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RMA Chapt. 14
| 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 |
| Which of the following is an 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 |
| Which of the following Medicare programs covers hospital charges? | Part A |
| If Medicare sends a check for payment to the medical office, the physician is considered which one of the following parties? | 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 catastrophic or prolonged injury or illness? | Major medical |
| Which of the following is a federal health insurance plan? | Medicare |
| Which of the following terms describes a statement indicating that a patient has agreed to pay for a service that is likely to be rejected by Medicare? | Advance beneficiary notice |
| When a child is covered by separate insurance policies through each parent, the policy of which parent is considered primary? | The parent whose birthday falls first |
| Which of the following taxes is mandated by the federal government to be withheld from an employee’s paycheck? | Medicare |
| Which of the following terms best describes a part of an insurance plan in which a specified dollar amount is paid to physicians based on each patient served, rather than by services performed? | Copayment |
| The reimbursement system for Medicare Part A payments to hospitals is based on which of the following? | Patient’s age |
| Which of the following is a document that describes the reason for a denied insurance claim? | Explanation of benefits form |
| Which of the following is the insurance program that provides for the medically indigent? | Medicaid |
| Which of the following is a prepaid health insurance plan? | Health maintenance organization (HMO) |
| Which of the following steps must be taken to ensure coverage by a patient’s insurance company before the patient undergoes surgery to repair a rotator cuff? | Precertifying the surgical procedure |
| Which of the following insurance plans recommends a separate medical chart? | Workers’ compensation |
| Which of the following involves fixed payments by a Health Maintenance Organization (HMO) to a physician or hospital on a per person, per month basis? | Capitation |
| Which of the following plans covers spouses of veterans with permanent, service-related disabilities? | CHAMPVA |
| Which of the following types of insurance covers medical expenses for patients who are injured on a physician’s property | Liability |
| Which of the following is determined by payers comparing the actual fee charged by a physician? | Usual, customary, and reasonable fee |
| Which of the following is a 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 is a private insurance company, It follows a fee-for-service reimbursement planAll of the choices are correct |
| 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 $3,600, 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 services 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 patient's medical fees come to a total of $600 from a participating provider, and the EOB lists the following information: & Charges: $78 Not Eligible for Payment: $15 Allowed Charge: $63 Applied to Deductible: $ 7 Coinsurance: $ 5 Amount Due From | $12 |
| In the point-of-service option, | Plan members can see out-of-network providers for additional fees |
| In the staff model HMO, | Providers are employees of the HMO |
| Which of the following items is not covered by Medicare Part B? | Hospitalization |
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