Health Insurance and Reimbursement
Exam Answer Key
Course Introduction
This course provides an in-depth overview of health insurance and reimbursement processes within the healthcare industry. Students will explore the various types of health insurance plans, including private, employer-sponsored, Medicare, Medicaid, and managed care. The curriculum covers essential topics such as insurance verification, benefits coordination, claims submission, coding systems (ICD, CPT, HCPCS), and the role of third-party payers. Additionally, students will learn about reimbursement methodologies, compliance with government regulations, and strategies to maximize reimbursement while ensuring ethical billing practices. Practical case studies and simulations will prepare students for real-world administrative roles in healthcare settings.
Recommended Textbook
Health Insurance Today A Practical Approach 5th Edition by Janet I. Beik AA BA Med
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18 Chapters
1335 Verified Questions
1335 Flashcards
Source URL: https://quizplus.com/study-set/638 Page 2
Chapter 1: The Origins of Health Insurance
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45 Verified Questions
45 Flashcards
Source URL: https://quizplus.com/quiz/12084
Sample Questions
Q1) Which of the following is not a provision of HIPAA?
A) Allows portability of health insurance coverage
B) Protects workers and their families from preexisting conditions
C) Establishes national standards for electronic healthcare
D) Addresses the high cost of health insurance
Answer: D
Q2) In 1850,the Franklin Health Assurance Company began offering medical expense coverage,similar to today's health insurance,in the state of ____________________.
Answer: Massachusetts
Q3) The Patient Protection and Affordable Care Act was passed in:
A) 1999.
B) 2005.
C) 2008.
D) 2010.
Answer: D
Q4) The transformation of health insurance from what it was in the beginning to what we know it to be today can be compared with an organic process referred to as
Answer: metamorphosis
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Chapter 2: Tools of the Trade: A Career as a Health (Medical)Insurance
Professional
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40 Verified Questions
40 Flashcards
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Sample Questions
Q1) The new version of HIPAA's standard for filing electronic claims is:
A) CMS-1500.
B) AXC4.
C) Version 5010.
D) 4010A1.
Answer: C
Q2) Health insurance professionals are currently in high demand in the United States.
A)True
B)False
Answer: True
Q3) The focus of the health insurance professional's career is:
A) the insurance claim.
B) becoming certified.
C) patient account collections.
D) medical records documentation.
Answer: A
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Chapter 3: The Legal and Ethical Side of Medical Insurance
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67 Verified Questions
67 Flashcards
Source URL: https://quizplus.com/quiz/12086
Sample Questions
Q1) To be in conformance with HIPAA rules and for best defense against possible problems,medical practices should develop a written _______________.
Answer: compliance plan
Q2) A patient can terminate the doctor/patient contract simply by paying the bill and not returning to the practice.
A)True
B)False Answer: True
Q3) _________________ concerns the communication of private and personal information from one person to another.
Answer: Confidentiality
Q4) It is generally an accepted fact that medical records are the property of the healthcare facility.
A)True
B)False Answer: True
Q5) Legal form is only applicable in __________ contracts. Answer: written
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Chapter 4: Types and Sources of Health Insurance
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48 Verified Questions
48 Flashcards
Source URL: https://quizplus.com/quiz/12087
Sample Questions
Q1) An insurance contract made with a business entity that covers its employees under a single policy is called a/an:
A) group contract.
B) business contract.
C) equilateral contract.
D) managed care contract.
Q2) A periodic fee that is paid to an insurer for healthcare coverage.
Q3) Long-term care insurance covers nursing home care.
A)True
B)False
Q4) Most third-party payers do not pay for medical services that are:
A) diagnostic in nature.
B) considered outdated.
C) not medically necessary.
D) provided in another state.
Q5) The monthly (or periodic)fee paid for health insurance is commonly called a:
A) stipend.
B) premium.
C) penalty.
D) disbursement.
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Chapter 5: Claim Submission Methods
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70 Verified Questions
70 Flashcards
Source URL: https://quizplus.com/quiz/12088
Sample Questions
Q1) The insurance claim process begins when the health insurance professional submits the claim to the insurance processor.
A)True
B)False
Q2) Supplemental documents that provide additional information to the claims processor that normally cannot be included within the electronic claim format are called:
A) ancillary documents.
B) records attachments.
C) claim attachments.
D) certificates of necessity.
Q3) Services or supplies that are appropriate and necessary for the symptoms,diagnosis,and treatment of the medical condition and meet the standards of good medical practice is the definition for:
A) medical necessity.
B) demographic information.
C) principles of morality.
D) value-based medicine.
Q4) The _________ may grant a waiver from the mandatory electronic claims submission rule.
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Chapter 6: Traditional Fee For Service/Private Plans
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74 Verified Questions
74 Flashcards
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Sample Questions
Q1) How would the health insurance professional identify members of the BlueCard Program?
Q2) Blue Cross and Blue Shield claims must typically be filed within _____ following the last date of service provided to the patient.
A) 90 days
B) 365 days
C) 2 years
D) 5 years
Q3) HIPAA-AS sets standards for the electronic transmission of healthcare data and to protect the privacy of individually identifiable healthcare information.
A)True
B)False
Q4) Self-insured plans usually do not have to conform to traditional laws governing insurance,because they are technically not considered insurance companies.
A)True
B)False
Q5) Explain the function of a fiscal intermediary/Medicare administrative contractor.
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Page 8
Chapter 7: Unraveling the Mysteries of Managed Care
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) A healthcare provider trained in a particular medical specialty is a:
A) specialist.
B) consultant.
C) counselor.
D) participating provider.
Q2) The ____________________ model HMO is similar to an IPA,except that the organization contracts directly with individual providers.
Q3) An independent nonprofit organization that measures,assesses,and reports on the quality of care and service in MCOs.
A) AMA
B) NUCC
C) HIPAA
D) NCQA
Q4) Which federal act,passed in 1996,is intended to improve the efficiency of healthcare delivery,reduce administrative cost,and protect patient privacy?
A) HCFA
B) HIPAA
C) EMTLA
D) COBRA
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Chapter 8: Understanding Medicaid
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87 Verified Questions
87 Flashcards
Source URL: https://quizplus.com/quiz/12091
Sample Questions
Q1) The optional services authorized by the Medicaid Act include:
A) clinic services.
B) physical therapy.
C) dentures.
D) all of the above
Q2) In 1972 federal law established the supplemental security income (SSI)program.What does it provide?
Q3) Most states have their own specific form to use for Medicaid claims.
A)True
B)False
Q4) What is Medicaid?
Q5) Individuals who receive medical assistance because their income falls within the poverty or FPL guidelines or as a result of SSI eligibility are considered:
A) medically needy.
B) medically deprived.
C) categorically needy.
D) medically challenged.
Q6) The ____________ program provides comprehensive alternative care for non-institutionalized elderly who otherwise would be in a nursing home.
Page 10
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Chapter 9: Conquering Medicares Challenges
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105 Verified Questions
105 Flashcards
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Sample Questions
Q1) Postpayment Medicare audits are often triggered by statistical irregularities.
A)True
B)False
Q2) Medicare HICNs are typically in the format of nine numeric characters followed by one alpha character.
A)True
B)False
Q3) Medicare Parts A and B are provided free of charge for all individuals over 65.
A)True
B)False
Q4) Medicare's fee schedule is based on a system whereby each payment value is found within a range of payments known as:
A) OPPS.
B) RBRVS.
C) fee-for-service.
D) usual, customary, and reasonable.
Q5) Individual plans,such as group health insurance plans that include prescription coverage,offer varying benefits;however,they must offer no less than the basic Medicare coverage,referred to as ____________________.
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Chapter 10: Military Carriers
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80 Verified Questions
80 Flashcards
Source URL: https://quizplus.com/quiz/12093
Sample Questions
Q1) The TRICARE program is managed by _________.
Q2) Non-PAR providers may charge up to ____% above the TRICARE allowable charge (TAC)for their services.
A) 10
B) 15
C) 20
D) 25
Q3) There is one overseas region divided into three main areas.These are ______________,___________,and ____________.
Q4) CHAMPVA allows professional charges to be submitted on paper using the ____________ claim form and following TRICARE/CHAMPVA guidelines.
A) CMS-1500
B) CMS-1450
C) CHAMPVA Form L-10
D) any of the above
Q5) CHAMPVA follows the same claims filing deadline as TRICARE.
A)True
B)False
Q6) What is the Military Health System's mission?
Page 12
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Chapter 11: Miscellaneous Carriers: Workers Compensation and Disability Insurance
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55 Verified Questions
55 Flashcards
Source URL: https://quizplus.com/quiz/12094
Sample Questions
Q1) The time limit for filing a workers' compensation claim is established by:
A) the employer.
B) the federal government.
C) individual state statutes.
D) the insurance company that issues the policy.
Q2) Most short-term disability policies have a maximum benefit amount that is paid each month.
A)True
B)False
Q3) List at least six of the nine federal disability programs.
Q4) Disability income insurance replaces a portion of earned income when an individual is unable to do his or her work resulting from nonemployment-related injuries.
A)True
B)False
Q5) Income from employment (wages)is considered:
A) supplement income.
B) tax free income.
C) earned income.
D) certified income.
Page 13
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Chapter 12: Diagnostic Coding
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132 Verified Questions
132 Flashcards
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Sample Questions
Q1) A neoplasm results when abnormal cells grow uncontrollably,usually resulting in a tumor.
A)True
B)False
Q2) V codes are used to classify environmental events,circumstances,and other conditions that are the cause of injury and other adverse effects.
A)True
B)False
Q3) Nonessential modifiers provide an example of wording that might be in the provider's notes or diagnostic statement.
A)True
B)False
Q4) The part of the ICD-9 manual that serves as a basic foundation for diagnostic coding and aids in assigning diagnostic codes correctly is the
A) introductory pages
B) alphabetic list (index)
C) last few pages of the book
D) appendix
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Page 14
Chapter 13: Procedural, Evaluation and Management, and HCPCS Coding
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122 Verified Questions
122 Flashcards
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Sample Questions
Q1) The most important thing to remember when using modifiers is that the health record must contain ______________ to support the modifier.
A) adequate documentation
B) signatures of two physicians
C) an operative report
D) proof of insurance coverage
Q2) A main term can stand alone,or it can be followed by up to three _____ terms.
A) modifying
B) subsequent
C) secondary
D) procedural
Q3) What must accompany the claim when a rarely used,unusual,variable,or new service is performed?
A) A modifier
B) A special report
C) A special symbol
D) An EOB
Q4) The E/M codes are found at the end of the CPT manual.
A)True
B)False
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Chapter 14: The Patient
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74 Verified Questions
74 Flashcards
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Sample Questions
Q1) The __________________ applies to individuals or businesses that offer or extend consumer credit if certain conditions are met.
Q2) Patients who have either inadequate insurance or no insurance at all are referred to as:
A) deadbeats.
B) nonpayers.
C) self-pay patients.
D) red-flaggers.
Q3) Recent Congressional legislation established a program that provides incentives to physicians and hospitals that use certified EMR technology in a meaningful manner,referred to as _______________.
Q4) Name the three major groups that fall under the umbrella of "covered entities."
Q5) All medical staff should talk quietly among themselves or to patients so voices do not carry into adjacent rooms.
A)True
B)False
Q6) A listing of all expenses paid out to vendors such as building rent,office supplies,and salaries is called a _______________ journal.
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Chapter 15: Keys to Successful Claims Management
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60 Verified Questions
60 Flashcards
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Sample Questions
Q1) The book outlines 12 keys to successful claims processing.
A)True
B)False
Q2) Generally,if a claim is reduced or rejected,the problem lies with the:
A) provider's office.
B) patient.
C) insurance company.
D) fiscal intermediary.
Q3) Adjudication is the process by which:
A) a claim is paid in a timely manner.
B) a claim is reviewed and payment decisions are made by the payer.
C) data are entered into an electronic file or account.
D) a healthcare provider is sued by a patient.
Q4) An alternative to the suspension file is to record claims information on a columnar form called a/an:
A) explanation of benefits.
B) payment receiving form.
C) insurance claims register.
D) computerized claim form.
Q5) What are the basic rules for appealing a claim?
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Chapter 16: The Role of Computers in Health Insurance
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65 Verified Questions
65 Flashcards
Source URL: https://quizplus.com/quiz/12099
Sample Questions
Q1) The digital imaging hybrid EMR system provides the best of both worlds- providing easy access of an electronic system but keeping paper records in case of computer problems.
A)True
B)False
Q2) A physician,practitioner,facility,or supplier with fewer than 10 full-time equivalent (FTE)employees is called a/an _______________.
Q3) A ______________ sorts claims by payer and transmits them to the various insurance companies using the specific formats required by each.
Q4) HIPAA regulations do not apply to the Medicare program because it is not considered a "health plan."
A)True
B)False
Q5) A standard format used to transfer information electronically between two entities is known as:
A) PHI.
B) EDI.
C) ICD.
D) DHS.
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Chapter 17: Reimbursement Procedures: Getting Paid
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72 Verified Questions
72 Flashcards
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Sample Questions
Q1) The relative value of each service on Medicare's RVRVS fee schedule is multiplied by the ______________,an annually adjusted conversion factor for each Medicare locality.
A) GPCI
B) ALOS
C) ANSII
D) RBRVS
Q2) The current Medicare RBRVS physician fee schedule is calculated using the ____________ of the service provided (identified by a CPT code)and based on the resources the service consumes.
A) UCR rate
B) per diem rate
C) relative value
D) resource-based value
Q3) Under the inpatient psychiatric facility PPS,federal per diem rates include geographic factors,patient characteristics,and facility characteristics.
A)True
B)False
Q4) Define the term "cost outlier."
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Chapter 18: Hospital Billing and the UB-04
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89 Verified Questions
89 Flashcards
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Sample Questions
Q1) A process whereby a medical institution is recognized by an external body as meeting certain predetermined standards is called:
A) accreditation.
B) certification.
C) credentialing.
D) validation.
Q2) The letters O and I are not valid values in the ICD-10-PCS coding structure.
A)True
B)False
Q3) As required by law,all general acute-care healthcare providers must identify whether a diagnosis was present upon an inpatient admission.
A)True
B)False
Q4) Modern hospital construction is regulated by:
A) federal and state laws.
B) state health department policies.
C) city ordinances.
D) all of the above
Q5) Discuss the purpose of the new HIPAA edit.
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