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MED 112
MIDTERMS
| Question | Answer |
|---|---|
| Determine which method a self-funded health plan most often uses in setting up its provider network. | buy the use of existing networks from managed care organizations |
| Calculate the amount of money the insurance company would owe on a covered service costing $850 if there is a $500 deductible (which has not yet been met) and no coinsurance. | $350 |
| When is a deductible paid? | before benefits begin |
| An indemnity policy states that the coinsurance rate is 80-20. Which of the following is the payer’s portion? | 80 |
| Identify the type of HMO cost-containment method that requires patients to obtain approval for services before they receive the treatment. | requiring prior authorization for services |
| Medical insurance specialists use practice management programs to | All of these are correct. |
| On what is the PMPM rate usually based? | health-related characteristics of the enrollees |
| Name a benefit a provider usually gets from participation with a health plan. | an increased number of patients |
| Another term used for a primary care physician (PCP) is | gatekeeper |
| Which term best describes medical services that meet professional medical standards? | medical necessity |
| Professional organizations generally have a(n) __________Blank that its members should follow/possess. | code of ethics |
| When a POS option is elected under a health maintenance organization, the patient may | choose providers who are not in the HMO’s network |
| Higher copayments may be charged for patient visits to/for | the office of a specialist |
| Where do medical insurance companies summarize the payments they may make for medically necessary medical services? | schedule of benefits document |
| Out-of-pocket expenses must be paid by | the insured |
| The employment forecast for well-trained medical insurance and coding specialists is/are | increasing opportunities |
| According to the textbook, pick the rising occupation in the health care industry that requires the employee to have the highest level of proficiency in dealing with the public professionally and pleasantly | medical assistant |
| What kind of medical services are annual physical examinations and routine screening procedures? | preventive |
| The capitated rate per member per month covers | services listed on the schedule of benefits |
| Name the two components of a consumer-driven health plan (CDHP) | a health plan and a special “savings account” |
| For a patient insured by an HMO, the phrase “out-of-network” means providers who are | not under contract with the payer. |
| The most important characteristic for a medical insurance specialist to possess is | professionalism |
| Imagine you are a patient who wants to regulate your health care expenses on your own; what type of insurance plan would you use? | consumer-driven health plan |
| Under a fee-for-service plan, the third-party payer makes a payment | after medical services are provided |
| What skills are required for successful mastery of the tasks of a medical insurance specialist? | attention to detail and ability to work as a team member |
| Dependents of a policyholder may include his/her | spouse and children |
| In how many managed care plans may a physician participate? | many |
| Consumer-driven health plans combine a health plan with a special “savings account” that is used to pay what before the deductible is met? | medical bills |
| Determine which of the following types of services a health plan will not pay for | noncovered services |
| How is coinsurance defined? | the percentage of each claim that the insured pays |
| Describe the process of adjudication | the payer's process of putting a claim through a series of steps designed to judge whether it should be paid |
| What do providers participating in a PPO generally receive in exchange for accepting lower fees? | more patient visits |
| Which of the following programs covers people who cannot otherwise afford medical care? | Medicaid |
| What is the formula for calculating an insurance company payment in an indemnity plan? | charge-deductible-coinsurance |
| Identify the type of HMO cost-containment method that requires the patient to pay a copayment | cost-sharing |
| In what format are health care claims sent? | electronic or hard copy |
| Calculate the amount of money a patient would owe for a covered service costing $1,200 if their indemnity policy has a coinsurance rate of 75-25, and they have already met their deductible | $300 |
| Verifying insurance is part of which revenue cycle step? | Step 2, establish financial responsibility for the visit |
| The designation of Registered Medical Assistant (RMA) is awarded by | AMT |
| What step is used when patient payments are later than permitted under the financial policy? | Step 10, follow up patient payments and collections |
| Which of the following covers patients who are age 65 and over? | Medicare |
| In a medical practice, cash flow is required to | pay for office expenses. |
| Determine which of the following entities is not considered a provider | insurance companies |
| Under a written insurance contract, the policyholder pays a premium, and the insurance company provides | payments for covered medical services |
| Which of the following is an example of a private-sector payer? | insurance company |
| The key to receiving coverage and payment from a payer is the payer's definition of | medical necessity |
| In general, how do the cost of policies written for groups compare to those written for individuals? | Policies written for groups are cheaper |
| Under an insurance contract, the patient is the first party and the physician is the second party. Who is the third party? | insurance plan |
| Patients who enroll in a point-of-service type of HMO may use the services of | HMO network or out-of-network providers |
| To be fully covered, patients who enroll in an HMO may use the services of | only HMO network providers |
| The federal agency that runs Medicare and Medicaid is | CMS |
| CMS stands for | Centers for Medicare & Medicaid Services |
| NPI is the abbreviation for | National Provider Identifier |
| A __________Blank is an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI | breach |
| Which of the following is America’s “law office”? | DOJ |
| A progress report documents a patient's | type of treatment still needed and duration |
| A vendor such as a software firm that does business with a covered entity is called a(n) | business associate |
| Patients' medical records must document all of the following except | next of kin |
| Which of the following require(s) CEs to establish safeguards to protect PHI? | HIPAA Security Rule |
| The responsibility of licensed health care professionals to observe state medical standards of care is called | medical professional liability |
| An important part of a compliance plan is a commitment to keep both physicians and medical office staff current by providing | ongoing training on coding and billing |
| PHI may be released without the patient’s authorization in all of the following situations except | attorneys |
| A court order to appear, testify, and bring specified documents or items is a | subpoena duces tecum |
| Which of the following is an action that misuses money that the government has allocated? | abuse |
| Disguising an electronic message so that only recipients with the correct key can read it is called? | encryption |
| The Health Care Fraud and Abuse Control Program was created by | HIPAA |
| The minimum necessary standard means to | take reasonable safeguards to protect PHI |
| An encounter is defined as a | face-to-face meeting between a provider and a patient. |
| OIG is the abbreviation for | Office of the Inspector General |
| The activity of copying files to another medium so that they will be preserved in case the originals are no longer available is | backing up |
| A __________Blank is a person who makes an accusation of fraud or abuse | relator |
| An authorization to disclose PHI that a patient signs must have all of the following except | signature of the nurse who treated the patient |
| According to the OIG compliance plans should contain how many elements? | seven |
| Which of the following is a systematic, logical, and consistent recording of a patient's health status in a medical record? | documentation |
| A complete H&P is documented with how many type(s) of information? | four |
| EDI is the abbreviation for | electronic data interchange |
| SOAP is the abbreviation for which of the following? | Subjective/Objective/Assessment/Plan |
| What did HIPAA create to uncover and prosecute fraud and abuse? | The Health Care Fraud and Abuse Control Program |
| How have most privacy complaints under HIPAA been resolved? | voluntary compliance |
| The ACA requires the adoption of __________Blank for each of the HIPAA Standard transactions. | operating rules |
| PHI is the abbreviation for | protected health information |
| A valid authorization must include all of the following except | a statement about whether the CE is able to base prescriptions on the authorization |
| EHR is the abbreviation for | electronic health record |
| Which of the following is required for releasing protected health information for reasons other than treatment, payment, or health care operations? | patient’s signed authorization |
| TPO is an abbreviation for | treatment, payment, and health care operations |
| Where is an assignment of benefits statement filed? | patient medical records and patient billing records |
| If a patient authorizes a provider to accept assignment, what can the provider now do on their behalf? | File claims for the patient and receive payments directly from the payer |
| What type of charges do practices routinely collect at the time of service? | copays, noncovered, and self-pay patients |
| What does COB stand for in medical insurance terms? | coordination of benefits |
| What means are available for completing an encounter form? | All of these answers are correct |
| The practice's rules for payment for medical services are found in their | financial policy |
| An RTA generates | the actual amount the patient will owe |
| NonPAR stands for | nonparticipating |
| What Medicare form is used to show charges to patients for potentially non-covered services? | Advance Beneficiary Notice |
| What type of number is assigned to a HIPAA 270 electronic transaction? | trace number |
| Pick the type of use of PHI that a practice would employ to train their staff to improve the quality of their health care. | health care operations |
| Which of the following is used to send necessary data to payers for a claim? | X12 837 |
| Under what rule is a child's primary coverage under the father's plan when both parents have coverage? | gender rule |
| The document patients sign to signify that they have read and understood how the provider will protect their PHI is the | Acknowledgment of Receipt of Notice of Privacy Practices |
| Which HIPAA transaction is used to check patients’ insurance coverage? | Eligibility for a Health Plan |
| Sometimes the use of a third payer is necessary after two health plans have made payments on a claim. This type of insurance is known as | tertiary insurance |
| Identify the information that is not typically included on an encounter form | the patient's plan benefits |
| A patient with no previous balance presents for an encounter and wants to know what their bill will be. Calculate the patient's estimated balance if they will receive a non-covered service worth $127 | $127 |
| When should the insurance specialist update the encounter form? | when codes change |
| You are working at a practice and need to get prior approval from a payer. Which of the following HIPAA transactions would you use to do so? | Referral Certification and Authorization |
| Patients who elect to pay a higher copayment, greater coinsurance, or both, are most likely visiting a | nonPAR |
| Under what rule is a child's primary coverage determined based upon which parent's day of birth is earlier in the calendar year? | birthday rule |
| Patients will have the same chart number when | none of these; chart numbers are unique |
| If a retired patient with Medicare also has coverage under a working spouse's plan, the primary plan is | the spouse's plan |
| If an employed patient has coverage under two insurance plans, one the employer's plan and the other a government plan, the primary plan is | the employer's plan |
| What does a provider complete during or just after a patient's visit to summarize their billing information? | encounter form |
| If the practice accepts credit and debit cards it must | pay a fee to a credit card company |
| What should be verified when someone requests PHI for TPO purposes? | the identity of the person and person's authority to access PHI |
| Determine how a policyholder can authorize physicians to submit claims on their behalf and receive payments directly from payers | signing and dating an assignment of benefits statement |
| Determine what you should ask the patient to do upon arrival. | Complete all required forms before their first encounter with the provider |
| What type of questions should physicians be asked regarding billing and coding issues? | essential |
| When the practice can get answers quickly from insurance plans, it will benefit from | quicker payment for services |
| When a provider asks a health plan for approval of a service, the response is known as the | X12 278 |
| If an employed patient has coverage under two insurance plans, one from a current employer and one from a previous employer, the primary plan is | the current employer's plan |
| Which of these documents will the patient not complete? | encounter form |
| In ICD-10-CM coding the first character is a | letter |
| In order to correctly code a disease or diagnosis you must first look in the __________Blank Index and then confirm in the __________Blank List | ALPHABETIC; TABULAR |
| Which of the following provides an index of the disease descriptions? | Alphabetic Index |
| Excludes 2 in ICD-10-CM is an indication that | the patient could have both conditions at the same time |
| Not otherwise specified codes are used | when no other information is available for assigning the disease a more specific code |
| Which of the following codes is considered a category code? | S82 |
| Which ICD-10-CM code follows the main term in the Alphabetic Index? | default code |
| The smallest division is considered a “code” and can be __________Blank alphanumeric characters long | three, four, five, six or seven |
| In ICD-10-CM, combination code is a single code that describes both | the etiology and manifestation |
| Updates to ICD-10-CM are called | addenda |
| Which of the following is a definition of etiology? | cause or origin of a disease or condition |
| A valid code in ICD-10-CM must have at least how many characters? | 3 |
| If the ICD-10-CM code requires a seventh character and there is no sixth character, what should the coder do? | Use an “x” in the sixth character position |
| The diseases and injuries located here are organized into chapters according to etiology, body system, or purpose | Tabular List |
| Laterality coding in ICD-10-CM shows that the classification system can | capture which side of the body is being coded |
| ICD-10-CM was mandated under the HIPAA | Transactions and Code Sets |
| L03 is an example of what type of code? | category |
| A code in ICD-10-CM has how many characters? | All of these answers are correct |
| Some conditions require two codes, one for the etiology and one for the | manifestation |
| A category in ICD-10-CM is how many characters? | three |
| In ICD-10-CM, the term conventions means | typographic techniques that provide visual guidance |
| When the patient has a coexisting condition that the physician diagnoses and treats, the coder must | code the primary diagnosis first and then the current coexisting condition |
| Who was not required to switch to ICD-10-CM on October 1, 2015? | workers’ compensation |
| Nonessential or supplementary terms use what type of punctuation? | parentheses |
| If a see cross reference appears after a main term, the coder | must look up the term that follows the word see in the index |
Created by:
Felicia26