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Chapter 13
Medical Insurance
| Question | Answer |
|---|---|
| The range of fees charged by most physicians in a community is called the | customary fee |
| If a child is covered by both of her parents' insurance and the total medical charges come to $365, $280 of which is covered by the primary insurance, how are the rest of the charges handled | a claim is submitted to secondary insurance for $85 |
| Example of fraud | Altering a patient's chart to increase the amount reimbursed |
| a participating provider in a managed health-care program must write off | disallowed charges |
| What Medicare program covers hospital charges | Part A |
| If Medicare sends a check for payment to the medical office, the physician is considered which party | participating |
| Assume that John Smith got an X-ray through Dr. Jones, a participating provider in Mr. Smith's HMO. The allowed charge for such an X-ray is $75, but Dr. Jones's usual fee is $100. John Smith's copayment due for each office visit is $15. how much can Dr. J | $15 |
| If a person is covered under both Medicare and Medicaid, to which program should the claim be sent first? | Medicare |
| THe amount due from the patient for covered services from a participating provider is the difference between | the allowed charge and the patient's deductible and/or coinsurance |
| Which of the following types of medical insurance is designed to offset medical expenses resulting from prolonged injury or illness? | major medical |
| What is the third-party health plan that is funded by the federal government? | TRICARE |
| Which of the following is true about Blue Cross and Blue Shield? | It offers prepaid health services, it follows a fee-for-service reimbursement plan |
| Capitation is | fixed payment made for each enrolled patient rather than reimbursement based on the type and number of services provided |
| Providers are required by law to file which of the following for all eligible Medicare patients? | CMS-1500 |
| If a nonparticipating provider's charge for a service is $65 and the allowed charge is $50, the amount due from the patient is | $15 |
| The most common insurance claim form is the | CMS-1500 |
| If a policy holder of an 80:20 plan had foot surgery that cost $3600, how much of this bill is the subscriber responsible to pay? | $720 |
| An authorization to the insurance company to make payments directly to the physician is called | assignment of benefits |
| The primary difference between an HMO and a PPO is that | an HMO locks patients into receiving servies from providers with whom it has contracts whereas a PPO allows patients to choose among providers in return for higher deductibles and copayments |
| TRICARE is a health-care benefit program for all of the following except | families of veterans with service related disabilities |
| Fee-for-service reimbursement is | retroactive payment made after services are provided |
| A patien'ts medical fees come to a total of $600 from participating provider, and EOB lists following: Charges $78, not eligible $15, allowed charge $63, applied to deduct $7, coinsurance $5, amt due from carrier $51. what amt is pt required to pay? | $12 |
| In the point-of-service option, | plan members can see out-of-network providers for additional fees |
| In group network model | HMO has capitation contracts with provider groups |
| What is not covered by Medicare part B | hospitalization |
Created by:
walton33