Ch 12

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 False

False

There are no government managed care plans. True False

False

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

d. All are correct

RBRVS consists of three parts, including which of the following? a. Provider work b. Charge-based professional liability expenses c. Charge-based overhead d. All are correct

d. All are correct

The Affordable Care Act includes which of the following categories of essential health benefits? a. Emergency services b. Laboratory services c. Prescription drugs d. All are correct

d. All are correct

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 are correct

d. All are correct

Which of the following services must be covered by Medicaid in each state? a. Family planning services b. Transportation of medical care c. Nurse Midwife services d. All are correct

d. All are correct

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

d. policy.

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

A. D

A provider can choose whether to accept Medicaid patients. True False

True

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

True

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

True

Employee group plans usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected. However, these employee 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. Both statements are false. d. The first statement is false; the second is true.

a. The first statement is true; the second is false.

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

a. fee schedule.

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

a. workers' compensation

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. Out-of-pocket expenses tend to be less than traditional insurance. d. Most preventive medical treatment is covered.

b. Access to specialized care and referrals is limited.

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

b. Authorized services usually are covered.

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: a. policy. b. explanation of benefits. c. fee schedule. d. claim.

b. explanation of benefits

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

b. preventive.

The allowed amount for Medicare charges is determined using: a. provider network. b. resource-based relative value scale. c. utilization management. d. fee schedule.

b. resource-based relative value scale.

Which type of referral is usually processed immediately? a. Regular b. Urgent c. STAT d. All are correct

c. STAT

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

c. premium

A review of individual cases by a committee to make sure that services are medically necessary is called a(n): a. credentialing committee review. b. audit committee review. c. utilization review. d. peer review committee evaluation.

c. utilization review.

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. All government-sponsored health plans and most privately sponsored health plans e. All are correct

d. All government-sponsored health plans and most privately sponsored health plans

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

d. Physician's office visits

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

d. TRICARE.

A designated person who receives funds from an insurance policy is: a. gatekeeper. b. claimant. c. indigent. d. beneficiary.

d. beneficiary.

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

d. copayment.

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

d. referral.

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

b. Medicaid