Chapter 8 SB

Which of the following apply to CDHPs? (Select all that apply.) - CDHPs discourage consumers from managing their healthcare services. - CDHPs empower consumers to manage their use of healthcare services. - CDHPs eliminate most copayment coverage. - CDHPs shift payment responsibility to the individual.

- CDHPs empower consumers to manage their use of healthcare services. - CDHPs eliminate most copayment coverage. - CDHPs shift payment responsibility to the individual

Which of the following apply to check-in procedures related to up-front collections? (Select all that apply.) - If the plan summary grid for the patient's plan lists an office visit copay, collect the copay and post it to the patient's account. - Copayments should be waived if the patient was not happy with the charge. - Be sure the correct copayment has been collected. - Copayments should be collected after the visit and sent through the mail.

- If the plan summary grid for the patient's plan lists an office visit copay, collect the copay and post it to the patient's account. - Be sure the correct copayment has been collected

Private exchanges are eligible to offer IHPs to which of the following? (Select all that apply.) Multiple select question. State governments Small businesses Federal government Individuals

Small businesses Individuals

PPOs generally pay participating providers based on a discount from their physician fee schedules, called a discounted _____. co-insurance deductible fee-for-service premium

fee-for-service

Which of the following apply to preregistration of patients? (Select all that apply.) - An optional step - Step 1 of the revenue cycle - Step 2 of the revenue cycle - Collecting and entering basic demographic and insurance information - The last step of the revenue cycle

- Step 1 of the revenue cycle - Collecting and entering basic demographic and insurance information

The group health plan has rules that can cover which of the following? (Select all that apply.) Multiple select question. Personal health care decisions Conditions for enrolling dependents Eligibility Employment status

Conditions for enrolling dependents Eligibility Employment status

Which of the following apply to establishing policies for no-shows? (Select all that apply.) - Often a physician cannot bill for services not delivered, including cancellations and no-shows. - The contract determines whether a provider can charge for a product when there is a no-show. - Physicians are always allowed to bill for services and products on no-show patients. - Often a physician may bill only for a rendered service.

- Often a physician cannot bill for services not delivered, including cancellations and no-shows. - The contract determines whether a provider can charge for a product when there is a no-show. - Often a physician may bill only for a rendered service.

How can the medical insurance specialist know a patient's eligibility for a procedure? Multiple choice question. Have the patient bring their plan manual into the office. Ask the physician. Contact the payer. Ask the patient.

Contact the payer.

A key goal of the ACA is to reduce the number of uninsured citizens and legal residents by providing affordable _____. Multiple choice question. medication dental procedures individual health plans surgical procedures

individual health plans

Which of the following are among the major national insurance payers? (Select all that apply.) Multiple select question. CIGNA Health Care Aetna Humana Inc. Northwestern UnitedHealth Group Health Plus Group Kaiser Permanente Anthem

CIGNA Health Care Aetna Humana Inc. UnitedHealth Group Kaiser Permanente Anthem

Step 1 of the revenue cycle is _____. Multiple choice question. performing billing procedures preregistering patients monitoring payer adjudication performing coding procedures

preregistering patients

Which of the following types of CDHP funding options allow unused funds to roll over indefinitely? Multiple choice question. Health reimbursement accounts Health savings accounts Retirement accounts Flexible savings (spending) accounts

Health savings accounts

What is the purpose of following the first seven steps of the standard revenue cycle? Multiple choice question. To collect payment from patients To complete correct claims and transmit them to private payers To begin the collections process To perform payer adjudication to determine the payment of claims

To complete correct claims and transmit them to private payers

Which of the following improvements are in effect for patients with private health insurance? - A payer is now required to show why they did not hire someone based on their gender. - Appeals are now allowed for pre-existing cancellations. - A payer can no longer drop a beneficiary from a plan because of a pre-existing illness. - A payer cannot discriminate against individuals based on gender, occupation, or employer size.

- A payer can no longer drop a beneficiary from a plan because of a pre-existing illness. - A payer cannot discriminate against individuals based on gender, occupation, or employer size.

Identify all of the correct statements related to an evaluation team. - An outside attorney usually reviews the contract. - A practice manager or a committee of physicians usually leads the team. - All plans pay more than the physicians' fees schedule. - The managed care organization's business history, accreditation standing, and licensure status are reviewed.

- An outside attorney usually reviews the contract. - A practice manager or a committee of physicians usually leads the team. - The managed care organization's business history, accreditation standing, and licensure status are reviewed.

Which of the following apply to the check-out process? (Select all that apply.) - The patient does not need to be present for check out because all forms and receipts should be mailed. - Apply collected payments to the patient's account. - Update the practice management program to reflect appropriate diagnoses, services, and charges. - Analyze the patient's financial responsibility according to the practice's financial policy.

- Apply collected payments to the patient's account. - Update the practice management program to reflect appropriate diagnoses, services, and charges. - Analyze the patient's financial responsibility according to the practice's financial policy.

Which of the following apply to the Federal Health Benefits (FEHB) program? (Select all that apply.) - Contains three major health care plans - Largest employer-sponsored health program in the United States - Contains more than 250 health plans - Covers more than 8 million federal employees, retirees, and their families

- Largest employer-sponsored health program in the United States - Contains more than 250 health plans - Covers more than 8 million federal employees, retirees, and their families

Identify all of the correct statements related to the role and services of commercial insurance companies. - Local or regional payers are often affiliated with a national plan. - One large company dominates that national market for commercial insurance. - Local or regional payers are not affiliated with the BlueCross BlueShield Association. - Local or regional payers are often affiliated with the BlueCross BlueShield Association. - A small number of large companies dominate the national market for commercial insurance.

- Local or regional payers are often affiliated with a national plan. - Local or regional payers are often affiliated with the BlueCross BlueShield Association. - A small number of large companies dominate the national market for commercial insurance.

Which of the following apply to medical home model plans? (Select all that apply.) - Primary care physician is responsible for arranging patients' visits to specialists. - Replace illness-based primary care with coordinated care - Physician-centered - Emphasize communication among a patient's physicians - Focus primarily on illness-based primary care

- Primary care physician is responsible for arranging patients' visits to specialists. - Replace illness-based primary care with coordinated care - Emphasize communication among a patient's physicians

Which of the following apply to silent PPOs? (Select all that apply.) - Silent PPOs can lead to a practice accepting a PAR payment. - Silent PPOs are required by the government in order to provide services to patients. - They allow a managed care organization to lease its PPO provider network list to another entity. - Most experts recommend trying to negotiate a phrase in contracts stating the MCO cannot lease any terms of the agreement.

- Silent PPOs can lead to a practice accepting a PAR payment. - They allow a managed care organization to lease its PPO provider network list to another entity. - Most experts recommend trying to negotiate a phrase in contracts stating the MCO cannot lease any terms of the agreement.

Identify all of the correct statements related to copayments. - Some plans require a copayment only when an E/M service is provided. - Copayment amounts remain the same for all procedures. - Some plans require a copayment when the patient visits the office for any procedure or service. - Copayment amounts vary depending on the procedure.

- Some plans require a copayment only when an E/M service is provided. - Some plans require a copayment when the patient visits the office for any procedure or service. - Copayment amounts vary depending on the procedure.

Which of the following are answered by plan summary grids or similar aids? (Select all that apply.) - What the patient's prognosis is - Which services are not covered - What the patient is responsible for paying at the time of the encounter - What the plan's billing rules are

- Which services are not covered - What the patient is responsible for paying at the time of the encounter - What the plan's billing rules are

Step _____ of the revenue cycle is checking in patients. Multiple choice question. 6 8 2 3

3

Reviewing coding compliance is which step of the revenue cycle? Multiple choice question. 9 4 3 1

4

Checking billing compliance is which step of the revenue cycle? Multiple choice question. 5 4 7 3

5

Which of the following statements apply to private payers? (Select all that apply.) CDHPs combine a high deductible plan with a funding option of some type. HMOs are the most popular type of private plan. Few employees choose indemnity health plans. PPOs are the most popular type of private plan.

CDHPs combine a high deductible plan with a funding option of some type. Few employees choose indemnity health plans. PPOs are the most popular type of private plan.

In private exchanges, employees are able to do which of the following in their IHPs? Multiple choice question. Opt out of the health plan Make changes to the plan Change the rates of the plan Choose their own plans using a specific amount of money the employer allocates

Choose their own plans using a specific amount of money the employer allocates

Indemnity plans require which of the following types of payments or cost-sharing? (Select all that apply.) Multiple select question. Coinsurance Premiums Deferred Deductibles

Coinsurance Premiums Deductibles

Which of the following apply to self-funded or self-insured health plans? Multiple select question. Employee assumes the risk of paying directly for medical services. Employer assumes the risk of paying directly for medical services. Created by large employers to save money Employers cover the costs of employee medical benefits themselves rather than buying insurance from other companies.

Employer assumes the risk of paying directly for medical services. Created by large employers to save money Employers cover the costs of employee medical benefits themselves rather than buying insurance from other companies.

What is a benefit to employers when offering medical benefits to their employees? Federal income tax advantages Federal income tax penalties Earn additional income from employee payments Pay employees lower wages

Federal income tax advantages

Which of the following plan types are purchased from insurance companies by employers for their employees? Multiple choice question. Combined health plans Group health plans (GHP) Employer health plans Employee health plans

Group health plans (GHP)

Of the three plan types offered by BCBS, which of the following requires the patient to choose a primary care physician? PMS POS HMO Private plan

HMO

Which of the following types of managed care programs are offered by BCBS? (Select all that apply.) Multiple select question. Temporary Plan HMO PPO Government HMO plans POS

HMO PPO POS

Which of the following are types of private payers? (Select all that apply.) Multiple select question. Health maintenance organizations (HMOs) Preferred provider plans (PPPs) Preferred provider organizations (PPOs) Consumer-driven health plans (CDHPs)

Health maintenance organizations (HMOs) Preferred provider organizations (PPOs) Consumer-driven health plans (CDHPs)

Which of the following applies to elective surgery? Multiple choice question. An elective surgery is always medically necessary. It is a procedure that can be scheduled ahead of time but which may or may not be medically necessary. An elective surgery cannot be scheduled ahead of time and is done on an emergency basis. A physician can require elective surgery.

It is a procedure that can be scheduled ahead of time but which may or may not be medically necessary.

Who may be required to keep logs of referral activities? (Select all that apply.) Multiple select question. PCPs Specialists Patients Medical insurance specialists

PCPs Specialists

Which of the following statements apply to self-funded or self-insured health plans? (Select all that apply.) The employer establishes the benefit levels and the plan types offered. Self-funded health plans also may buy other types of insurance, such as vision, instead of insuring the benefit themselves. Self-insured employers cover more than half of all employees in the United States. Self-funded health plans must lease a managed care organization's network.

The employer establishes the benefit levels and the plan types offered. Self-funded health plans also may buy other types of insurance, such as vision, instead of insuring the benefit themselves. Self-insured employers cover more than half of all employees in the United States.

Providers must evaluate health plans, and they judge which plans to participate in based primarily on the _____. Multiple choice question. reputation of the plan history of the plan feedback financial arrangements offered

financial arrangements offered

Half of the states that were required by the ACA to create a public government-run online marketplace to offer IHPs chose to run their own _____. Multiple choice question. health insurance exchanges state policy procedures insurance plans health care plans

health insurance exchanges

Plans that coordinate patients' treatments are referred to as _____. Multiple choice question. coordinated plans multiplan treatment centers medical home model plans patient treatment plan events

medical home model plans

When a practice's contract evaluation team is considering a participation contract, a _____ may be asked to assist. Multiple choice question. physician consultant medical insurance specialist nurse consultant tax specialist

medical insurance specialist

The list that capitated plans send with the payment is called the _____ list. Multiple choice question. monthly payment monthly member plan monthly enrollment

monthly enrollment

A silent PPO is also known as a _____. Multiple choice question. personal pay agreement private pay personal network agreement network sharing agreement

network sharing agreement

Compiling billing data permits the practice to track how much revenue it has lost as a result of _____. Multiple choice question. raising the fee rates participating in a particular contract changing the plan services lowering the fee rates

participating in a particular contract

A plan that is a hybrid of HMO and PPO networks is called a(n) _____ plan. Multiple choice question. blended service point-of-service (POS) HMO/PPO mixed

point-of-service (POS)

Under income tax law, the employer can collect an employee's insurance costs through a _____. Multiple choice question. payment plan pretax payroll deduction third-party service general fund

pretax payroll deduction

People who are not covered by government-sponsored health insurance are often covered by _____. Multiple choice question. TRICARE Medicaid Medicare private insurance

private insurance

Consumer-driven health plans _____ providers' cash flow because visit copayments are being replaced by high deductibles that may not be collected until after claims are paid. Multiple choice question. increase supplement eliminate reduce

reduce

As more employer-sponsored plan members are covered under CDHPs, physician reimbursement up to the amount of the deductible will come from _____. the employer deductibles the patient's funding plan options the patient's insurance company

the patient's funding plan options

Which of the following apply to the BlueCross BlueShield Association (BCBS)? (Select all that apply) - BCBS is an association and not a payer. - BCBS only works with for-profit organizations and members. - BCBS has both for-profit and nonprofit members. - BCBS's national scope means that knowing about its programs is important for all medical insurance specialists. - BCBS is a major national payer.

- BCBS is an association and not a payer. - BCBS has both for-profit and nonprofit members. - BCBS's national scope means that knowing about its

Which of the following are referral requirements for HMOs? (Select all that apply.) - Both PCPs and specialists may be required to keep logs of referral activities. - They may require a PCP for out-of-network provider referrals. - HMOs only require referrals if a patient does not have a primary care physician. - Patients who self-refer to nonparticipating providers may be balance-billed for those services. - There are no referral requirements for HMOs.

- Both PCPs and specialists may be required to keep logs of referral activities. - They may require a PCP for out-of-network provider referrals. - Patients who self-refer to nonparticipating providers may be balance-billed for those services.

Which of the following should be done to verify insurance eligibility? (Select all that apply.) Multiple select question. - Refer to an eligibility roster. - Verbally verify eligibility with the patient. - Assume the patient is eligible and bill after the procedure has been performed. - Contact the payer to double-check. - Accurately enter the patient's name and ID number.

- Contact the payer to double-check. - Accurately enter the patient's name and ID number.

Which of the following apply to the filing deadlines for claims? (Select all that apply.) - Deadlines are based on the date of service. - Deadlines are not based on the received date. - No deadlines apply for surgical procedures. - Deadlines are not based on the sent date.

- Deadlines are based on the date of service. - Deadlines are not based on the received date. - Deadlines are not based on the sent date.

The monthly enrollment list contains which of the following to show eligibility? (Select all that apply.) - Patient history - Effective date of plan - Identification numbers - Family members' names - Patient names

- Effective date of plan - Identification numbers - Patient names

Identify all of the correct statements related to billing surgical procedures. - Elective surgery usually requires preauthorization. - Preauthorizations are never required for surgical procedures. - The preauthorization requirement is usually shown on the patient's insurance card. - Emergency surgery usually must be approved within a specified period after admission was required.

- Elective surgery usually requires preauthorization. - The preauthorization requirement is usually shown on the patient's insurance card. - Emergency surgery usually must be approved within a specified period after admission was required.

Which of the following apply to HMOs? (Select all that apply.) - Employer-sponsored HMOs are beginning to replace copayments with coinsurance for some benefits. - HMOs have traditionally emphasized preventive and wellness services. - HMOs do not cover preventive care and maintenance. - HMOs may now apply deductibles to family coverage.

- Employer-sponsored HMOs are beginning to replace copayments with coinsurance for some benefits. - HMOs have traditionally emphasized preventive and wellness services - HMOs may now apply deductibles to family coverage..

Which of the following are insurance services that are supplied by private payers? (Select all that apply.) - Establishing fees - Managing insurance risk - Processing claims - Purchasing addendum plans

- Establishing fees - Managing insurance risk - Processing claims

Which of the following are CDHP funding options? (Select all that apply.) - Flexible savings (spending) accounts - Health savings accounts - Health reimbursement accounts - Retirement accounts - Nonhealth-related funding accounts

- Flexible savings (spending) accounts - Health savings accounts - Health reimbursement accounts

The first part of a CDHP is a ____ health plan. Multiple choice question. high-deductible managed care nondeductible low-deductible

high-deductible

Which of the following apply to communication with payers? (Select all that apply.) - Good communication between payers and medical insurance staff is necessary for effective contract and claim management. - There should be no communication once a claim is in the processing stage. - As claims are processed, questions and requests for information go back and forth. - All communication regarding claims must be in writing.

- Good communication between payers and medical insurance staff is necessary for effective contract and claim management. - As claims are processed, questions and requests for information go back and forth.

Which of the following apply to indemnity plan reimbursements? (Select all that apply.) - Many have managed care features. - They typically cover 70 to 80 percent of costs after the deductible is met. - Some have higher deductibles in order to keep costs down. - They typically have lower deductibles.

- Many have managed care features. - They typically cover 70 to 80 percent of costs after the deductible is met. - Some have higher deductibles in order to keep costs down.

Which of the following apply to billing excluded services? (Select all that apply.) - The plan's summary grid does not list the plan's payment method. - Medical insurance specialists need to organize this information for billing. - The plan's summary grid should indicate the plan's payment method for the additional services to be balance-billed. - Under a capitated contract, providers bill patients for services not covered by the cap rate.

- Medical insurance specialists need to organize this information for billing. - The plan's summary grid should indicate the plan's payment method for the additional services to be balance-billed. - Under a capitated contract, providers bill patients for services not covered by the cap rate.

Which of the following statements apply to copayments? (Select all that apply.) - Copayments are never collected under the secondary plan. - Copayments are always collected for both primary and secondary plans. - Medical insurance specialists should verify whether a copayment is to be collected under the secondary plan. - A variable in collecting copayments involves primary and secondary plans.

- Medical insurance specialists should verify whether a copayment is to be collected under the secondary plan. - A variable in collecting copayments involves primary and secondary plans.

Which of the following apply to point-of-service (POS) plans? (Select all that apply.) - Monthly premiums are slightly higher than for HMOs. - POS plans do not allow copayments. - Patients in POS plans can see any provider and have no affiliation with networks. - Like HMOs, POS plans charge an annual premium and a copayment for office visits. - A POS may be structured as a tiered plan with different rates for different providers.

- Monthly premiums are slightly higher than for HMOs. - Like HMOs, POS plans charge an annual premium and a copayment for office visits. - A POS may be structured as a tiered plan with different rates for different providers.

Consumer-driven health plans (CDHPs) combine which of the two following components? - One or more tax-preferred savings accounts that the physician directs - One or more tax-preferred savings accounts that the patient directs - Low deductible health plans - High deductible health plans

- One or more tax-preferred savings accounts that the patient directs - High deductible health plans

Which of the following improvements are now in effect for patients with private health insurance? - Payers cannot impose lifetime financial limits on benefits. - Insurance plan beneficiaries have expanded rights to appeal denials or cancellations. - Young adults up to age twenty-six can remain as dependents on their parents' private health insurance plan. - Young adults can stay on their parents' private health plan until age twenty-one.

- Payers cannot impose lifetime financial limits on benefits. - Insurance plan beneficiaries have expanded rights to appeal denials or cancellations. - Young adults up to age twenty-six can remain as dependents on their parents' private health insurance plan.

The patient's financial responsibility is analyzed according to the practice's financial policy for which of the following? (Select all that apply.) - Payment for noncovered services - Balance due from previous encounter - Deductibles - Deposit for future services

- Payment for noncovered services - Balance due from previous encounter - Deductibles

Identify all of the correct statements related to preferred provider plans (PPOs). - Medical providers can still be listed in the PPO network but not accept the plan's fee schedule. - Physicians, hospitals, clinics, and pharmacies contract with the PPO plan to provide care to its insured people. - Physicians, hospitals, clinics, and pharmacies do not usually participate in PPOs. - Medical providers accept the PPO plan's fee schedule and guidelines for managed care.

- Physicians, hospitals, clinics, and pharmacies contract with the PPO plan to provide care to its insured people. - Medical providers accept the PPO plan's fee schedule and guidelines for managed care.

Identify all of the correct statements related to compiling billing data. - Practices generally bill from their normal fee schedules. - The practice has no way of tracking data to see how much revenue is lost by participation in a particular plan. - Practices do not typically bill the contracted fees. - After the RA is processed, differences can be written off between normal fees and payments. - Differences cannot be written off.

- Practices generally bill from their normal fee schedules. - Practices do not typically bill the contracted fees. - After the RA is processed, differences can be written off between normal fees and payments.

Which of the following are steps in preparing the correct claims? (Select all that apply.) - Preregister patients. - Review history of patients. - Check in patients. - Establish financial responsibility for visits.

- Preregister patients. - Check in patients. - Establish financial responsibility for visits.

Identify services that are usually NOT subject to the deductible under the HDHP plan. (Select all that apply.) - Preventive care - Vision care - Elective surgery - Dental care - Cosmetic surgery

- Preventive care - Vision care - Dental care

Which of the following apply to preparing and transmitting claims? (Select all that apply.) - Private payer claims can be completed using the HIPAA 837P claim. - Private payer claims can be completed using the CMS-1500 paper claim. - Claims always have a one-year deadline for processing. - Claims must be submitted according to the plan's guidelines for timely filing. - The HIPAA 837P claim form is only used for government health plans.

- Private payer claims can be completed using the HIPAA 837P claim. - Private payer claims can be completed using the CMS-1500 paper claim. - Claims must be submitted according to the plan's guidelines for timely filing.

Which of the following statements apply to self-funded or self-insured health plans? (Select all that apply.) - Self-insured employers cover more than half of all employees in the United States. - The employer establishes the benefit levels and the plan types offered. - Self-funded health plans also may buy other types of insurance, such as vision, instead of insuring the benefit themselves. - Self-funded health plans must lease a managed care organization's network.

- Self-insured employers cover more than half of all employees in the United States. - The employer establishes the benefit levels and the plan types offered. - Self-funded health plans also may buy other types of insurance, such as vision, instead of insuring the benefit themselves.

Which of the following apply to reviewing coding compliance? (Select all that apply.) - The payer is responsible for linking the diagnostic and procedure codes. - Show the medical necessity for the services. - A coding compliance review is not needed if you documented and coded properly. - Verify that the diagnosis and procedure codes are current as of the date of service. - Check that the codes are properly linked and documented.

- Show the medical necessity for the services. - Verify that the diagnosis and procedure codes are current as of the date of service. - Check that the codes are properly linked and documented.

Which of the following apply to group health plans? (Select all that apply.) - The individual is considered the policyholder. - The group is considered the policyholder. - The individual is considered the certificate holder. - Employers' human resource departments manage GHP benefits. - Employees manage their own benefits and negotiate with the health plans.

- The group is considered the policyholder. - The individual is considered the certificate holder. - Employers' human resource departments manage GHP benefits.

Which of the following are addressed by plan summary grids or similar aids? (Select all that apply.) - What services are covered under the plan - Whether services are correctly coded and linked - How much time was spent - Whether the patient has a past surgical history - What conditions establish medical necessity for these services

- What services are covered under the plan - Whether services are correctly coded and linked - What conditions establish medical necessity for these services

The payer's provider representatives may need to deal with the difficulties that arise when claims are _____. long overdue correctly submitted approved paid in a timely manner

long overdue

The FEHB is administered by which of the following? Office of Personnel Management (OPM) State Department State government Occupational Safety and Health Administration

Office of Personnel Management (OPM)

Because managed care organizations are the predominant healthcare delivery systems, most medical practices have contracts with _____. Multiple choice question. every plan in the area a small number of plans outside the area a large number of plans outside the area a number of plans in the area

a number of plans in the area

If a provider does not participate in a particular health plan, its patients should _____ before scheduling procedures. Multiple choice question. see a counselor amend the insurance contract agree to pay in writing verbally agree to pay

agree to pay in writing

Using the plan summary grid, you should verify that all charges planned for the claim are _____. Multiple choice question. coded not documented billable negotiable

billable

Under a(n) _____ contract, providers write off services not covered under the cap rate. out-of-network fee-for-service capitated consumer-driven health plan

capitated

Health maintenance organizations were originally designed to cover all basic services for an annual premium and visit copayments under an arrangement called _____ coverage. Multiple choice question. annual premium basic first-dollar

first-dollar