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MED112 CODE/BILL
MED112 CH 08 PRIVATE PAYERS/ACA PLANS SB
| Question | Answer |
|---|---|
| MED112 CH 08 SB | |
| Which of the following is a benefit to employers when offering medical benefits to their employees? A. Pay employees lower wages B. Earn additional income from employee payments C. Federal income tax advantages D. Federal income tax penalties | C. Federal income tax advantages |
| Which of the following apply to group health plans? (MAY BE MORE THAN ONE) A. The individual is considered the certificate holder. B. Employees manage their own benefits and negotiate with the health plans. C. The individual is considered the policyholder. D. Employers’ human resource departments manage GHP benefits. E. The group is considered the policyholder. | A. The individual is considered the certificate holder. D. Employers’ human resource departments manage GHP benefits. E. The group is considered the policyholder. |
| The FEHB is administered by which of the following? A. Occupational Safety and Health Administration B. State Department C. Office of Personnel Management (OPM) D. State government | C. Office of Personnel Management (OPM) |
| Which of the following apply to self-funded or self-insured health plans? (MAY BE MORE THAN ONE) A. Created by large employers to save money B. Employee assumes the risk of paying directly for medical services C. Employers cover the costs of employee medical benefits themselves rather than buying insurance from other companies D. Employer assumes the risk of paying directly for medical services | A. Created by large employers to save money C. Employers cover the costs of employee medical benefits themselves rather than buying insurance from other companies D. Employer assumes the risk of paying directly for medical services |
| The group health plan has rules that can cover which of the following? (MAY BE MORE THAN ONE) A. Employment status B. Eligibility C. Personal health care decisions D. Conditions for enrolling dependents | A. Employment status B. Eligibility D. Conditions for enrolling dependents |
| People who are not covered by government-sponsored health insurance are often covered by ______. A. TRICARE B. Medicaid C. Medicare D. Private insurance | D. Private insurance |
| Which of the following statements apply to private payers? (MAY BE MORE THAN ONE) A. PPOs are the most popular type of private plan. B. CDHPs combine a high-deductible plan with a funding option of some type. C. Few employees choose indemnity health plans. D. HMOs are the most popular type of private plan. | A. PPOs are the most popular type of private plan. B. CDHPs combine a high-deductible plan with a funding option of some type. C. Few employees choose indemnity health plans. |
| Which of the following plan types are purchased from insurance companies by employers for their employees? A. Combined health plans B. Employee health plans C. Employer health plans D. Group health plans (GHP) | D. Group health plans (GHP) |
| Identify all of the correct statements related to preferred provider plans (PPOs). (MAY BE MORE THAN ONE) A. Medical providers can still be listed in the PPO network but not accept the plan’s fee schedule. B. Physicians, hospitals, clinics, and pharmacies contract with the PPO plan to provide care to its insured people. C. Medical providers accept the PPO plan’s fee schedule and guidelines for managed care. D. Physicians, hospitals, clinics, and pharmacies do not usually participate in PPOs. | B. Physicians, hospitals, clinics, and pharmacies contract with the PPO plan to provide care to its insured people. C. Medical providers accept the PPO plan’s fee schedule and guidelines for managed care. |
| Which of the following apply to the Federal Health Benefits (FEHB) program? (MAY BE MORE THAN ONE) A. Covers more than 8 million federal employees, retirees, and their families B. Contains three major health care plans C. Largest employer-sponsored health program in the United States D. Contains more than 250 health plans | A. Covers more than 8 million federal employees, retirees, and their families C. Largest employer-sponsored health program in the United States D. Contains more than 250 health plans. |
| Which of the following apply to HMOs? (MAY BE MORE THAN ONE) A. HMOs do not cover preventive care and maintenance. B. HMOs may now apply deductibles to family coverage. C. Employer-sponsored HMOs are beginning to replace copayments with coinsurance for some benefits. D. HMOs have traditionally emphasized preventive and wellness services. | B. HMOs may now apply deductibles to family coverage. C. Employer-sponsored HMOs are beginning to replace copayments with coinsurance for some benefits. D. HMOs have traditionally emphasized preventive and wellness services. |
| Which of the following apply to point-of-service (POS) plans? (MAY BE MORE THAN ONE) A. Monthly premiums are slightly higher than for HMOs. B. Like HMOs, POS plans charge an annual premium and a copayment for office visits. C. A POS may be structured as a tiered plan with different rates for different providers. D. POS plans do not allow copayments. E. Patients in POS plans can see any provider and have no affiliation with networks. | A. Monthly premiums are slightly higher than for HMOs. B. Like HMOs, POS plans charge an annual premium and a copayment for office visits. C. A POS may be structured as a tiered plan with different rates for different providers. |
| Identify services that are usually NOT subject to the deductible under the HDHP plan. (MAY BE MORE THAN ONE) A. Elective surgery B. Vision care C. Cosmetic surgery D. Dental care E. Preventive care | B. Vision care D. Dental care E. Preventive care |
| Contributions to a health savings account (HSA) are commonly made through a ________. A. General fund B. Payment plan C. Pretax payroll deduction | C. Pretax payroll deduction |
| Indemnity plans require which of the following types of payments or cost-sharing? (MAY BE MORE THAN ONE) A. Coinsurance B. Premiums C. Deductibles D. Deferred payments | A. Coinsurance B. Premiums C. Deductibles |
| Which of the following are types of private payers? (MAY BE MORE THAN ONE) A. Preferred provider organizations (PPOs) B. Health maintenance organizations (HMOs) C. Preferred provider plans (PPPs) D. Consumer-driven health plans (CDHPs) | A. Preferred provider organizations (PPOs) B. Health maintenance organizations (HMOs) D. Consumer-driven health plans (CDHPs) |
| Plans that coordinate patients’ treatments are referred to as ________. A. Medical home model plans B. Multiplan treatment centers C. Patient treatment plan events D. Coordinated plans | A. Medical home model plans |
| PPOs generally pay participating providers based on a discount from their physician fee schedules, called a discounted ________. A. Fee-for-service B. Deductible C. Premium D. Co-insurance | A. Fee-for-service |
| Consumer-driven health plans (CDHPs) combine which of the two following components? (MAY BE MORE THAN ONE) A. High deductible health plans B. Low deductible health plans C. One or more tax-preferred savings accounts that the physician directs D. One or more tax-preferred savings accounts that the patient directs | A. High deductible health plans D. One or more tax-preferred savings accounts that the patient directs |
| Which of the following apply to indemnity plan reimbursements? (MAY BE MORE THAN ONE) A. Many have managed care features. B. They typically cover 70 to 80 percent of costs after the deductible is met. C. Some have higher deductibles in order to keep costs down. D. They typically have lower deductibles. | A. Many have managed care features. B. They typically cover 70 to 80 percent of costs after the deductible is met. C. Some have higher deductibles in order to keep costs down. |
| Which of the following types of CDHP funding options allow unused funds to roll over indefinitely? A. Retirement accounts B. Flexible savings (spending) accounts C. Health savings accounts D. Health reimbursement accounts | C. Health savings accounts |
| Which of the following apply to medical home model plans? (MAY BE MORE THAN ONE) A. Primary care physician is responsible for arranging patients’ visits to specialists. B. Physician-centered C. Focus primarily on illness-based primary care D. Replace illness-based primary care with coordinated care E. Emphasize communication among a patient’s physicians | A. Primary care physician is responsible for arranging patients’ visits to specialists. D. Replace illness-based primary care with coordinated care E. Emphasize communication among a patient’s physicians |
| Consumer-driven health plans ________ providers’ cash flow because visit copayments are being replaced by high deductibles that may not be collected until after claims are paid. A. Supplement B. Eliminate C. Increase D. Reduce | D. Reduce |
| Which of the following apply to CDHPs? (MAY BE MORE THAN ONE) A. CDHPs empower consumers to manage their use of healthcare services. B. CDHPs eliminate most copayment coverage. C. CDHPs shift payment responsibility to the individual. D. CDHPs discourage consumers from managing their healthcare services. | A. CDHPs empower consumers to manage their use of healthcare services. B. CDHPs eliminate most copayment coverage. C. CDHPs shift payment responsibility to the individual. |
| Which of the following are insurance services that are supplied by private payers? (MAY BE MORE THAN ONE) A. Purchasing addendum plans B. Processing claims C. Establishing fees D. Managing insurance risk | B. Processing claims C. Establishing fees D. Managing insurance risk |
| Which of the following are among the major national insurance payers? (MAY BE MORE THAN ONE) A. Anthem B. Northwestern C. Health Plus Group D. CIGNA Health Care E. Aetna F. Humana Inc. G. Kaiser Permanente | A. Anthem D. CIGNA Health Care E. Aetna F. Humana Inc. G. Kaiser Permanente |
| The first part of a CDHP is a ________ health plan. A. Managed care B. High-deductible C. Cost effective D. Low-deductible | B. High-deductible |
| Of the three plan types offered by BCBS, which of the following requires the patient to choose a primary care physician? A. PMS B. POS C. Private plan D. HMO | D. HMO |
| Which of the following are CDHP funding options? (MAY BE MORE THAN ONE) A. Health savings accounts B. Nonhealth-related funding accounts C. Flexible savings (spending) accounts D. Retirement accounts E. Health reimbursement accounts | A. Health savings accounts C. Flexible savings (spending) accounts E. Health reimbursement accounts |
| As more employer-sponsored plan members are covered under CDHPs, physician reimbursement up to the amount of the deductible will come from ________. A. The patient's insurance company B. Deductibles C. The employer D. The patient's funding plan options | D. The patient's funding plan options |
| Which of the following apply to the ACA? (MAY BE MORE THAN ONE) A. Using federal subsidies to help cover costs is part of the ACA. B. The ACA is on good footing and in no danger of change. C. Medical insurance specialists should stay updated on all aspects of the regulations as they emerge. D. Congressional decisions on the funding and legality of the act make aspects of the law uncertain. | A. Using federal subsidies to help cover costs is part of the ACA. C. Medical insurance specialists should stay updated on all aspects of the regulations as they emerge. D. Congressional decisions on the funding and legality of the act make aspects of the law uncertain. |
| Identify all of the correct statements related to the role and services of commercial insurance companies. (MAY BE MORE THAN ONE) A. Local or regional payers are often affiliated with the BlueCross BlueShield Association. B. Local or regional payers are not affiliated with the BlueCross BlueShield Association. C. A small number of large companies dominate the national market for commercial insurance. D. Local or regional payers are often affiliated with a national plan. | A. Local or regional payers are often affiliated with the BlueCross BlueShield Association. C. A small number of large companies dominate the national market for commercial insurance. D. Local or regional payers are often affiliated with a national plan. |
| A key goal of the ACA is to reduce the number of uninsured citizens and legal residents by providing affordable ________. A. Physician procedures B. Medicare coverage C. Group health plans D. Individual health plans | D. Individual health plans |
| Which of the following apply to the BlueCross BlueShield Association (BCBS)? (MAY BE MORE THAN ONE) A. BCBS is a major national payer. B. BCBS has both for-profit and nonprofit members. C. BCBS only works with for-profit organizations and members. D. BCBS is an association and not a payer. E. BCBS's national scope means that knowing about its programs is important for all medical insurance specialists. | B. BCBS has both for-profit and nonprofit members. D. BCBS is an association and not a payer. E. BCBS's national scope means that knowing about its programs is important for all medical insurance specialists. |
| Which of the following types of managed care programs are offered by BCBS? (MAY BE MORE THAN ONE) A. Temporary Plan B. HMO C. POS D. PPO E. Government HMO plans | B. HMO C. POS D. PPO |
| In private exchanges, employees are able to do which of the following in their IHPs? A. Opt out of the health plan B. Change the rates of the plan C. Make changes to the plan D. Choose their own plans using a specific amount of money the employer allocates | D. Choose their own plans using a specific amount of money the employer allocates |
| Providers must evaluate health plans, and they judge which plans to participate in based primarily on the ________. A. Feedback B. Reputation of the plan C. Financial arrangements offered D. History of the plan | C. Financial arrangements offered |
| Identify the act that aims to improve healthcare and protects patients in the United States. A. Affordable and Accountable Care Act (AAC) B. Patient Protection and Affordable Care Act (ACA) C. Healthcare Protection Act (HPA) D. Patient Care Act (PCA) | B. Patient Protection and Affordable Care Act (ACA) |
| When a practice's contract evaluation team is considering a participation contract, a ________ may be asked to assist. A. Physician consultant B. Nurse consultant C. Medical insurance specialist D. Tax specialist | C. Medical insurance specialist |
| Half of the states that were required by the ACA to create a public government-run online marketplace to offer IHPs chose to run their own ________. A. State policy procedures B. Health insurance exchanges C. Insurance plans D. Health care plans | B. Health insurance exchanges |
| Compiling billing data permits the practice to track how much revenue it has lost as a result of ________. A. Lowering the fee rates B. Participating in a particular contract C. Changing the plan services D. Raising the fee rates | B. Participating in a particular contract |
| If a provider does not participate in a particular health plan, its patients should ________ before scheduling procedures. A. See a counselor B. Agree to pay in writing C. Amend the insurance contract D. Verbally agree to pay | B. Agree to pay in writing |
| Private exchanges are eligible to offer IHPs to which of the following? (MAY BE MORE THAN ONE) A. State governments B. Small businesses C. Federal government D. Individuals | B. Small businesses D. Individuals |
| Identify all of the correct statements related to copayments. (MAY BE MORE THAN ONE) A. Copayment amounts vary depending on the procedure. B. Some plans require a copayment when the patient visits the office for any procedure or service. C. Copayment amounts remain the same for all procedures. D. Some plans require a copayment only when an E/M service is provided. | A. Copayment amounts vary depending on the procedure. B. Some plans require a copayment when the patient visits the office for any procedure or service. D. Some plans require a copayment only when an E/M service is provided. |
| Because managed care organizations are the predominant healthcare delivery systems, most medical practices have contracts with ________. A. A number of plans in the area B. A small number of plans outside the area C. A large number of plans outside the area D. Every plan in the area | A. A number of plans in the area |
| Which of the following apply to silent PPOs? (MAY BE MORE THAN ONE) A. Most experts recommend trying to negotiate a phrase in contracts stating the MCO cannot lease any terms of the agreement. B. Silent PPOs can lead to a practice accepting a PAR payment. C. Silent PPOs are required by the government in order to provide services to patients. D. They allow a managed care organization to lease its PPO provider network list to another entity. | A. Most experts recommend trying to negotiate a phrase in contracts stating the MCO cannot lease any terms of the agreement. B. Silent PPOs can lead to a practice accepting a PAR payment. D. They allow a managed care organization to lease its PPO provider network list to another entity. |
| Identify all of the correct statements related to an evaluation team. (MAY BE MORE THAN ONE) A. An outside attorney usually reviews the contract. B. All plans pay more than the physicians' fee schedule. C. The managed care organization's business history, accreditation standing, and licensure status are reviewed. D. A practice manager or a committee of physicians usually leads the team. | A. An outside attorney usually reviews the contract. C. The managed care organization's business history, accreditation standing, and licensure status are reviewed. D. A practice manager or a committee of physicians usually leads the team. |
| Identify all of the correct statements related to billing surgical procedures. (MAY BE MORE THAN ONE) A. Elective surgery usually requires preauthorization. B. The preauthorization requirement is usually shown on the patient's insurance card. C. Preauthorizations are never required for surgical procedures. D. Emergency surgery usually must be approved within a specified period after admission was required. | A. Elective surgery usually requires preauthorization. B. The preauthorization requirement is usually shown on the patient's insurance card. D. Emergency surgery usually must be approved within a specified period after admission was required. |
| Identify all of the correct statements related to compiling billing data. (MAY BE MORE THAN ONE) A. Practices do not typically bill the contracted fees. B. After the RA is processed, differences can be written off between normal fees and payments. C. Differences cannot be written off. D. Practices generally bill from their normal fee schedules. E. The practice has no way of tracking data to see how much revenue is lost by participation in a particular plan. | A. Practices do not typically bill the contracted fees. B. After the RA is processed, differences can be written off between normal fees and payments. D. Practices generally bill from their normal fee schedules. |
| Which of the following apply to establishing policies for no-shows? (MAY BE MORE THAN ONE) A. Often a physician cannot bill for services not delivered, including cancellations and no-shows. B. Often a physician may bill only for a rendered service. C. Physicians are always allowed to bill for services and products on no-show patients. D. The contract determines whether a provider can charge for a product when there is a no-show. | A. Often a physician cannot bill for services not delivered, including cancellations and no-shows. B. Often a physician may bill only for a rendered service. D. The contract determines whether a provider can charge for a product when there is a no-show. |
| Which of the following statements apply to copayments? (MAY BE MORE THAN ONE) A. Copayments are always collected for both primary and secondary plans. B. Medical insurance specialists should verify whether a copayment is to be collected under the secondary plan. C. Copayments are never collected under the secondary plan. D. A variable in collecting copayments involves primary and secondary plans. | B. Medical insurance specialists should verify whether a copayment is to be collected under the secondary plan. D. A variable in collecting copayments involves primary and secondary plans. |
| Which of the following are answered by plan summary grids or similar aids? (MAY BE MORE THAN ONE) A. Which services are not covered B. What the patient is responsible for paying at the time of the encounter C. What the patient's prognosis is D. What the plan's billing rules are Correct Answers: | A. Which services are not covered B. What the patient is responsible for paying at the time of the encounter D. What the plan's billing rules are |
| A silent PPO is also known as a ________. A. Personal pay agreement B. Network sharing agreement C. Private pay D. Personal network agreement | B. Network sharing agreement |
| What is the purpose of following the first seven steps of the standard revenue cycle? A. To begin the collections process B. To perform payer adjudication to determine the payment of claims C. To complete correct claims and transmit them to private payers D. To collect payment from patients | C. To complete correct claims and transmit them to private payers |
| Which of the following applies to elective surgery? A. An elective surgery is medically necessary. B. A physician can require elective surgery. C. An elective surgery cannot be scheduled ahead of time and is done on an emergency basis. D. An elective surgery may or may not be medically necessary. | D. An elective surgery may or may not be medically necessary. |
| Which of the following apply to preregistration of patients? (MAY BE MORE THAN ONE) A. Collecting and entering basic demographic and insurance information B. The last step of the revenue cycle C. Step 1 of the revenue cycle D. An optional step E. Step 2 of the revenue cycle | A. Collecting and entering basic demographic and insurance information C. Step 1 of the revenue cycle |
| How can the medical insurance specialist know a patient's eligibility for a procedure? A. Have the patient bring their plan manual into the office. B. Contact the payer. C. Ask the patient. D. Ask the physician. | B. Contact the payer. |
| Step ________ of the revenue cycle is checking in patients. A. 8 B. 3 C. 6 D. 2 | B. 3 |
| Which of the following are addressed by plan summary grids or similar aids? (MAY BE MORE THAN ONE) A. Whether services are correctly coded and linked B. Whether the patient has a past surgical history C. How much time was spent D. What services are covered under the plan E. What conditions establish medical necessity for these services | A. Whether services are correctly coded and linked D. What services are covered under the plan E. What conditions establish medical necessity for these services |
| Which of the following are steps in preparing the correct claims? (MAY BE MORE THAN ONE) A. Preregister patients. B. Review history of patients. C. Check in patients. D. Establish financial responsibility for visits. | A. Preregister patients. C. Check in patients. D. Establish financial responsibility for visits. |
| The codes need to be linked and documented to show what? A. Proper billing B. Medical necessity C. Coding compliance D. Preauthorization | B. Medical necessity |
| Step 1 of the revenue cycle is ________. A. Preauthorizing patients B. Preregistering patients C. Monitoring payer adjudication D. Applying medical codes | B. Preregistering patients |
| Using the plan summary grid, you should verify that all charges planned for the claim are ________. A. Coded B. Billable C. Not documented D. Negotiable | B. Billable |
| Which of the following should be done to verify insurance eligibility? (MAY BE MORE THAN ONE) A. Contact the payer to double-check. B. Assume the patient is eligible and bill after the procedure has been performed. C. Accurately enter the patient's name and ID number. D. Refer to an eligibility roster. E. Verbally verify eligibility with the patient. | A. Contact the payer to double-check. C. Accurately enter the patient's name and ID number. |
| Which of the following apply to check-in procedures related to up-front collections? (MAY BE MORE THAN ONE) A. 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. B. Copayments should be waived if the patient was not happy with the charge. C. Be sure the correct copayment has been collected. D. Copayments should be collected after the visit and sent through the mail. | A. 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. C. Be sure the correct copayment has been collected. |
| The patient's financial responsibility is analyzed according to the practice's financial policy for which of the following? (MAY BE MORE THAN ONE) A. Deductibles B. Payment for noncovered services C. Balance due from previous encounter D. Deposit for future services | A. Deductibles B. Payment for noncovered services C. Balance due from previous encounter |
| Which of the following apply to preparing and transmitting claims? (MAY BE MORE THAN ONE) A. Private payer claims can be completed using the CMS-1500 paper claim. B. Private payer claims can be completed using the HIPAA 837P claim. C. Claims always have a one-year deadline for processing. D. The HIPAA 837P claim form is only used for government health plans. E. Claims must be submitted according to the plan's guidelines for timely filing. | A. Private payer claims can be completed using the CMS-1500 paper claim. B. Private payer claims can be completed using the HIPAA 837P claim. E. Claims must be submitted according to the plan's guidelines for timely filing. |
| Which of the following apply to reviewing coding compliance? (MAY BE MORE THAN ONE) A. A coding compliance review is not needed if you documented and coded properly. B. Show the medical necessity for the services. C. Check that the codes are properly linked and documented. D. Verify that the diagnosis and procedure codes are current as of the date of service. E. The payer is responsible for linking the diagnostic and procedure codes. | B. Show the medical necessity for the services. C. Check that the codes are properly linked and documented. D. Verify that the diagnosis and procedure codes are current as of the date of service. |
| Which of the following apply to communication with payers? (MAY BE MORE THAN ONE) A. Good communication between payers and medical insurance staff is necessary for effective contract and claim management. B. As claims are processed, questions and requests for information go back and forth. C. All communication regarding claims must be in writing. D. There should be no communication once a claim is in the processing stage. | A. Good communication between payers and medical insurance staff is necessary for effective contract and claim management. B. As claims are processed, questions and requests for information go back and forth. |
| Checking billing compliance is which step of the revenue cycle? A. 4 B. 3 C. 5 D. 7 | C. 5 |
| The monthly enrollment list contains which of the following to show eligibility? (MAY BE MORE THAN ONE) A. Patient history B. Family members' names C. Identification numbers D. Effective date of plan E. Patient names | C. Identification numbers D. Effective date of plan E. Patient names |
| Which of the following apply to the check-out process? (MAY BE MORE THAN ONE) A. Apply collected payments to the patient's account. B. Analyze the patient's financial responsibility according to the practice's financial policy. C. The patient does not need to be present for check out because all forms and receipts should be mailed. D. Update the practice management program to reflect appropriate diagnoses, services, and charges. | A. Apply collected payments to the patient's account. B. Analyze the patient's financial responsibility according to the practice's financial policy. D. Update the practice management program to reflect appropriate diagnoses, services, and charges. |
| Which of the following are referral requirements for HMOs? (MAY BE MORE THAN ONE) A. HMOs only require referrals if a patient does not have a primary care physician. B. There are no referral requirements for HMOs. C. They may require a PCP for in-network provider referrals. D. Both PCPs and specialists may be required to keep logs of referral activities. E. Patients who self-refer to nonparticipating providers may be balance-billed for those services. | C. They may require a PCP for in-network provider referrals. D. Both PCPs and specialists may be required to keep logs of referral activities. E. Patients who self-refer to nonparticipating providers may be balance-billed for those services. |
| Which of the following apply to the filing deadlines for claims? A. Deadlines are not based on the sent date B. Deadlines are not based on the received date C. Deadlines are based on the date of service D. No deadlines apply for surgical procedures | A. Deadlines are not based on the sent date B. Deadlines are not based on the received date C. Deadlines are based on the date of service |
| Which of the following apply to the filing deadlines for claims? (MAY BE MORE THAN ONE) A. Deadlines are not based on the sent date. B. Deadlines are not based on the received date. C. Deadlines are based on the date of service. D. No deadlines apply for surgical procedures. | A. Deadlines are not based on the sent date. B. Deadlines are not based on the received date. C. Deadlines are based on the date of service. |
| Identify the correct criteria for encounter reports and write-offs. (MAY BE MORE THAN ONE) A. Most HMOs require capitated providers to submit encounter reports for patient encounters. B. Some plans do require the use of a regular claim with CPT codes. C. Plans do not require the use of a regular claim with the CPT codes for encounter reports. D. Few HMOs require capitated providers to submit encounter reports for patient encounters. | A. Most HMOs require capitated providers to submit encounter reports for patient encounters. B. Some plans do require the use of a regular claim with CPT codes. |
| The payer's provider representatives may need to deal with the difficulties that arise when claims are ________. A. Paid in a timely manner B. Long overdue C. Correctly submitted D. Approved | B. Long overdue |
| Which of the following apply to billing excluded services? (MAY BE MORE THAN ONE) A. Medical insurance specialists need to organize this information for billing. B. Under a capitated contract, providers bill patients for services not covered by the cap rate. C. The plan's summary grid does not list the plan's payment method. D. The plan's summary grid should indicate the plan's payment method for the additional services to be balance-billed. | A. Medical insurance specialists need to organize this information for billing. B. Under a capitated contract, providers bill patients for services not covered by the cap rate. D. The plan's summary grid should indicate the plan's payment method for the additional services to be balance-billed. |
| The list that capitated plans send with the payment is called the ________ list. A. Monthly member B. Monthly payment C. Plan D. Monthly enrollment | D. Monthly enrollment |
| Who may be required to keep logs of referral activities? (MAY BE MORE THAN ONE) A. Medical insurance specialists B. Specialists C. PCPs D. Patients | B. Specialists C. PCPs |
| Which of the following statements apply to write-offs? (MAY BE MORE THAN ONE) A. Patients are required to pay the write-off amount and are reimbursed upon their next visit. B. Billing staff knows not to expect additional payment based on a claim for a capitated-plan patient. C. The PMP does not write off charges. D. PMPs can be set up to automatically write off fees for patients under capitated plans. E. If the service charges were not written off, the PMP would double-count the revenue. | B. Billing staff knows not to expect additional payment based on a claim for a capitated-plan patient. D. PMPs can be set up to automatically write off fees for patients under capitated plans. E. If the service charges were not written off, the PMP would double-count the revenue. |
| Under a(n) ________ contract, providers write off services not covered under the cap rate. A. Out-of-network B. Fee-for-service C. Capitated D. Consumer-driven health plan | C. Capitated |
| Identify the correct criteria for encounter reports and write-offs. (MAY BE MORE THAN ONE) A. Most HMOs require capitated providers to submit encounter reports for patient encounters. B. Plans do not require the use of a regular claim with the CPT codes for encounter reports. C. Some plans do require the use of a regular claim with CPT codes. D. Few HMOs require capitated providers to submit encounter reports for patient encounters. | A. Most HMOs require capitated providers to submit encounter reports for patient encounters. C. Some plans do require the use of a regular claim with CPT codes. |
| Because patients must choose PCPs each month, the insurance plan sends a monthly enrollment list that should list the current members. Verify that the patient is eligible for services. | Patient eligibility |
| An HMO may require a PCP to refer a patient to an in-network provider or to get authorization from the plan to refer a patient to an out-of-network provider. Patients who self-refer to nonparticipating providers may be balance-billed for those services. Both PCPs and specialists may be required to keep logs of referral activities. | Referral requirements |
| Most HMOs require capitated providers to submit encounter reports for patient encounters. Some do not require regular procedural coding and charges on the reports. However, some plans do require the use of a regular claim with CPT codes. | Encounter reports |
| Providers bill patients for services not covered by the cap rate. Medical insurance specialists need to organize this information for billing. The plan’s summary grid should indicate the plan’s payment method for the additional services to be balance-billed, such as discounted fee-for-service. | Billing for excluded services |
| Charges for service under capitated plans are written off as an adjustment to the patient’s account. The billing staff knows not to expect additional payment based on a claim for a capitated-plan patient. If the service charges were not written off, the practice-management program would double-count the revenue for these patient encounters. Thus, the regular charges for the services that are included in the cap rate are written off by the biller. | Claim write-offs |
| The nation’s largest health insurer in terms of enrollment; the largest owner of BlueCross and BlueShield plans, serving as the BlueCross licensee in California and the BlueCross and BlueShield licensee in Georgia, Missouri, and Wisconsin; also serves Colorado, Connecticut, Indiana, Kentucky, Maine, Nevada, New Hampshire, Ohio, and Virginia under Anthem BlueCross and BlueShield | Anthem |
| Another large health insurer that runs plans and owns other major regional insurers | United Healthcare |
| Benefits include health care, dental, pharmacy, group life, behavioral health, disability and long-term care benefits | Aetna |
| American-based multinational managed healthcare corporation | CIGNA Health Care |
| One of the largest nonprofit plans, it runs physician groups, hospitals, and health plans across the United States. | Kaiser Permanente |
| A very large for-profit healthcare company that handles TRICARE operations in the Southeast | Humana Inc. |
| Document of eligible members of a capitated plan registered with a particular PCP for a monthly period | monthly enrollment list |
| Payer preauthorization for elective hospital-based services and outpatient surgeries | precertification |
| Document that modifies an insurance contract | rider |
| Insurance plan, usually a PPO, that requires a large amount to be paid before benefits begin; part of a consumer driven health plan | high-deductible health plan |
| Another type of healthcare plan between a primary care physician and a patient that eliminates an insurance plan | concierge medicine |
| A company hired by a payer to evaluate the appropriateness and medical necessity of hospital-based health care services | utilization review organization |
| Quick-reference table for health plans | plan summary grid |
| In a BlueCard program, the provider’s local BCBS plan | host plan |
| Contractual guarantee against a participating provider’s financial loss due to an unusually large demand for high-cost services | stop-loss provision |
| Surgical procedure that can be scheduled in advance | elective surgery |
| Term for the new designs of health plans created by the ACA | metal plans |
| Arrangement by which a capitated provider prepays an ancillary provider | subcapitation |
| A vendor that processes a payer’s out-of-network claims | repricer |
| The largest employer-sponsored health program in the United States is A. workers’ compensation. B. Federal Employees Health Benefits program. C. Medicare. D. Medicaid. | B. Federal Employees Health Benefits program. |
| In employer-sponsored health plans, employees may choose their plan during the A. birthday rule period. B. contract period. C. open enrollment period. D. concierge plan. | C. open enrollment period. |
| Which laws govern the portability of health insurance? A. ERISA and HIPAA B. FEHB and ERISA C. COBRA and HIPAA D. PPO and HMO | C. COBRA and HIPAA |
| Self-funded health plans are regulated by A. PHI. B. ERISA. C. PPO. D. FEHB. | B. ERISA. |
| BlueCross BlueShield Association member plans offer Multiple Choice A. HMOs only. B. PPOs only. C. all major types of health plans. D. indemnity plans only. | C. all major types of health plans. |
| Emergency surgery usually requires A. a deductible paid to the hospital or clinic. B. a referral before the procedure. C. precertification (preauthorization) within a specified time after the procedure. D. a maximum benefit limit. | C. precertification (preauthorization) within a specified time after the procedure. D. a maximum benefit li |
| Providers who participate in a PPO are paid A. a discounted fee-for-service. B. an episode-of-care payment. C. according to their usual physician fee schedule. D. a capitated rate. | A. a discounted fee-for-service. |
| Under a capitated HMO plan, the physician practice receives A. a secondary insurance identification number. B. an encounter report. C. a monthly enrollment list. D. precertification for services. | C. a monthly enrollment list. |
| What document is researched to uncover rules for private payers’ definitions of insurance-related terms? A. HIPAA Security Rule B. participation contract C. ERISA D. rider | B. participation contract |
| Consumer-driven health plans have what effect on a practice’s cash flow? A. A high-deductible payment from the patient takes longer to collect than does a copayment. B. There is no effect on cash flow. C. The effect is the same as the effect of a capitated plan. D. The health plan’s payment arrives faster than under other types of plans. | A. A high-deductible payment from the patient takes longer to collect than does a copayment. |
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