Introduction to Health Insurance Question
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Course Introduction
Introduction to Health Insurance provides students with a comprehensive overview of the principles, terminology, and structures that underpin health insurance systems. The course explores the history and evolution of health insurance, the different types of health insurance models (including private, public, and employer-sponsored plans), and the role of government regulation. Students will learn about policy coverage, common terms such as premiums, deductibles, copayments, and out-of-pocket costs, as well as the processes for claims, reimbursement, and appeals. Through analysis of current trends and challenges, such as cost containment and access to care, students will develop a foundational understanding crucial for navigating and making informed decisions within the healthcare sector.
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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Page 2
Chapter 1: Role of an Insurance Billing Specialist
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Sample Questions
Q1) Working in a physician's office as an insurance billing specialist carries greater responsibilities than operating a self-owned insurance billing business.
A)True
B)False
Answer: False
Q2) Which code of ethics is most appropriate for an insurance billing specialist who handles medical records?
A) The American Health Information Management Association (AHIMA) code of ethics
B) The American Association of Medical Assistants, Inc. (AAMA) code of ethics
C) The claims assistance professional (CAP) code of ethics
D) The Certified Coding Specialist (CCS) code of ethics
Answer: A
Q3) What is the name of the modern code of ethics that the American Medical Association (AMA) adopted in 1980?
A) The Modern Standards of Conduct Code
B) The Principles of Medical Ethics
C) The Oath of Hippocrates
D) The American Medical Association Code of Ethics
Answer: B
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Page 3
Chapter 2: Compliance, Privacy, Fraud, and Abuse in Insurance Billing
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Sample Questions
Q1) The Stark Law is commonly referred to as the Anti-Kickback statute.
A)True
B)False
Answer: False
Q2) Define compliance.
Answer: Compliance in the health care industry is the process of meeting regulations, recommendations, and expectations of federal and state agencies that pay for health care services and regulate the industry.
Q3) Qui tam suits are those cases in which a private citizen known as a whistleblower reports a fraudulent activity within his or her organization.
A)True
B)False
Answer: True
Q4) Notes, papers, and memos regarding patient information should be disposed of using a shredding device.
A)True
B)False
Answer: True
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Chapter 3: Basics of Health Insurance
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Sample Questions
Q1) An insurance policy is a legally enforceable agreement called a/an ____________________.
Answer: contract
Q2) A daily record sheet used to record daily business transactions is called a/an
A) ledger.
B) encounter form.
C) daysheet.
D) transaction slip.
Answer: C
Q3) The first legal item in the business of handling medical insurance is the insurance ____________________ or policy.
Answer: contract
Q4) A state-sponsored program that provides free low-cost health coverage for low-income children is: ___________________________
Answer: State Children's Health Insurance Program (SCHIP)
State Children's Health Insurance Program SCHIP
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Chapter 4: Medical Documentation and the Electronic Health Record
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Sample Questions
Q1) The term ____________________ refers to a disease that persists over a long time.
Q2) A referral is the same as a consultation. A)True B)False
Q3) Private insurance carriers have the right to claim refunds in the event of accidental miscoding.
A)True B)False
Q4) A consultation may take place in a home, office, hospital, or extended care facility. A)True B)False
Q5) A problem-focused examination is more complex than a detailed examination. A)True B)False
Q6) Identify three ways that a physician may withdraw formally from further provision of care to a patient when the patient is noncompliant.
Q8) WNL is the abbreviation for _________________________. Page 6
Q7) PFSH is the abbreviation for ___________________________________.
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Page 7
Chapter 5: Diagnostic Coding
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Sample Questions
Q1) The proficient coder begins the coding process in ICD-10-CM Volume 1.
A)True
B)False
Q2) Diagnostic codes on an insurance claim explain
A) the patient's condition that was treated during the visit.
B) the professional services provided during the visit.
C) the supplies that were provided to the patient.
D) the provider's identification.
Q3) Which statement is true regarding neoplasms?
A) They are new growths.
B) They may be malignant.
C) They may be benign.
D) All of the above.
Q4) ICD-10-PCS used in hospital billing replaces which volume of ICD-9-CM?
A) Volume 1
B) Volume 2
C) Volume 3
D) Both Volumes 1 and 2
Q5) ICD-10-CM classifies __ and __ information for statistical purposes.
Q6) ICD-10-CM codes have from ____ to ___ characters.
Page 8
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Chapter 6: Procedural Coding
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Sample Questions
Q1) Some private insurance companies may or may not accept HCPCS codes.
A)True
B)False
Q2) Private health insurance plans using the UCR system may pay a physician's full charge if it does not exceed UCR charges.
A)True
B)False
Q3) Coding and billing numerous CPT codes to identify procedures that are usually described by a single code is called ____________________.
Q4) A patient appears at an outpatient medical facility with extensive lacerations. Simple repair of wounds measuring 2.5, 4.6, and 3.5 cm on the hands, along with complex repair of a 1.5-cm wound on the nose and intermediate repair of wounds measuring 7.3 and 4.6 cm on the scalp, are performed. List the code(s) required for the repairs.
Q5) The two-digit modifier -57 means
A) prolonged E/M services.
B) reduced services.
C) decision for surgery.
D) mandated services.
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Chapter 7: The Paper Claim: Cms-1500 02-12
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Sample Questions
Q1) The CMS-1500 claim form is divided into which of the following major sections?
A) Diagnosis and procedure information
B) Physician and procedure information
C) Patient and physician information
D) Patient and procedure information
Q2) A dirty claim is one that had coffee spilled on it before it was sent to the insurance carrier.
A)True
B)False
Q3) If several services are being billed on the same insurance claim form, you may "ditto" the dates on each line of service below the first line.
A)True
B)False
Q4) Which of the following is a lifetime 10-digit number issued to physicians that replaces all other numbers assigned by various health plans?
A) TIN
B) PIN
C) UPIN
D) NPI
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Chapter 8: The Electronic Claim
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Sample Questions
Q1) Research unpaid claims.
A)Daily
B)Weekly
C)End of month
D)Daily or weekly
Q2) For assignment of benefits, each patient's ___ must be obtained.
Q3) What does an electronic remittance advice (RA) do?
Q4) Identify common claim attachments that provide additional medical information to a claims processor.
Q5) The HIPAA Security Rule addresses security of electronic PHI in which area?
A) Administrative safeguards
B) Technical safeguards
C) Physical safeguards
D) All of the above
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.
Page 11
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Chapter 9: Receiving Payments and Insurance Problem
Solving
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Sample Questions
Q1) If the provider is notified by a commercial insurance carrier that an overpayment has been made, investigate the refund request.
A)True
B)False
Q2) The correct method to send documents for a Medicare reconsideration (Level 2) is by
A) certified mail with return receipt requested.
B) certified mail.
C) standard mail.
D) overnight mail.
Q3) The following are examples of problem claim filing EXCEPT:
A) payment paid to patient.
B) payment lost in the mail.
C) denied for no preauthorization.
D) all are examples of problem claim filing.
Q4) There is standardization of format for the explanation of benefits document for all private insurance carriers.
A)True
B)False
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Chapter 10: Office and Insurance Collection Strategies
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Sample Questions
Q1) According to the FDCPA, debtors can never be contacted at work.
A)True
B)False
Q2) You should not give patients the option of whether they would like to pay now or have a bill sent.
A)True
B)False
Q3) What is a card called that permits bank customers to make cashless purchases from funds on deposit without incurring revolving finance charges for credit?
A) Private-label card
B) Credit card
C) Debit card
D) VeriFone card
Q4) In a bankruptcy case, most medical bills are considered
A) secured debt.
B) unsecured debt.
C) nonexempt assets.
D) exempt assets.
Q5) All discounted fees need to be noted on the patient's ____________________.
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Chapter 11: The Blue Plans, Private Insurance, and Managed Care Plans
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Sample Questions
Q1) In certain managed care plans there is an incentive for the gatekeeper to limit patient referrals to specialists.
A)True B)False
Q2) 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.
Q3) When a managed care plan requires the primary care physician to seek approval before referring a patient to a specialist, it is called obtaining
Q4) If a primary care physician sends a patient to a specialist for consultation and the specialist is not in the managed care plan, the specialist may bill the primary care physician for payment.
A)True B)False
Q5) Exclusive provider organizations (EPOs) are regulated by the federal government. A)True B)False
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Chapter 12: Medicare
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Sample Questions
Q1) In the Medicare program, a physical examination is a covered benefit when performed within 12 months of enrollment.
A)True
B)False
Q2) 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.
Q3) What type of coverage does a Medi-Medi patient have?
Q4) Medicare provides insurance for people ____________________ years of age or older who are retired on Social Security.
Q5) A program that contracts with CMS to review medical necessity and appropriateness of inpatient medical care is known as a
A) QIO.
B) PCP.
C) HMO.
D) HHS.
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Chapter 13: Medicaid and Other State Programs
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Sample Questions
Q1) Medicaid managed care patient claims should be sent to the A) Medicaid fiscal agent or carrier.
B) state government office.
C) local Medicaid office.
D) managed care organization and not the Medicaid fiscal agent.
Q2) The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act are federal legislation passed in _________________.
Q3) The _______________________________________ Law prevents the community spouse from being impoverished by his or her spouse's institutionalization in a nursing facility.
Q4) It is not possible for an immigrant to have Medicaid coverage.
A)True B)False
Q5) Home health care is never covered under Medicaid. A)True B)False
Q6) The Medicaid medical assistance program in California is called
Q7) The ____________________ form accompanies all Medicaid payment checks.
Page 16
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Chapter 14: Tricare and Veterans Health Care
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Sample Questions
Q1) TRICARE Prime and TRICARE Extra claims are
A) filed by the beneficiary to a TRICARE subcontractor.
B) filed by the provider to a TRICARE subcontractor.
C) paid by capitation, so no claim needs to be filed.
D) filed the same as for TRICARE Standard and CHAMPVA claims.
Q2) CHAMPVA is a/an
A) insurance program.
B) service benefit program.
C) both a and b.
D) neither a nor b.
Q3) 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.
Q4) Where are claims for patients on active duty sent?
Q5) The physician who provides medical care at contracted rates to beneficiaries under the TRICARE Extra program is called a/an ____________________ provider.
Q6) Who determines eligibility in the CHAMPVA program?
Page 17
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Chapter 15: Workers Compensation
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Sample Questions
Q1) A date of injury is a requirement for all workers' compensation insurance claims.
A)True
B)False
Q2) Premiums for workers' compensation insurance are paid by the A) employee.
B) employer.
C) employee and employer in equal amounts.
D) state in which the employee works.
Q3) An abnormal condition caused by exposure to environmental factors associated with employment is termed a/an
A) physical injury.
B) occupational illness.
C) temporary disability.
D) permanent disability.
Q4) Name the five types of workers' compensation benefits.
Q5) A physician hired by the insurance company or appointed by the referee or appeals board to examine an injured worker and render an unbiased opinion regarding the degree of disability is referred to as a/an ____________________.
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Page 18
Chapter 16: Disability Income Insurance and Disability Benefit Programs
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Sample Questions
Q1) 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.
Q2) Temporary disability exists when an illness or injury prevents a person from performing one or more of the functions of his or her regular job.
A)True
B)False
Q3) For people trying to qualify for SSDI or SSI, determination is made by the physician. A)True
B)False
Q4) Benefits for medical expenses are provided through disability income insurance. A)True
B)False
Q5) What are the four levels of the appeal process used if disagreement with determination of disability occurs?
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Chapter 17: Hospital Billing
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Sample Questions
Q1) On the CMS 1450 (UB-04) claim form, the patient's date of birth should be entered using six digits in block 14.
A)True
B)False
Q2) A review for additional Medicare reimbursement is called
A) DRG validation.
B) day outlier review.
C) cost outlier review.
D) procedure review.
Q3) ______________________ is a preexisting condition that will, because of its effect on the specific principal diagnosis, require more intensive therapy or cause an increase in length of stay by at least 1 day in approximately 75% of cases.
Q4) A patient has a right to request an itemized bill from a hospital stay with no cost to the patient.
A)True
B)False
Q5) The __________________________________________________ is used to list procedural codes for Medicare patients on hospital insurance claims that are not in the CPT book.
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Chapter 18: Seeking a Job and Attaining Professional Advancement
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Sample Questions
Q1) What should a cover letter end with?
Q2) An alien employee must have on file with his or her employer an Employment Eligibility Verification Form.
A)True
B)False
Q3) A medical insurance billing specialist prices his or her services by
A) percentage of reimbursement.
B) an annual or hourly fee.
C) a set fee per claim.
D) all of the above.
Q4) A blind mailing means sending information to potential employers who have not advertised a job opening.
A)True
B)False
Q5) Cover letters should be A) customized.
B) typed for neatness.
C) addressed to a specific person.
D) all of the above.
Q6) List five ways to search for a job. Page 21
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Page 22