Chapter 1: SB OST 148

Which of the following is the largest nonprofit HMO?

Kaiser Permanente

Standards of conduct based on moral principles are called _____.

ethics

Which of the following are true of medical ethics? (Select all that apply.)

-Professional organizations have codes of ethics to be followed by members. -They are standards of behavior requiring honesty, truthfulness, and integrity. -They guide the behavior of physicians.

Which of the following are true of preparing and transmitting claims? (Select all that apply.)

-A claim communicates information about the diagnoses, procedures, and charges to the payer. -Most practices use the PMP to prepare claims.

Which of the following tasks are part of step 1 (preregistering patients) of the revenue cycle? (Select all that apply.)

-Appointments are scheduled and updated. -Demographic and insurance information is collected. -Patients are asked about the medical reason for the visit upon scheduling.

Which of the following are private-payer health plans?

-Blue Cross and Blue Shield Association -Kaiser Permanente

Which of the following are major government-sponsored healthcare programs? (Select all that apply.)

-CHAMPVA -Medicaid -TRICARE -Medicare

Which of the following are benefits of professional certification? (Select all that apply.)

-Certified specialists earn credentials for their career field. -It allows for advancement in an employee's career field. -Prospective employers will know that applicants have demonstrated superior skill on a national test.

Which of the following are true of managed care insurance plans? (Select all that apply.)

-Choice of and access to providers are restricted. -Premiums and deductibles are lower than those of traditional indemnity insurance. -MCOs establish links between provider, patient, and payer.

Which of the following are true of group plans? (Select all that apply.)

-Dependents are customarily covered under the plans. -They are bought by employers or organizations. -They cost less than individual plans.

Which of the following are true of compliance in the area of coding?

-Diagnostic and procedure codes must be checked for errors. -Official guidelines should be followed when codes are assigned. -Diagnoses and services documented should be linked for medical necessity.

Which of the following statements are true of a medical insurance policy? (Select all that apply.)

-It is a written policy. -It states the terms between a policyholder and an insurance company.

What are the two essential types of insurance plans?

-Managed care -Indemnity

Which of the following are tasks that a medical insurance specialist might be responsible for? (Select all that apply.)

-Medical insurance billing -Bill collection procedures -Payment processing -Insurance verification

Which of the following are true of indemnity plans? (Select all that apply.)

-Physicians send healthcare claims to the payer on behalf of the patient. -The payer indemnifies the policyholder against costs of medical services listed on the benefits schedule. -They offer protection against loss.

Which of the following is true of step 8 (monitor payer adjudication) in the revenue cycle? (Select all that apply.)

-The amount of payment depends on the practice's contract with the payer. -A common reason for claim denial is a failure to meet medical necessity guidelines. -Payers review the claims during the adjudication process.

Which of the following are part of step 3 (check in patients) of the revenue cycle?

-The front and back of insurance cards are copied for the patient's record. -Returning patient information is updated. -Detailed information is collected for new patients.

Which of the following are true of self-funded health plans? (Select all that apply)

-The organization assumes the risk of paying directly for medical services. -An account is set up by the organization from which to pay claims. -The organization establishes the benefit level and the types of plans to be offered.

Which of the following statements are true of insurance specialist careers? (Select all that apply.)

-The work of an insurance specialist is an increasingly complex job. -Employment in positions that help providers handle insurance demands is growing. -Good, experienced billing/coding specialists are in short supply.

Which of the following are true of healthcare plans? (Select all that apply)

-There are two essential types. -There are many variations of each type of plan.

Which of the following are true of copayments? (Select all that apply.)

-They are a specified amount to be paid at the time of the encounter. -Primary care providers sometimes have a lower copayment than specialists. -They are a form of cost-sharing with the health plan.

Which of the following are true of professionals? (Select all that apply.)

-They are motivated to do their best. -They act with honor and integrity. -They act for the good of the public. -They convey a professional image in their appearance, actions, and communications.

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

-They are usually required to provide preventive care services. -They combine coverage of medical costs and delivery of healthcare for a prepaid premium. -They use networks of physicians, hospitals, and other providers by negotiating contracts.

Which of the following are true of point-of-service health plans? (Select all that apply.)

-They reduce restrictions versus traditional HMO plans. -They allow members to choose providers who are not in the HMO's network. -Members must pay an additional fee to use out-of-network providers.

What two elements characterize consumer-driven-health plans?

-They use "savings accounts" to pay medical bills before the deductible is met. -They provide health plans with high deductibles and low premiums.

Which of the following procedures are followed to determine financial responsibility? (Select all that apply.)

-Verify patients' eligibility for their health plan -Check the health plan's coverage -Meet the payers' conditions for payment -Determine the first payer if there is more than one health plan

Which of the following questions must be asked during Step 2 (establish financial responsibility) of the revenue cycle? (Select all that apply.)

-What are the billing rules of the plan? -What services are not covered under the plan? -What is the patient responsible for paying? -What services are covered under the plan?

Which of the following are true of patient billing? (Select all that apply.)

-Whether a code can be billed depends on the payer's rules. -Following billing rules ensures billing compliance. -Most practices have a standard fee schedule that lists usual fees.

Which of the following are reasons why the work of insurance specialists is an increasingly complex job? (Select all that apply)

-providers must follow federal and state regulations -providers deal with many health plans -healthcare practices work with managed care contracts

Which of the following are true of current trends in the healthcare industry? (Select all that apply.)

-there is a shift of payment responsibility to patients -knowledgeable medical office employees are in demand -physicians must manage the business side of their practices as well

Where are payers' payments applied to?

Appropriate patient accounts

A medical insurance that combines a high-deductible health plan with a medical savings plan is called a(n) _____.

CDHP

Which of the following is the last step that occurs while the patient is still in the office?

Checking out the patient

What type of insurance provides reimbursement for income lost due to an inability to work?

Disability insurance

How do indemnity plans usually reimburse medical costs?

Fee-for-service basis

Which type of plan is usually bought by employers or organizations?

Group Plan

Match the skills of a medical insurance specialist with their descriptions.

HIT Skills: Choice, Medical insurance specialists need to know how to use computers to handle bills and process claims, keep patient records, perform data entry, and use the Internet. Medical insurance specialists need to know how to use computers to handle bills and process claims, keep patient records, perform data entry, and use the Internet. Honesty & Integrity: Choice, Medical insurance specialists must maintain patient confidentiality. Medical insurance specialists must maintain patient confidentiality. Ability to Work as a Team Member: Choice, Medical insurance specialists must cooperate with physicians and other staff in the healthcare practice. Medical insurance specialists must cooperate with physicians and other staff in the healthcare practice.

Match the skills of a medical insurance specialist with their descriptions.

Knowledge of medical terminology, anatomy, physiology, and medical coding: Medical insurance specialists must analyze physician's descriptions of patients' conditions and treatments. Communication Skils: Choice, Medical insurance specialists explain or clarify instructions to patients, answer questions, and work with memos, letters, telephone calls, and e-mail. Medical insurance specialists explain or clarify instructions to patients, answer questions, and work with memos, letters, telephone calls, and e-mail. Attention to Detail: Choice, Healthcare claims must be completed accurately, patients' medical records must be filed correctly, and payments must be calculated and posted correctly. Healthcare claims must be completed accurately, patients' medical records must be filed correctly, and payments must be calculated and posted correctly. Flexibility: Medical insurance specialists need to possess the ability to adapt to new procedures, handle problems, and deal with interactions throughout a busy day.

Match the government insurance type to its description.

Medicare: covers individuals who are age 65 and older, are disabled, or have end-stage renal disease Medicaid: covers low-income people who cannot afford medical care TRICARE: covers medical expenses for active-duty or retired members of the uniformed services and their dependents CHAMPVA: covers medical expenses for veterans with 100 percent service-related disabilities and their dependents

Where are providers' fees for services located?

On the fee schedule

A(n) _____ is a managed care plan in which a network of providers supplies discounted treatment for plan members.

PPO

What does it mean when a payment is retroactive?

The fee is paid after the patient receives services.

A practice's operating expenses are _____.

accounts payable (AP)

Which of the following statements describes a major trend in the healthcare industry today?

There is a shift of payment responsibility from employers and insurance companies to patients.

Acting for the good of the public and the medical practice is considered _____.

professionalism

When is the collection process for overdue balances started?

When patient payments are later than permitted under the practice's financial policy

What type of insurance pays benefits and provides medical care for employees who are injured in job-related accidents?

Workers' compensation insurance

Step 2 of the revenue cycle is to _____.

establish financial responsibility

Recognition of a superior level of skill by an official organization is called _____.

certification

Step 3 of the revenue cycle is to _____.

check in patients

Step 6 of the revenue cycle is _____.

checking out patients

Actions that satisfy official requirements are considered _____.

compliance

A specified (fixed) amount that a beneficiary must pay at the time of a healthcare encounter is called a _____.

copayment

Step 10 of the revenue cycle is to _____.

follow up payments and collections

Step 9 of the revenue cycle is to _____.

generate patient statements

Which type of health plan combines coverage of medical costs and delivery of healthcare for a prepaid premium to providers?

health maintenance organization (HMO)

A health plan that offers protection against loss is called a(n) _____ plan.

indemnity

A person or entity that supplies medical or health services and bills for them is called a ________.

provider

A system combining the financing and delivery of healthcare services is called _____.

managed care

A _____ is a staff member with specialized training who handles diagnostic and procedural coding.

medical coder

A healthcare plan that covers the cost of hospital and medical care is called _____.

medical insurance

Staff members who handle billing, check insurance, and process payments are typically known as _____.

medical insurance specialists

It is important to verify codes with data from the patient's _____.

medical record

Accounts receivable is considered _____.

monies owed to a medical practice used to run the practice

Accounts receivable are _____.

monies owed to a practice

Point-of-service plans are also called _____.

open HMOs

A _____ is a managed care plan in which a network of providers supplies discounted treatment for plan members.

preferred provider organization

Step 7 of the revenue cycle is to _____.

prepare and transmit claims

Step 1 in the revenue cycle is to _____.

preregister patients

Step 5 of the revenue cycle is _____.

reviewing billing compliance

A list of medical expenses covered by a health plan is called a _____.

schedule of benefits

An organization that pays for health insurance directly and sets up a fund from which to pay is called a(n) _____.

self-funded health plan