for the patient to see a specialist or to get certain medical services.

Organizations that fund their own insurance programs offer their employees: -group coverage. -individual coverage. -government plans. -self-funded plans.

self-funded plans.- When companies or organizations have an employee base large enough to allow them to fund their own insurance program, it is called a self-funded plan.

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 are correct

All are correct- The medical assistant should always verify the effective date, or date of 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 MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility? -Medicare/Medicaid -PPOs -HMOs -BC/BS -IPA

HMOs- HMO plans typically have the lowest monthly premiums among other health insurance plans, with lower patient financial responsibility. There are different types of managed care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) that provide healthcare in return for scheduled payments and that coordinate healthcare through a defined network of primary care providers (PCPs), hospitals, and other providers. BC/BS offers incentive contracts to healthcare providers. PARs agree to write off the difference or balance between the amount charged by the provider and the approved fee established by the insurance plan. They also agree to bill the patient only for the deductible and copayment/co-insurance amounts that are based on BC/BS allowed rates, and the full charge for any uncovered services.

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.

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.

Nearly all of the provider's income is derived from the insurance payments received for services rendered.

True- Nearly all of the provider's income is derived from the insurance payments received for services rendered.

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.

worker's 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. -Providers' 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.

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 copayment from the patient.

There are no government managed care plans.

False- In an effort to reduce costs and increase the delivery of efficient care, Medicare and many Medicaid programs offer their members the option to join a managed care plan. These managed care plans must cover all services that would be covered under Medicare or Medicaid. The identification cards will look just like the ones issued to people, not on Medicare or Medicaid. The government managed care plan may have a copayment that the patient would be responsible for.

A certain percentage of the allowed amount that the policyholder is responsible for is: -premium. -deductible. -copayment. -co-insurance.

co-insurance.- After the deductible has been met, the policyholder may need to pay a certain percentage of the bill and the insurance company pays the rest. This is called co-insurance.

A set dollar amount that the policyholder must pay for each office visit is: -premium. -deductible. -copayment. -co-insurance.

copayment.- A copayment is a set dollar amount that the policyholder must pay for each office visit.

A designated person who receives funds from an insurance policy is: -beneficiary. -claimant. -gatekeeper. -indigent.

beneficiary.- A beneficiary is a designated person who receives funds from an insurance policy.

Services that are needed to improve the patient's current health are considered: -elective. -preventive. -medically necessary. -provider network.

medically necessary.- Medically necessary services are those that are necessary to improve the patient's current health.

If Mr. Jones's insurance has a $500 deductible and then pays 80% of the charges, how much will his policy pay on his bill of $4,359? -$3027.20 -$3087.20 -$3447.20 -$3487.20

$3087.20- $4359 - $500= $3859 $3,859 x 0.8 = $3,087.20.

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.- Limitations on referrals and on access to specialized care are disadvantages of managed care.

Which of the following managed care plans require preauthorization for medical services such as surgery? -HMOs -PPOs -EPOs -HMOs and PPOs -All are correct

All are correct- All managed care plans, including HMOs, PPOs, and EPOs, require preauthorization for medical services such as surgery, expensive medical tests, and medication therapy.

Medigap polices cover which of the following? -Medicare deductible -Medicare co-insurance -Services not covered under Medicare -All are correct

All are correct- Medigap policies cover the deductible, co-insurance, and services not covered under Medicare.

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.

False- Most health insurance plans do not cover "elective" procedures.

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

False- TRICARE is for active military, not veterans.

Which part of Medicare covers inpatient hospital charges? -Part A -Part B -Part C -Part D

Part A- Part A covers inpatient hospital care, skilled nursing facilities, home healthcare, and hospice services.

Veterans of the U.S. armed forces may be covered by: -CHAMPVA. -TRICARE. -workers' compensation. -Blue Cross/Blue Shield.

TRICARE.- 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.