Chapter 4

What was the first type of insurance created? accident, basic medical, dental, vision

C) Accident insurance

Who most frequently files insurances claims and handles insurers's pyaments to a medical practice?

C) Medical Assistant

The prepaid concept became the foundation for _____insurance. A. Aetna b. Prudential c. State Farm d. Blue Cross

D. Blue Cross

The average fee a physician charges for a service or procedure is the___fee. A. customary B. reasonable C. prevailing D. usual

D. usual

All medical practices have to cover worker's compenstation cases

False

After World War 2, group health insurance became a commonly accepted employment benefit.

True

Blue Cross/Blue Shield is one large corporation

True

Expenses such as routine eye examinations or dental care not covered by an insurance company are called exlusions.

True

It is almost certain that insurance processing in the twenty-first century will be entirely on-line, with insurers, hospitals, and doctors all contributing electronically to a patient's record.

True

It is likely that all claims in the United States will eventually be filed electronically.

True

Medicaid is an insurance program

True

Older or disabled patients who have Medicare and cannot pay the difference between the bill and the Medicare payment qualify for Medi/Medi

True

Outpatient care mena that patient is not confined to the hospital for treatment

True

Some insurers will not pay a claim unless it is filed within 6 months of the date of service

True

The Blue Cross/Blue Shield service beneift policy provides payment in full for all services it covers.

True

The Health Care Financing Administration (HCFA) is the most common insurance claim form.

True

The concept of usual, customary, and reasonable (UCR) fees was originally developed by Congress to pay medical insurance claims under Medicare.

True

CHAMPUS was created b/c:

a. the Korean War created a need for medical services for families of military personnel

Which statement is true about CHAMPUS/TRICARE?

a. the person in uniform is not eligible for paid medical care until he retires

Which of the following applies to a physician who has an accepting assignment with Medicaid?

a. the physician can bill the patient for services that Medicaid does not cover

Which of the following is an accurate statement about participating versus non participating doctors?

d. a 'par fee' schedule outlines the fees a participating doctor can charge

Which of the following applies to payment of CHAMPUS/TRICARE OR CHAMPVA benefits?

d. a patient who lives 40 miles or more from a military base does not need advance authorization

In most cases, the insurer pays an annual cost or___for health care insurance

premium

The Physicians' Current Procedural Terminology (CPT) manual provides:

procedures codes

The person whose name the insurance is carried in is called the?

subscriber

The first national health insurance for American age 65 and older is:

Medicare

The first group coverage emerged in a. 1929 b. 1943 c. 1847 d. 1965

1929

In a typical medical practice, insurance claims are filed:

7 to 10 business days from the date of service

Health insurance was first offered in hte United States when? 1847, 1929, 1943, 1965

A) 1847

Health insurance first became an employment benefit b/c: a. a group of school teachers in Dallas, Texas joined forces and requested it b. a World War 2 and a 'hold ;the line' wage freeze c. there was a financial need to keep health care costs down d. there was no coverage for the elderly population who retired

B. a World War 2 and a hold the line wage freeze

An organization that provides pain relief to termially ill patients and supports these patients and their families is a:

B. hospice

The goal of Blue Cross/Blue shiled was to: A. cover only the frequesnt disasters of the era B. coverlost income b/c of a disability C. make health insurance accessible to as many people as possible D. negotiate for fringe benefits of employment

C. make health insurance accessible to as many people as possible

When an insurance claims department compares the fee the doctor charges with the benefits provided by the patient's health insurance, it is called the: a. payment of benefits b. review of medical necessity c. review for allowable benefits d. explanation of benefits

C. review for allowable benefits

Fold the HCFA-1500 form for OCR before mailing

False-DO Not fold

Medicare covers all health care expenses

False-Medicare does not cover all all health care expenses

Generally, disability insurance is less expensive than life, home, automobile insurance.

False-More expensive

A patient belongine to an HMO does not need pre-approval or authorization for inpatient surgery from the primary care physician or HMO

False-Needs

A medical assistant has the responsibility to interpret the patient's insurance policy or extent of coverage.

False-does not

Medicare discourages practices to file calims electronically.

False-encourages

A co payment is a fixed percentage of coveraged charges after the deductible is met.

False-it is a set payment covered at the time of srevice

Most HMO co-payments are:

a. $5-$10

A patient who has been hospitalized up to 90 days for each benefit period is covered under:

a. Medicare part A

An appropriate approach to maintain patient confidentiality on the computer is to:

a. change your password every 90 days

Groups of procedures or test related directly to a given diagnosis that are likely to be covered by an insurer:

a. diagnosis related groups

The groups of health care professionals who check hospital diagnosis, qualify of services, and patient admissions and discharges related to government-funded health care within each state are called:

a. peer review organizations

Which of the following is included under Workder's Compensation insurance:

a. rehabiitation costs are covered to return an employee to work

The authorizaiton for an insurance carrier to pya the physician or practice directly is the:

assignement of benefits

A benefit period for Medicare begins the day a patient goes into the hospital and ends when the patient has not been hospitalized for ____days

b. 60

The law that sets reimbursement based on diagnosis-related groups is the:

b. Tax equity and Fiscall responsiblity Act of 1982

The need for a flexible fee schedule for medical services that can reflect regional cost differences and differences in medical education and specialty is facilitated by: a. DRGs b. the UCR system c. PROs d. HMOs

b. UCR system

Comorbidity is:

b. a preexisting condition

The average fee charged for a procedure by similar doctors in the same region or the ninetieth percentile of the fees charged for the procedure by similar doctors in the same are is the _____fee. a. usual b. customary c. reasonable d. accepted

b. customary

The prevailing fee for that service or procedure in the geographic region is the___fee. a. usual b. customary c. reasonable d. accepted

b. customary

The correct procedure an HMO patient must follow for coverage when she discovers a breast lump is to make an appointment with:

b. her primary care physician

Patients under the age of 65 who are blind or widowed or who have serious long-term disabilities, such as chronic joint pain or_______, may also be entitled to Medicare.

b. kidney failure

Which of the following types of insurance covers injuries caused by the insured or that occurred on the insurere's property?

b. liability

CHAMPUS/TRICARE covers which of the following services?

b. magnetic resonance imaging (MRI)

The apprpriate way to filed a Medicare form for a patient who cannot sign a claim form is to:

b. submit the patient's signature on a Lifetime Beneficiary Claim Authorization and Information Release

Medicare's new fee schedule regulating payment for all services and procedures provided by doctors is based on:

b. the geographical practice cost index (GPI) called gypsy, which takes regional differences into account

A husband and wife, both employed and have work sponsored insurance plans that cover each other and their three children. Which insurance plan is the primary payer?

b. the insurance plan of the person whose birthday comes first in the calendar year

You should do which of the following when filling out the HCFA-1500 for optical character reader (OCR) scanning? a. enter all data by hand b. use all upercase (CAPITAL) letters for all entries c. use colories ink d. use the abbreviation N/A to indicate that a field is not applicable

b. use all capital letters

The amount Medicare pays the physician or health care provider after the $100 annual deductible is met is:

c. 80%

Which of the following is applicable when filing a Medicaid claim?

c. avoid treating the patient as inferior to patients with private insurance

The most appropriate response from a medical assistant when a patient calls the medical practicwe questioning why an insurance claim was rejected is:

c. check your explanation of benefits

Which of the following is a characterisitic of medicaid?

c. covers 12 days of inpatient hospital care per year

The most likely outcome of a submitted insurance claim with a diagnosis code of a sore throat and a treatment code indicating a cast for a broken leg would be: a. coverage at 100 percent b. the fee for service would be applied toward the patient's deducible c. denied as a billing error b/c the treatment was not medically necesary based on diagnosis d. the patient may have to pay a coinsurance after the deductible is met

c. denied as a billing error b/c the treatment was not medically necessary based on diagnosis

Electronic claims transmission (ECT) includes:

c. instant identification on the screen of errors and omissions that could cause a claim to be rejected

The first health insurance was created to cover: a. basic medical expenses b. the frequent railroad and steamboat disasters of the area c. lost income b/c of a disability d. as many poeople as possible under group coverage

c. lost income b/c of a disability

Blue cross/Blue shield (BCBS) have the reserved right of:

c. obtaining the state insurance commissioner's approval for statewide rate or benefit changes

A characterisitic of a health maintenance organization (HMO) is:

c. physicians enrolling in an HMO are called participating physicians

Which of the following is what hte patient owes after the insurancecompany has paid?

c. subscriber liability

The UCR rate includes the fee submitted, the provideer's usual fee profile, and: a. the patient prognosis b. capitation c. the customary profile for the area d. comorbidity

c. the customary profile for the area

Medicare encourages all practices to file claims electronically because:

c. the process saves time

Which of the following are included in Medicare benefits for respite care?

c. the terminally ill pt is moved to a care facility for the respite

Some medical practices may require the subscriber to pay a small fee at the time of service, called a

co payment

Which of the following is correct regarding electronic claims submission?

d. an ECT system is quick, uses no paper, and permits fewer mistakes and omission than other methods of transmitting claims

Diagnosis-related group are classified first by:

d. major diagnostic category

The generally accepted fee a physician charges for an exceptionally difficult or complicated service is the___fee. a. usual b. customary c. prevailing d. reasonable

d. reasonable

Under Medicare Part B, patients are not permitted to

d. submit their own claims for reimbursement

Which of the following is a Medicare requirment for home health care?

d. the patient must be in need of physical therapy, speech therapy, or skilled nursing care

A fixed dollar amount the subscriber must pay or "meet" each year before the insurer begins to cover expenses is the:

deductible