Medical Insurance & Billing Ch.8

Which of the following apply to point-of-service (POS) plans? (Select all that apply.)

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.

Which of the following are among the major national insurance payers? (Select all that apply.)

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

Which of the following apply to the check-out process? (Select all that apply.)

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

Which of the following apply to communication with payers? (Select all that apply.)

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

Which of the following apply to the BlueCross BlueShield Association (BCBS)? (Select all that apply.)

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

The patient's financial responsibility is analyzed according to the practice's financial policy for which of the following? (Select all that apply.)

Balance due from previous encounter Deductibles Payment for noncovered services

Which of the following apply to check-in procedures related to up-front collections? (Select all that apply.)

Be sure the correct copayment has been collected. 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.

The group health plan has rules that can cover which of the following? (Select all that apply.)

Conditions for enrolling dependents Eligibility Employment status

Which of the following should be done to verify insurance eligibility? (Select all that apply.)

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

Which of the following apply to the Federal Health Benefits (FEHB) program? (Select all that apply.)

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

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 sent date. Deadlines are not based on the received date.

Which of the following apply to self-funded or self-insured health plans? (Select all that apply.)

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

Which of the following are steps in preparing the correct claims? (Select all that apply.)

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

Which of the following are insurance services that are supplied by private payers? (Select all that apply.)

Establishing fees Processing claims Managing insurance risk

What is a benefit to employers when offering medical benefits to their employees?

Federal income tax advantages

Which of the following are CDHP funding options? (Select all that apply.)

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

Consumer-driven health plans (CDHPs) combine which of the two following components?

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

Which of the following improvements are now in effect for patients with private health insurance?

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

The FEHB is administered by which of the following?

Office of Personnel Management (OPM)

Which of the following types of managed care programs are offered by BCBS? (Select all that apply.)

POS HMO PPO

Which of the following are referral requirements for HMOs? (Select all that apply.)

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

Identify all of the correct statements related to compiling billing data.

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

Identify services that are usually NOT subject to the deductible under the HDHP plan. (Select all that apply.)

Preventive care Vision care Dental care

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. Emphasize communication among a patient's physicians Replace illness-based primary care with coordinated 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. Claims must be submitted according to the plan's guidelines for timely filing. Private payer claims can be completed using the CMS-1500 paper claim.

Which of the following statements apply to self-funded or self-insured health plans? (Select all that apply.)

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. The employer establishes the benefit levels and the plan types offered.

Private exchanges are eligible to offer IHPs to which of the following? (Select all that apply.)

Small businesses Individuals

Who may be required to keep logs of referral activities? (Select all that apply.)

Specialists PCPs

Under income tax law, the employer can collect an employee's insurance costs through a _____.

pretax payroll deduction

As more employer-sponsored plan members are covered under CDHPs, physician reimbursement up to the amount of the deductible will come from _____.

the patient's funding plan options

Which of the following improvements are in effect for patients with private health insurance?

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.

Identify all of the correct statements related to the role and services of commercial insurance companies.

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.

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. Few employees choose indemnity health plans. PPOs are the most popular type of private plan.

Which of the following apply to CDHPs? (Select all that apply.)

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

The monthly enrollment list contains which of the following to show eligibility? (Select all that apply.)

Effective date of plan Patient names Identification numbers

Identify all of the correct statements related to billing surgical procedures.

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

Which of the following apply to HMOs? (Select all that apply.)

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.

Which of the following are types of private payers? (Select all that apply.)

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

Which of the following statements apply to copayments? (Select all that apply.)

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.

Identify all of the correct statements related to preferred provider plans (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.

Which of the following apply to establishing policies for no-shows? (Select all that apply.)

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

Identify all of the correct statements related to copayments.

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

Which of the following apply to group health plans? (Select all that apply.)

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

Identify all of the correct statements related to an evaluation team.

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

Which of the following apply to billing excluded services? (Select all that apply.)

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.

Which of the following apply to silent PPOs? (Select all that apply.)

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

Which of the following apply to indemnity plan reimbursements? (Select all that apply.)

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

What is the purpose of following the first seven steps of the standard revenue cycle?

To complete correct claims and transmit them to private payers

Which of the following apply to reviewing coding compliance? (Select all that apply.)

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

Which of the following are addressed by plan summary grids or similar aids? (Select all that apply.)

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

Which of the following are answered by plan summary grids or similar aids? (Select all that apply.)

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