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MED112 CODE/BILL
MED112 CH 01 INTRODUCTION TO THE REVENUE CYCLE
| Question | Answer |
|---|---|
| MED112 CH 1 INTRO TO THE REVENUE CYCLE | |
| Which of the following combines a health plan that has a high deductible and low premiums with a special “savings account” that is used to pay medical bills before the deductible has been met? A. EHR B. CDHP C. HMO D. PPO | CDHP |
| Health plans pay for _____ services. A. indemnity B. coded C. covered D. out-of-network | covered |
| In an HMO, securing ______ may be required before services are provided. A. formulary B. preauthorization C. utilization D. gatekeeper | preauthorization |
| A self-insured health plan may use its own A. gatekeepers. B. primary care physicians. C. funds. D. physician-employees. | funds. |
| The major government-sponsored health programs are A. Medicare and TRICARE. B. TRICARE, CHAMPVA, Medicare, and Medicaid. C. Medicare and Medicaid. D. HEDIS, Medicare, Medicaid, and CHAMPUS. | TRICARE, CHAMPVA, Medicare, and Medicaid. |
| Coinsurance is calculated based on A. a percentage of a charge. B. a fixed charge for each visit. C. a capitation rate. D. the number of policyholders in a plan. | a percentage of a charge. |
| When a patient has insurance coverage for which the practice will create a claim, the patient bill is usually created A. after the encounter and after the payer’s payment is posted. B. before the encounter. C. after the encounter when the health care claim is transmitted. D. during the encounter. | after the encounter and after the payer’s payment is posted. |
| If a patient’s payment is later than permitted under the financial policy of the practice, the _____ may be started. A. copayment process B. coding process C. collection process D. appeal process | collection process |
| Can earn the title CMA or RMA: A. Medical assisting certification B. Coding certification C. Health information certification D. Continuing education | Medical assisting certification |
| Can earn RHIA or RHIT certification; work in office-based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies. A. Medical assisting certification B. Coding certification C. Health information certification D. Continuing education | Health information certification |
| Experts in classifying medical data; includes: CCA, CCS, CCS-P, CPC, and CPC-A certifications. A. Medical assisting certification B. Coding certification C. Health information certification D. Continuing education | Coding certification |
| Required by most professional organizations A. Medical assisting certification B. Coding certification C. Health information certification D. Continuing education | Continuing education |
| Unlike an HMO, a PPO permits its members to use ____ providers, but at a higher cost. A. nonphysician practitioner B. subcapitated C. out-of-network D. primary care | out-of-network |
| Which of the following statements describes a major trend in the healthcare industry today? A. Patients are required to pay less out-of-pocket costs, as insurance companies assume more cost. B. Employees are now paying 100% of patient benefits with no out-of-pocket expenses to the patient. C. A state fund covers all expenses that are not approved by the health plans. D. There is a shift of payment responsibility from employers and insurance companies to patients. | There is a shift of payment responsibility from employers and insurance companies to patients. |
| Which are reasons why the work of insurance specialists is an increasingly complex job? □ Providers deal with many health plans □ Healthcare practices work with managed care contracts □ Providers must follow federal and state regulations □ Each practice only works with one health plan | Providers deal with many health plans; Healthcare practices work with managed care contracts; Providers must follow federal and state regulations |
| Movement of monies into or out of a business is called ____ A. cash flow B. accounts receivable C. accounts payable D. cash stratification | cash flow |
| Which of the following statements are true of a medical insurance policy? □ It states the terms between a doctor and a patient. □ It is an agreement between a policyholder and an insurance company. □ It is a written policy. □ It states the terms between a provider and an insurance company. □ It is an oral agreement. | It is an agreement between a policyholder and an insurance company; It is a written policy. |
| A list of medical expenses covered by a health plan is called a A. fee schedule B. payment schedule C. covered service D. schedule of benefits | schedule of benefits |
| Which of the following is true of current trends in the healthcare industry? □ payment responsibility is shifting from employers and insurance companies to patients. □ physician practices are moving away from hiring certified healthcare employees. □ most healthcare practices have adopted a "not-for-profit" philosophy. □ knowledgeable medical office employees are in demand. | payment responsibility is shifting from employers and insurance companies to patients; knowledgeable medical office employees are in demand |
| Typically, insurance policies that are written for groups cost the policyholders ____ those written for individuals. A. three times as much as B. less than C. more than D. the same as | less than |
| Which of the following is true of insurance specialist careers? □ there is no opportunity for career development for insurance specialists. □ employment in positions that help providers handle insurance demands is growing. □ the work of an insurance specialist is an increasingly complex job. □ good, experienced billing/coding specialists are in short supply. □ the market is flooded with experienced medical insurance specialists. | employment in positions that help providers handle insurance demands is growing; the work of an insurance specialist is an increasingly complex job; good, experienced billing/coding specialists are in short supply. |
| Which type of insurance pays benefits and provides medical care for employees who are injured in job-related accidents? A. disability insurance B. workers' compensation insurance C. Medicare advantage plans D. automotive insurance | workers' compensation insurance |
| Accounts receivable are ____ A. a practice's operating expenses B. the movement of monies into or out of a business C. monies owed to a practice used to run the practice D. not part of the accounting process | monies owed to a practice used to run the practice |
| What are 2 essential types of insurance plans? □ government □ claim-focused □ managed care □ indemnity | managed care; indemnity |
| A healthcare plan that covers the cost of hospital and medical care is called ____ A. medical insurance B. provider networking C. liability insurance D. a policyholder | medical insurance |
| A person or entity that supplies medical or health services and bills for them is called a ____) A. payer B. provider C. health plan D. patient | provider |
| Which type of plan is usually bought by employers or organizations? A. all-inclusive plan B. individual plan C. exempt plan D. group plan | group plan |
| What type of insurance provides reimbursement for income lost due to an inability to work? A. disability insurance B. social security insurance C. indemnity plans D. loss prevention insurance | disability insurance |
| How do indemnity plans usually reimburse medical costs? A. capitation B. pyramid structure C. fee-for-service basis D. managed care payment | fee-for-service basis |
| A system combining the financing and delivery of healthcare services is called A. bipartisan B. managed care C. fee for service D. an indemnity plan | managed care |
| Which type of health plan combines coverage of medical costs and delivery of healthcare for a prepaid premium to providers? A. Health maintenance organization B. Indemnity plan C. Fee-for-service plan D. Consumer-driven health plan | Health maintenance organization |
| A service that has met ____ is considered reasonable and consistent with generally accepted standards for the diagnosis or treatment. A. third-party guidelines B. medical necessity C. preventative measures D. continuity of care standards | medical necessity |
| A health plan that offers protection against loss is called a(n) ____ plan. A. government B. managed care C. affordable care D. indemnity | indemnity |
| Point-of-service plans are also called ____ A. open indemnity plans B. access care plans C. open HMOs D. CHIP plans | open HMOs |
| Payment method base on provider charges is called ____ A. prospective payment B. point of service C. fee for service D. capitated rate | fee for service |
| A(n) ____ is a managed care plan in which a network of providers supplies discounted treatment for plan members. A. POS b. MCO c. HMO d. PPO | PPO |
| MCO stands for A. managed care organization B. managed care operation C. managed coordination organization D. maintenance care organization | managed care organization |
| What is the main idea behind consumer-driven health plans? A. When patients pay more for medical expenses, the cost of healthcare rises for the insurance companies. B. When patients pay for healthcare services, they become more careful consumers, which reduces cost C. Patients are discouraged from using their healthcare benefits altogether. D. Patients are encouraged to seek higher levels of healthcare regardless of the cost. | When patients pay for healthcare services, they become more careful consumers, which reduces cost |
| Select the following that are true of HMOs. □ Patients are able to use any provider of their choice. □ They combine coverage of medical costs and delivery of healthcare for a prepaid premium. □ HMO stands for health maintenance operation. □ They use a network of physicians, hospitals, and other providers by negotiating contracts. | They combine coverage of medical costs and delivery of healthcare for a prepaid premium; They use a network of physicians, hospitals, and other providers by negotiating contracts. |
| Which of the following are private-payer health plans? □ Blue Cross and Blue Shield Association □ Kaiser Permanente □ Medicare □ Medicaid | Blue Cross and Blue Shield Association; Kaiser Permanente |
| Which of the following are true of copayments? □ Primary care providers sometimes have a lower copayment than specialists □ They are a form of cost-sharing with the health plan □ They are a specified amount to be paid at the time of the encounter □ They are a percentage of the encounter's charges | Primary care providers sometimes have a lower copayment than specialists; They are a form of cost-sharing with the health plan; They are a specified amount to be paid at the time of the encounter |
| Which of the following are true of self-funded health plans? □ The organization pays large premiums to private health plans □ 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 □ Most are set up as HMOs | 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 are true of point-of-service health plans? □ Members must remain within the network for care. □ They have reduced restrictions compared to traditional HMO plans □ Members must pay an additional fee to use out-of-network providers □ They are more restrictive than traditional HMO plans □ They allow members to choose providers who are not in the HMO's network | They have reduced restrictions compared to traditional HMO plans; Members must pay an additional fee to use out-of-network providers; They allow members to choose providers who are not in the HMO's network |
| A ____ is a managed care plan in which a network of providers supplies discounted treatment for plan members. A. preferred provider organization B. health maintenance organization C. point-of-service plan D. provider care network | preferred provider organization |
| Which of the following are tasks that a medical insurance specialist might be responsible for? □ payment processing □ bill collection procedures □ taking vital signs □ assisting with a minor surgical procedure □ insurance verification □ medical insurance billing | payment processing; bill collection procedures; insurance verification; medical insurance billing |
| A medical insurance that combines a high-deductible health plan with a medical savings plan is called a(n) A. POS B. CDHP C. PPO D. HMO | CDHP |
| Step 1 in the revenue cycle is to ____ A. preregister patients B. establish financial responsibility C. check in patients D. prepare and transmit claims | preregister patients |
| Which of the following is the largest nonprofit HMO? A. Kaiser Permanente B. Medicare C. Blue Cross and Blue Shield Association D. Aetna | Kaiser Permanente |
| Which of the following questions must be asked during Step 2 (establish financial responsibility) of the revenue cycle? □ What is the time frame in which claims must be submitted? □ What services are not covered under the plan? □ What is the patient responsible for paying? □ What services are covered under the plan? □ 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? What are the billing rules of the plan? |
| An organization that pays for health insurance directly and sets up a fund from which to pay is called a(n) A. for-profit health plan B. self-funded health plan C. consumer-driven health plan D. health maintenance organization | self-funded health plan |
| Step 3 of the revenue cycle is to ____ A. prepare and transmit claims B. establish financial responsibility C. check in patients D. check out patients | check in patients |
| Staff members who handle billing, check insurance, and process payments are typically known as ____ A. medical insurance specialists B. front office specialists C. medical coding professionals D. customer service representative | medical insurance specialists |
| A ____ is a staff member with specialized training who handles diagnostic and procedural coding. A. medical coder B. medical assistant C. coding assistant D. code specialist | medical coder |
| Which of the following tasks are part of step 1 (preregistering patients) of the revenue cycle? □ Appointments are scheduled and updated □ Demographic and insurance information is collected □ Patients are asked about the medical reason for the visit upon scheduling □ The payers conditions for payment are met □ The health plan coverage is checked | Appointments are scheduled and updated; Demographic and insurance information is collected; Patients are asked about the medical reason for the visit upon scheduling |
| Step 2 of the revenue cycle is to ____ A. review coding compliance B. monitor payer adjudication C. establish patient insurance D. establish financial responsibility | establish financial responsibility |
| Actions that satisfy official requirements are considered ____ A. compliance B. etiquette C. ethics D. professional standards | compliance |
| Which of the following are true of self-funded health plans? □ An account is set up by the organization from which to pay claims. □ The organization assumes the risk of paying directly for medical services □ The organization pays large premiums to private health plans □ Most are set up as HMOs □ The organization establishes the benefit level and the types of plans to be offered | An account is set up by the organization from which to pay claims; The organization assumes the risk of paying directly for medical services; The organization establishes the benefit level and the types of plans to be offered |
| Step 5 of the revenue cycle is ____ A. checking out patients B. transmitting claims C. reviewing billing compliance D. reviewing coding compliance | reviewing billing compliance |
| Which of the following are part of step 3 (check in patients) of the revenue cycle? □ detailed information is collected for new patients □ diagnostic and procedure codes are reviewed □ arrangements are made to bill the patient for copayment at a later date □ returning patient information is updated □ the front and back of insurance cards are copied for the patients record | detailed information is collected for new patients; returning patient information is updated; the front and back of insurance cards are copied for the patients record |
| Step 6 of the revenue cycle is ____ A. checking out patients B. preregistering patients C. reviewing coding compliance D. reviewing billing compliance | checking out patients |
| Step 4 of the revenue cycle is to ____ A. monitor payer adjudication B. check out patients C. establish financial responsibility D. review coding compliance | review coding compliance |
| Step 7 of the revenue cycle is to ____ A. apply medical codes to claims B. monitor payer adjudication C. check out patients D. prepare and transmit claims | prepare and transmit claims |
| Which of the following are true of compliance in the area of coding? □ diagnostic and procedure codes must be checked for errors □ diagnoses and services documented should be linked for medical necessity □ additional codes should be included to ensure payment □ official guidelines need to be followed only after claims are rejected □ official guidelines should be followed when codes are assigned | diagnostic and procedure codes must be checked for errors; diagnoses and services documented should be linked for medical necessity; official guidelines should be followed when codes are assigned |
| Step 9 of the revenue cycle is to ____ A. monitor payer adjudication B. follow up payments and collections C. generate patient statements D. prepare and transmit claims | generate patient statements |
| Which of the following are true of patient billing? □ most practices have a standard fee schedule that lists usual fees □ the provider should charge more for services for patients with health insurance □ whether a code can be billed depends on the payer's rules □ all codes can be billed to the payer □ following billing rules ensures billing compliance | most practices have a standard fee schedule that lists usual fees; whether a code can be billed depends on the payer's rules; following billing rules ensures billing compliance |
| When is the collection process for overdue balances started? A. at the end of every month B. when patient payments are later than permitted under the practice's financial policy C. when the patient is checking out and all services have been performed D. upon receipt of the health plan's payment | when patient payments are later than permitted under the practice's financial policy |
| Which of the following is the last step that occurs while the patient is still in the office? A. monitoring payer adjudication B. establishing financial responsibility C. checking out the patient D. reviewing billing compliance | checking out the patient |
| Acting for the good of the public and the medical practice is considered ____ A. professionalism B. trust C. accountability D. etiquette | professionalism |
| Choose from the list all of the following that are true of preparing and transmitting claims. □ most practices send claims to the payer by mail □ most practices use the PMP to prepare claims □ a claim communicates information about the diagnoses, procedures, and charges to the payer □ claims communicate patients' test results to the payers | most practices use the PMP to prepare claims; a claim communicates information about the diagnoses, procedures, and charges to the payer |
| Which of the following is true of step 8 (monitor payer adjudication) in the revenue cycle? □ the payer will pay the provider the exact fee listed on the feel schedule □ a common reason for claim denial is a failure to meet medical necessity guidelines □ the amount of payment depends on the practice's contract with the payer □ when patients are covered by more than one health plan, the remainder of the claims are sent to the patients □ payers review the claims during the adjudication process | a common reason for claim denial is a failure to meet medical necessity guidelines; the amount of payment depends on the practice's contract with the payer; payers review the claims during the adjudication process |
| Where are payers' payments applied to? A. appropriate patient accounts B. secondary insurance plans C. practice's accounts payable D. third-party account | appropriate patient accounts |
| Which of the following are true of medical ethics? □ professional organizations have codes of ethics to be followed by members □ they are standards of behavior requiring honesty, truthfulness, and integrity □ ethical codes avoid referring to issues of confidentiality □ they guide the behavior of physicians □ only physicians need to observe the ethical code | 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 |
| Step 10 of the revenue cycle is to ____ A. monitor payer adjudication B. follow up payments and collections C. follow up on claim forms D. generate patient statements | follow up payments and collections |
| Select all of the following that are benefits of professional certification: □ Certified specialists earn credentials for their career field. □ It provides a degree in the field of choice. □ It guarantees the professional will get a job in their chosen field. □ Prospective employers will know that applicants have demonstrated superior skill on a national test. □ It allows for advancement in an employee's career field. | Certified specialists earn credentials for their career field; Prospective employers will know that applicants have demonstrated superior skill on a national test; It allows for advancement in an employee's career field. |
| Step 8 of the revenue cycle is ____ A. reviewing coding compliance B. preparing and transmitting claims C. monitoring payer adjudication D. reviewing billing compliance | monitoring payer adjudication |
| Standards of conduct based on moral principals are called ____ A. ethics B. morals C. etiquette D. values | ethics |
| Recognition of a superior level of skill by an official organization is called: A. certification B. professional status C. diplomacy D. an achievement award | certification |
| Acting for the good of the public and the medical practice is considered: A. professionalism B. etiquette C. accountability D. trust | professionalism |
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