Introduction to Health Insurance
Exam Answer Key
Course Introduction
Introduction to Health Insurance provides students with a foundational understanding of the health insurance system in the United States. The course explores the historical development of health insurance, key concepts such as premiums, deductibles, and copayments, as well as the roles of private insurers, employer-sponsored plans, and government programs like Medicare and Medicaid. Students learn about policy structures, coverage options, and regulatory frameworks affecting insurance providers and patients. The course also emphasizes contemporary issues such as the Affordable Care Act, health equity, and the impact of health insurance on access to healthcare services.
Recommended Textbook
Insurance Handbook for the Medical Office 14th Edition by Marilyn Fordney
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18 Chapters
1231 Verified Questions
1231 Flashcards
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Chapter 1: Role of an Insurance Billing Specialist
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Sample Questions
Q1) A self-employed medical insurance biller who does independent contracting is responsible for
A) advertising.
B) billing.
C) accounting.
D) all of the above.
Answer: D
Q2) Cost pressures on health care providers are forcing employers to reduce personnel costs by hiring
A) specialized health care practitioners.
B) health care workers with college degrees.
C) multiskilled health care practitioners.
D) untrained health care practitioners.
Answer: C
Q3) In some states, giving an insured client advice on purchase or discontinuance of insurance policies is construed as being an insurance agent.
A)True
B)False
Answer: True
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Page 3
Chapter 2: Compliance, Privacy, Fraud, and Abuse in Insurance Billing
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Sample Questions
Q1) Charging excessively for services and supplies.
A)Abuse
B)Fraud
Answer: A
Q2) Submitting a claim for services that is not medically necessary is a violation of the False Claims Act.
A)True
B)False
Answer: True
Q3) Under more recent legislation known as the Affordable Care Act, _________ compliance program requirements were implemented.
Answer: mandatory
Q4) A HIPAA compliance exception to the right of privacy and privileged communication is a patient's records pertaining to his or her industrial accident case.
A)True
B)False
Answer: True
Page 4
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Chapter 3: Basics of Health Insurance
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Sample Questions
Q1) When the physician's services have been submitted to the patient's insurance company by the physician's office, the patient should
A) not be sent a statement.
B) be sent a monthly statement indicating the insurance company has been billed.
C) be sent the first statement as soon as the insurance company has paid.
D) be expected to pay the physician and receive reimbursement from the insurance company.
Answer: B
Q2) The Supreme Court deemed the Affordable Care Act's requirement to require individuals to have health insurance coverage or face a penalty as unconstitutional.
A)True
B)False
Answer: False
Q3) Most physician/patient contracts are
A) implied.
B) expressed.
C) written.
D) verbal.
Answer: A
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Page 5
Chapter 4: Medical Documentation and the Electronic Health Record
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Sample Questions
Q1) As a health insurance claims professional, you may be required to _______ information from a medical record to justify a Health Insurance Claim Form after professional services are rendered.
Q2) Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician.
A)Concurrent care
B)Consultation
C)Continuity of care
D)Counseling
E)Critical care
F)Emergency
G)Referral
Q3) When a discussion takes place with a patient concerning the risks and benefits of treatment options, it is considered
A) an office visit.
B) a consultation.
C) counseling.
D) a "no-charge" visit.
Q4) PFSH is the abbreviation for ___________________________________.
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Chapter 5: Diagnostic Coding
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Sample Questions
Q1) Computer-assisted coding is technology that is expected to reduce the number of coders needed by health care organizations.
A)True
B)False
Q2) It is possible for the primary diagnosis and the principal diagnosis to be the same.
A)True
B)False
Q3) Fractures are coded as open if there is no indication of whether the fracture is open or closed.
A)True
B)False
Q4) Alphabetic Index entries with the acronym ____ indicate that there is no further classification of the disease in ICD-10-CM.
Q5) Where does the Alphabetic Index of the ICD-10-CM coding manual instruct the coder to go when looking up the condition leiomyosarcoma?
Q6) Always code to the highest level of ____.
Q7) ICD-10-CM classifies __ and __ information for statistical purposes.
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Chapter 6: Procedural Coding
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Sample Questions
Q1) The E/M code 99203 is considered a level ____________________ code.
Q2) When multiple lacerations of the same classification are repaired in the same body area
A) report only the largest wound.
B) add the lengths of all lacerations and report them with a single code.
C) list the codes for all lacerations separately in descending order of value.
D) be sure to add a code for the anesthesia and chemical or electrocauterization if needed.
Q3) Coding and billing numerous CPT codes to identify procedures that are usually described by a single code is called ____________________.
Q4) The CPT publication is updated and revised
A) annually.
B) biannually.
C) every 3 years.
D) every 5 years.
Q5) Deliberate manipulation of CPT codes for increased payment is called ____________________.
Q6) CPT uses a basic ____________________-digit system for coding services rendered by physicians, plus ____________________-digit add-on modifiers.
Page 8
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Chapter 7: The Paper Claim: Cms-1500 02-12
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Sample Questions
Q1) An insurance claim submitted with errors is referred to as A) a dingy claim.
B) a dirty claim.
C) a rejected claim.
D) an incomplete claim.
Q2) When completing a claim form, if any question is unanswerable
A) leave the space blank.
B) use DNA (does not apply).
C) use N/A (not applicable).
D) use NA (not applicable).
Q3) The CMS-1500 paper claim can be purchased through a medical office supply company or through the ____.
Q4) When a non-physician practitioner sees a patient in the office, while another physician in the practice provides direct supervision, the claim can be billed to Medicare using the physician's NPI, referred to as ______ services.
Q5) Copies of submitted claim forms should be maintained in a ticker file and followed up on every ___ days.
Q6) All paper claims that are generated should be ___ for misspelling of patient names.
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Chapter 8: The Electronic Claim
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Sample Questions
Q1) Post payments in practice management system.
A)Daily
B)Weekly
C)End of month
D)Daily or weekly
Q2) What does an electronic remittance advice (RA) do?
Q3) The implementation of standard formats, procedures, and data content into the electronic data interchange process is the result of ______ regulations.
Q4) The three-digit standard transaction for transmission of the electronic claim is referred to in the physician's office as ___.
Q5) Why was the HIPAA Transaction Code Set developed?
Q6) When a medical practice has its own computer and transmits claims electronically directly to the insurance carrier, this system is known as
A) carrier-direct.
B) immediate response.
C) clearinghouse.
D) straight-line submission.
Q7) A screen prompt is a __.
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Chapter 9: Receiving Payments and Insurance Problem
Solving
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Sample Questions
Q1) The first level of appeal in the Medicare program is A) redetermination.
B) inquiry.
C) fair hearing.
D) appeals council review.
Q2) A request for a Medicare administrative law judge hearing can be made if the amount in controversy is at least
A) $130.
B) $250.
C) $350.
D) $500.
Q3) All of the following are responsibilities of the insurance payment poster EXCEPT:
A) posting insurance reimbursements for every code submitted in the insurance claim.
B) adjusting the amount charged to match the allowable charge.
C) filing the appeal for denial.
D) sending statements for patient deductibles and coinsurance balances.
Q4) FTC stands for _________________________.
Q5) Requests to the insurance commissioner must be submitted _______________.
Page 11
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Chapter 10: Office and Insurance Collection Strategies
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Sample Questions
Q1) What is the name of the federal act that prohibits discrimination in all areas of granting credit?
A) Equal Credit Opportunity Act
B) Fair Credit Reporting Act
C) Fair Credit Billing Act
D) Truth in Lending Act
Q2) What does the insurance billing specialist need to monitor to be able to evaluate the effectiveness of the collection process?
A) Number of statements sent
B) Number of claims processed
C) Accounts payable
D) Accounts receivable
Q3) A personal check is a guarantee of payment.
A)True
B)False
Q4) The collection abbreviation TTA means ____________________.
Q5) In dealing with an estate claim, a call to the ____________________ can be made periodically to check on the status of the estate.
Q6) All discounted fees need to be noted on the patient's ____________________.
Page 12
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Chapter
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Sample Questions
Q1) When a managed care plan requires the primary care physician to seek approval before referring a patient to a specialist, it is called obtaining
Q2) What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care?
A) Foundation for medical care
B) Physician provider group
C) Health care cost containment organization
D) Professional review organization
Q3) In an independent practice association (IPA), physicians are
A) paid salaries by their own independent group.
B) paid salaries by the practice association.
C) not employees and are not paid salaries.
D) not paid until the end of the year in which services were rendered.
Q4) A significant contribution to HMO development was the A) CIGNA plan.
B) Kaiser Permanente plan.
C) Health Maintenance Organization Act of 1973.
D) Omnibus Budget Reconciliation Act.
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Chapter 12: Medicare
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Sample Questions
Q1) When a Medicare carrier transmits a Medigap claim electronically to the Medigap carrier, it is referred to as a/an
A) electronic carryover claim.
B) crossover claim.
C) referral claim.
D) Medi-Medi claim.
Q2) Medicare Part A is administered by
A) the local Social Security Administration office.
B) a regional fiscal intermediary.
C) the Centers for Medicare and Medicaid Services.
D) the National Blue Cross Association.
Q3) An explanation of benefits document for a patient under the Medicare program is referred to as the
A) Medicare remittance advice document.
B) reimbursement report.
C) summary payment report.
D) explanation of Medicare benefits.
Q4) What type of coverage does a Medi-Medi patient have?
Q5) A patient classified with ESRD may be provided benefits from Medicare. What does ESRD stand for?
14
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Chapter 13: Medicaid and Other State Programs
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Sample Questions
Q1) The ____________________ form accompanies all Medicaid payment checks.
Q2) The federal government designs the Medicaid program for each state on the basis of the needs of the state.
A)True
B)False
Q3) A physician may accept or refuse Medicaid patients on the basis of the individual patient and his or her circumstances.
A)True
B)False
Q4) Medicaid eligibility must always be checked for the
A) month of service.
B) type of service.
C) year of service.
D) both a and b
Q5) The time limit to appeal a claim varies from state to state, but it is usually
A) 30-60 days.
B) 90-120 days.
C) 6 months.
D) 1 year.
Q6) The abbreviation for the Deficit Reduction Act of 1984 is
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Chapter 14: Tricare and Veterans Health Care
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Sample Questions
Q1) The TRICARE fiscal year extends from
A) January 1 to December 31.
B) April 1 to March 31.
C) July 1 to June 30.
D) October 1 to September 30.
Q2) The time limit within which a TRICARE inpatient claim must be filed is
A) within 1 year from the date a service is provided.
B) by the end of the year in which the service is provided.
C) within 1 year from a patient's discharge from an inpatient facility.
D) by the end of the year following a patient's discharge from an inpatient facility.
Q3) What does the acronym CHAMPVA stand for?
Q4) An NAS is a
A) certification of the status of a military hospital.
B) certification of the status of a civilian hospital.
C) certification from a civilian hospital stating specific treatment that was denied.
D) certification from a military hospital stating that it cannot provide the necessary care.
Q5) Individuals who qualify for TRICARE are known as ____________________.
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Page 16
Chapter 15: Workers Compensation
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Sample Questions
Q1) In an industrial case, the physician's office may collect all amounts not covered by the workers' compensation fee schedule.
A)True
B)False
Q2) If a worker has a work-related injury or illness and is unable to perform the duties of his or her occupation for 2 months and then returns to modified work for 1 month before returning to full work, the claim is referred to as a
A) nondisability claim.
B) temporary disability claim.
C) permanent disability claim.
D) permanent and stationary claim.
Q3) The simplest type of workers' compensation claim is
A) temporary disability.
B) permanent disability.
C) nondisability.
D) partial disability.
Q4) Name the five types of workers' compensation benefits.
Q5) The legal words _________________________ mean to substitute one person for another.
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Chapter 16: Disability Income Insurance and Disability Benefit Programs
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Sample Questions
Q1) For a disability income insurance case, the time period from the beginning of disability to receiving the first payment of benefits is called a/an ____________________ period.
Q2) The maximum amount of time for which benefits will be paid to the injured or ill person for a disability is called the
A) waiting period.
B) elimination period.
C) benefit period.
D) payment period.
Q3) The Supplemental Security Income (SSI) program under Title XVI of the Social Security Act provides
A) monthly income benefits to workers and those self-employed who meet certain conditions.
B) disability payments to needy people with limited income and few resources.
C) for those who have worked for Civil Service and who become totally disabled.
D) income for those injured on the job.
Q4) Disability income policies do not provide medical expense benefits.
A)True
B)False
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Chapter 17: Hospital Billing
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Sample Questions
Q1) A review for additional Medicare reimbursement is called
A) DRG validation.
B) day outlier review.
C) cost outlier review.
D) procedure review.
Q2) The claim form transmitted to the insurance carrier for reimbursement for inpatient hospital services is called the A) UB-82.
B) CMS 1450 (UB-04).
C) CMS-1500.
D) standard hospital billing form.
Q3) PAT is an abbreviation for ____________________.
Q4) The Administrative Simplification provisions of the Health Information Portability and Accountability Act of 1996 prohibit the submission of most _____________________.
Q5) In an effort to reduce the processing time for each health insurance claim submitted and to reduce costs related to health care delivery, Medicare uses a ______________ prospective payment system on which hospital fee reimbursements are based.
Q6) Medicare provides stop-loss called _____________________ in its regulations.
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Chapter 18: Seeking a Job and Attaining Professional Advancement
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Sample Questions
Q1) Accounts receivable bookkeeping experience would be listed on a résumé under the heading
A) skills.
B) education.
C) professional experience.
D) references.
Q2) When an individual wishes to start his or her own medical billing service, he or she should have sufficient funds to run the business for a period of
A) 2-4 months.
B) 3-6 months.
C) 1 year or more.
D) 1-3 years.
Q3) An insurance billing specialist may be employed by a physician, hospital, or other medical facility or may choose to be self-employed.
A)True
B)False
Q4) It is discriminatory for an employer to ask if an applicant smokes.
A)True
B)False
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