HIT 230 Module 1-5
Blue Cross and Blue Shield has ________ types of accounts.
2
ICD-10-CM diagnosis codes include ________ digits.
3-5
The RAC appeals process has ____ levels.
5
Medicare Part ________ is inpatient hospital insurance.
A
Which of the following is the correct format for HCPCS Level II codes?
A1234
________ are automatically covered by TRICARE Prime or TRICARE Prime Remote.
All active-duty service members
Medicare Part ________ is supplemental medical insurance covering physician services, medical services, and medical supplies not covered by Medicare Part ________.
B; A
What healthcare organization is one of the most influential in the healthcare sector because it insures nearly one in three Americans?
BCBSA
All of the following are cost-sharing provisions except:
Benefit
Which of the following is an example of fraud?
Billing for a service not furnished as represented on the claim
Which of the following payment methods are global?
Block grants Surgical packages Bundling
Custodial care and dental services would be covered under Medicare Part ________.
C
Diagnoses and outpatient procedures
CPT
All of the following are discounted fee-for-service healthcare payment methods except _______.
CRG
Which type of reimbursement methodology is associated with the abbreviation "PMPM"?
Capitated payment
The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan was contracted with the health plan to serve 300 members, of which he provided services to 100. He received $4,500 from the health plan. What method is the health plan using to reimburse Dr. Tan?
Capitated rate
In the healthcare industry, what is another term for "fee"?
Charge
The bill that the pathologist's office submitted for a laboratory test was $54.00. In its payment notice (remittance advice), the healthcare plan lists its payment for the laboratory test as $28.00. What does the amount of $54.00 represent?
Charge
All of the following data elements are on a remittance advice except:
Claim attachment
In the healthcare sector, what is the term for the fixed dollar amount that the guarantor pays?
Copayment
________ the most common form of healthcare coverage for individuals who are not elderly in the United States.
Employer-based healthcare insurance is
Which of the following entities is also known as a "group plan"?
Employer-based healthcare insurance plan
In the healthcare industry, what is the term for the written report that insurers use to notify insureds about the extent of payments made on a claim?
Explanation of Benefits
In which type of healthcare payment method does the healthcare plan pay for each service that a provider renders?
Fee-for-service reimbursement
Which statement describes the per diem payment method?
Fixed rate for each day a covered member is hospitalized
Medical and surgical supplies
HCPCS LEVEL II
Diagnoses and inpatient procedures
ICD
The coding system that is used primarily for reporting diagnoses for hospital inpatients is known as _______.
ICD-10-CM
The coding system that is used primarily for reporting diagnoses for hospital inpatients is known as:
ICD-10-CM
Which of the following is not a common cause of improper payments?
Implementation of a documentation improvement program
________ are pools of people who work for companies that do not offer healthcare insurance.
Individual pools
________ are the least diverse type of pool.
Individual risk pools
Which of the following is/are true of CHIP?
It is a federal/state program ; It varies from state to state
Changes to CPT take effect on ________.
January 1 each year
an individual requiring nursing home care and services
LONG-TERM OR EXTENDED CARE INSURANCE
ICD-O-3 codes begin with ________.
M
All of the following entities are voluntary healthcare insurance EXCEPT _______.
Medicare
The largest single payer for healthcare services is ________.
Medicare
________ is responsible for updating and maintaining ICD-10-CM/PCS codes.
NCHS
Which national model for the delivery of healthcare services is financed by general revenue funds from taxes?
National health service (Beveridge) model
Which Part of the Medicare program does not include a cost-sharing provision?
PART A,B,C,D
There are 3 parties in healthcare reimbursement. Who is the first party?
Patient or guarantor
There are 3 parties in healthcare reimbursement. Who is the third party?
Payer
Which of the following phrases mean "per head"?
Per capita
A notice from a healthcare insurance plan used the abbreviation PMPM. How should the insurance analyst interpret this abbreviation?
Per member per month
What are the core areas of a coding compliance plan? (check all that apply)
Policies and procedures; Auditing and monitoring; Education and trainning
What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?
Policy
Which insurance model is used in the United States?
Private health insurance model
In which type of reimbursement methodology do healthcare insurance companies determine payment to providers before the services have been delivered?
Prospective payment
There are 3 parties in healthcare reimbursement. Who is the second party?
Provider of care or services
Which of the following is not a function of the Indian Health Service (IHS)?
Provides only inpatient healthcare services
Recovery Audit Contractors are different from other improper payment review contractors because:
RACs are reimbursed on a contingency-based system
Which discounted fee-for-service healthcare payment method does Medicare use to reimburse physicians?
RBRVS
In the healthcare industry, what is the term for receiving compensation for healthcare services that were previously provided?
Reimbursement
In which type of reimbursement methodology does the health insurance company have the greatest degree of risk?
Retrospective
In which type of reimbursement methodology do healthcare insurance companies reimburse providers after the costs have been incurred?
Retrospective payment
Which of the following is true of SCHIP?
SCHIP is a federal/state program
Which type of RAC review combines data analysis and submission of medical records to the RAC?
Semi-automated
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for:
Spouse or widow(er) of a veteran meeting specific criteria ; Children of a veteran meeting specific criteria
The worker had group healthcare insurance coverage through her employer. The worker's household included her spouse, two natural children (ages 28 and 12), an adopted child (age 8), a 6-month infant in the waiting period prior to adoption, and the worker's mother (age 58). Who may be included under dependent coverage in the healthcare insurance policy?
Spouse, natural child age 12, adopted child age 8, and 6-month infant in waiting period
Which of the following is true of Medicaid?
States must meet specified criteria to receive federal funds.
Which program replaced the Aid to Families with Dependent Children program?
TANF
Which government-sponsored program provides coverage for the dependents of active members of the armed forces (ADFM).
TRICARE
Both parents of a dependent child had employer-based group health insurance. Per the "birthday rule," the primary payer for the dependent child is the insurance of the parent whose birthday comes first in the calendar year.
TRUE
True or False? In private or commercial healthcare insurance plans, covered conditions are patient conditions, diseases, or injuries for which the healthcare plan will pay and, correspondingly, covered services are services related to treating the covered conditions, diseases, or injuries.
TRUE
Which government-sponsored program is designed to help needy families achieve self-sufficiency?
Temporary Assistance for Needy Families program (TANF)
Which of the following is a trend in healthcare reimbursement?
The federal government dominates healthcare payment methods.
In the accounting system of the physician office, the account is categorized as "self-pay." How should the insurance analyst interpret this category?
The guarantor will pay the entire bill.
In the United States, what is healthcare insurance?
The reduction of a person's or a group's exposure to risk for unknown healthcare costs by the assumption of that risk by an entity
What is the purpose of managed care?
To reduce the costs of healthcare services; To improve the quality of care for patients
The policies and procedures section of a Coding Compliance Plan should include:
Upcoding; Coding medical records without complete documentation; Correct use of encoding software
In the healthcare insurance sector, what does UCR stand for?
Usual Customary and Reasonable
_______ is the term that means evaluating the appropriateness of a healthcare service's setting and level of service.
Utilization review
Who maintains the International Classification of Diseases (ICD)?
WHO
A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Company, where the industrial accident occurred. Basic Manufacturing carries workers' compensation insurance. The workers' compensation insurance paid the fees of the neurosurgeon. Which entity is the "third party"?
Worker's compensation insurance
MS-DRGs are an example of ________.
a case-based payment system
an insured who becomes blind
accidental death and dismemberment insurance
The primary care physician did not meet the MCO's target for counseling cardiac patients about smoking cessation. The primary care physician could expect any of the following results except a(n) _______.
bonus
In the ________, providers get an established payment as a lump sum for each patient for a particular time period from the patients' insurance companies.
capitated payment method
In regards to healthcare insurance, the percentage that the guarantor pays is called the _______.
coinsurance
Case-based reimbursement rewards providers who ________.
consistently provide care that is above average
Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?
cpt
Medicaid does NOT require coverage of ________.
dental services
a homeowner who requires an eight-month recuperation after a fall down her basement stairs
disability income protection insurance
Universal healthcare coverage ________.
establishes a minimum level of health care for everyone
The digits following the decimal point in ICD-10-CM diagnosis codes indicate ________.
etiology, anatomic site, or manifestation
Doug has individual healthcare insurance. Generally, individual healthcare insurance plans provide ________ covered services at a ________ cost than group healthcare insurance plans.
fewer; higher
The per-diem payment method is traditionally used for ________.
inpatient hospital services
A POS is an example of ________.
managed care
Medicare part C is a (an) __________ option known as Medicare Advantage.
managed care
Which of the following entities does not perform improper payment reviews for CMS?
none of the above (qio, cert, rac, mac)
States have the flexibility to provide _______ as part of their Medicaid services.
optometry services
All of the following attributes characterize episode-of-care reimbursement EXCEPT _______.
retrospective fee-for-service
Although employees might contribute to a healthcare fund, the employer assumes all risks and pays all costs for the health care for the employees in a ________.
self-insured plan
Darren is the policyholder of a Blue Cross and Blue Shield plan. He is referred to as a ________.
subscribeR
The DSM-IV is used for ________.
substance abuse or mental disorders
True or False? Payers that use per-diem payment rates reimburse the provider a fixed rate for each day a covered member is hospitalized
true
True or False? The constant trend of increased national spending on healthcare is a concern because as spending on healthcare increases, the money available for other sectors of the economy decreases.
true
UCR stands for ________.
usual, customary, and reasonable
Medicaid coverage ________ across states.
varies a lot