Introduction to Health Insurance
Textbook Exam Questions
Course Introduction
Introduction to Health Insurance offers students a comprehensive overview of the fundamental principles, structures, and functions of health insurance systems. The course explores key concepts such as risk pooling, premium calculation, policy types, coverage options, and regulatory frameworks. Students will learn about public and private health insurance models, including government-sponsored programs like Medicaid and Medicare, and the role of health insurers in the healthcare industry. Emphasis is placed on understanding how health insurance impacts access to care, provider reimbursement, patient financial responsibility, and overall health system sustainability. Current trends, challenges, and reforms in health insurance are also discussed to prepare students for roles in healthcare administration, policy, or related fields.
Recommended Textbook
Health Insurance Today A Practical Approach 5th Edition by Janet I. Beik AA BA Med
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Chapter 1: The Origins of Health Insurance
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Sample Questions
Q1) The new healthcare reform laws make it more difficult for Americans to qualify for state Medicaid programs.
A)True
B)False
Answer: False
Q2) The federal act that allows employees who quit their jobs or get laid off to extend their group coverage is known by the acronym ___________________. Answer: COBRA
Q3) Usually,there are no deductibles to be met or claim forms to be completed with HMOs.
A)True
B)False
Answer: True
Q4) Under the new healthcare law,ACOs agree to manage all of the healthcare needs of a minimum of 5,000 Medicare beneficiaries for at least 3 years.
A)True
B)False
Answer: True
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Page 3
Chapter 2: Tools of the Trade: A Career as a Health (Medical)Insurance
Professional
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Sample Questions
Q1) CMS mandates that insurance claims be submitted electronically using a specific format;however,there are exceptions to this rule.
A)True
B)False
Answer: True
Q2) The key innovation that has dramatically transformed the health insurance industry that focuses on accuracy and efficiency rather than manual processes is the:
A) computer.
B) multiline telephone.
C) copy machine.
D) calculator.
Answer: A
Q3) The nationally recognized title for a health insurance professional is "insurance biller/coder."
A)True
B)False
Answer: False
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Page 4
Chapter 3: The Legal and Ethical Side of Medical Insurance
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Sample Questions
Q1) Direct and indirect contact with patients presents continuous ethical and legal responsibilities for the health insurance professional.
A)True
B)False
Answer: True
Q2) Elements of a legal contract include all of the following,except:
A) an attorney.
B) consideration.
C) competent parties.
D) offer and acceptance.
Answer: A
Q3) When an individual has the legal ability to handle another person's affairs,he or she is said to have ____________________.
Answer: power of attorney
Q4) The terms fraud and abuse are interchangeable.
A)True
B)False
Answer: False
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Page 5
Chapter 4: Types and Sources of Health Insurance
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Sample Questions
Q1) A family physician,internist,obstetrician-gynecologist,or pediatrician who is usually the patient's first contact for healthcare defines a/an:
A) participating provider.
B) initial provider.
C) primary care physician.
D) principal provider.
Q2) A provider who is under no contractual agreement with the insurer to accept reimbursement as payment in full.
Q3) 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.
Q4) Most health insurers ask that patients pay a portion (or percentage)of the charge for professional services.This charge is commonly referred to as:
A) usual, customary, and reasonable (UCR).
B) coinsurance.
C) deductible.
D) reimbursement.
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Chapter 5: Claim Submission Methods
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Sample Questions
Q1) All electronic claims must be routed through a claims clearinghouse.
A)True
B)False
Q2) If a medical facility has only one employee but is utilizing some type of electronic software,the office must be in compliance with HIPAA's privacy rules and regulations.This is referred to as the ___________ rule.
Q3) The two basic methods for submitting claims electronically are _____________ and ___________________.
Q4) The most common format used for computer text files and on the Internet is: A) OCR.
B) JAVA.
C) ASCII.
D) HTML.
Q5) Documents that are sometimes necessary to support the services and procedures reported on the claim are called ________________.
Q6) List the five documents needed for filing an insurance claim.
Q7) If the decision is made to go direct to the carrier,there will be multiple _______ that occur when a computer is programmed to automatically connect to another computer.
Page 7
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Chapter 6: Traditional Fee For Service/Private Plans
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Sample Questions
Q1) Identify the recent federal act that amended HIPAA's "credible coverage" rule.
A) Employee Retirement Income Security Act
B) The Patient Protection and Affordable Care Act
C) Federal Employees Health Benefits Act
D) Pre-Existing Condition Insurance Act
Q2) The "traditional" type of health insurance policy whereby the insurance company pays all or a portion of the fees for the services provided to the individual covered by the policy is called:
A) fee-for-service (FFS).
B) managed care.
C) health maintenance.
D) usual, customary, and reasonable.
Q3) One kind of commercial insurance that the government does pay is the FEHB program,which is healthcare coverage for its own civilian employees.
A)True
B)False
Q4) Fee-for-service plans offer the most choices of healthcare providers.
A)True
B)False
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Chapter 7: Unraveling the Mysteries of Managed Care
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Sample Questions
Q1) A group of healthcare providers working under one umbrella to provide medical services at a discount to the individuals who participate in the plan is referred to as a/an:
A) HMO.
B) FFS.
C) AMA.
D) PPO.
Q2) A predominant,standard-setting nonprofit organization that evaluates and accredits healthcare organizations in the United States is ____________________.
Q3) A specific provider who oversees the total healthcare treatment of an individual enrolled in certain managed care plans is generally referred to as a:
A) participating provider.
B) primary care physician.
C) principal care provider.
D) treatment administrator.
Q4) The two most common types of managed care organizations are ___________ and ____________.
Q5) List the three main objectives of HIPAA.
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Chapter 8: Understanding Medicaid
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Sample Questions
Q1) Congress established the Medicaid program under Title XIX of the Social Security Act in 1965.
A)True
B)False
Q2) As a general rule,Medicaid pays only for services that are determined to be:
A) over $100.
B) experimental.
C) federally mandated.
D) medically necessary.
Q3) Providers are not permitted to withhold care or services to individuals even when they do not meet their cost-sharing obligations.
A)True
B)False
Q4) In 1972 federal law established the ______________program,which provides federally funded cash assistance to qualifying elderly and disabled poor.
Q5) Under which federal act was the Medicaid program established?
Q6) The time limit for filing Medicaid claims varies from state to state but is typically
Q7) Discuss Medicaid Quality Practices
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Chapter 9: Conquering Medicares Challenges
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Sample Questions
Q1) All Medicare Advantage plans offer the exact same coverage as original Medicare.
A)True
B)False
Q2) One of the cost-sharing requirements of Medicare Part B is an annual deductible which is subject to change annually,after which Medicare pays ____ percent of
Q3) The term used when Medicare is not responsible for paying first because of coverage under another insurance policy is:
A) Medigap.
B) Medi-Medi.
C) supplemental payer.
D) Medicare secondary payer (MSP).
Q4) The private organization that determines payment of Part B covered items and services is called a peer review organization (PRO).
A)True
B)False
Q5) Workers' compensation would likely be a primary payer to Medicare.
A)True
B)False
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Chapter 10: Military Carriers
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Sample Questions
Q1) Identify eligible categories of individuals included under the TRICARE program.
Q2) If a TRICARE-eligible beneficiary has other healthcare coverage,such as employer group or private insurance,TRICARE considers this:
A) unlawful.
B) dual eligibility.
C) coordination of benefits.
D) other health insurance (OHI).
Q3) To be eligible for CHAMPVA,the individual must meet what specific criteria?
Q4) The TRICARE option that is structured similar to a preferred provider organization (PPO)is:
A) CHAMPVA.
B) TRICARE Standard.
C) TRICARE Extra.
D) TRICARE Prime.
Q5) Identify the benefit program designed for spouses or dependents of veterans who are 65 or older.
A) Medicare United
B) TRICARE for Life
C) CHAMPVA for Life
D) TRICARE-CHAMPVA Connect
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Chapter 11: Miscellaneous Carriers: Workers Compensation and Disability Insurance
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Sample Questions
Q1) Which of the following employers are not required to provide workers' compensation insurance to their employees?
A) Employers with fewer than three full-time employees
B) Individuals who are business partners
C) Volunteers
D) All of the above
Q2) Workers' compensation is considered no-fault,and benefits are paid regardless of who is to blame for the injury.
A)True
B)False
Q3) The Federal Employment Compensation Act (FECA)provides workers' compensation for _____ employees.
A) military federal
B) nonmilitary federal
C) military nonfederal
D) nonmilitary nonfederal
Q4) Certain classifications of businesses are not required to provide workers' compensation for their employees.List at least four.
Q5) List and explain the two major classifications of disability coverage.
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Chapter 12: Diagnostic Coding
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Sample Questions
Q1) There is one year time limit on when a late effect code can be used.
A)True
B)False
Q2) Version 4010/4010A standards accommodates the ICD-10 code sets.
A)True
B)False
Q3) Terms in parentheses following the main terms that are provided to assist the coder in locating the applicable main term are called:
A) essential modifiers.
B) nonessential modifiers.
C) eponyms.
D) conditions.
Q4) Volume 1 of ICD-9 has 17 subsections plus the sections on E codes and V codes,Appendices A through E,and Table A.
A)True
B)False
Q5) ___________ modifiers must be a part of the diagnosis documented in the patient health record.
Q6) Explain the difference between an essential and a nonessential modifier.
Page 14
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Chapter 13: Procedural, Evaluation and Management, and
HCPCS Coding
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Sample Questions
Q1) The category of codes established by the AMA as a set of temporary CPT codes for emerging technologies,services,and procedures is Category _____ codes.
A) I
B) II
C) III
D) IV
Q2) The CPT index is organized by ____________ listed alphabetically.
Q3) List items that must be included in a "special report" if and when one becomes necessary to accompany a claim to explain unusual circumstances.
Q4) A CPT code can be displayed one of three ways: as ____________,____________,or ______________.
Q5) E/M codes represent the services provided directly to the patient during an encounter that does not involve an actual procedure.
A)True
B)False
Q6) What are the four contributing factors that may impact the E&M coding level reported?
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Q7) Main terms can stand alone,or they can be followed by ______________terms.
Chapter 14: The Patient
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Q1) HIPAA's _____________________________ provisions require the HHS to adopt national standards for electronic healthcare transactions and national identifiers for providers,health plans,and employers.
Q2) HIPAA is a federal law designed to protect the privacy of individuals' health information.
A)True
B)False
Q3) A HIPAA-covered entity can use or disclose protected health information for any purpose.
A)True
B)False
Q4) The Fair Debt Collection Practices Act addresses:
A) debt collection in hospitals.
B) abusive methods used by third-party collectors.
C) debt collection in nursing homes.
D) abusive methods used by healthcare facilities.
Q5) A listing of all expenses paid out to vendors such as building rent,office supplies,and salaries is called a _______________ journal.
Q6) Name the three major groups that fall under the umbrella of "covered entities."
Page 16
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Chapter 15: Keys to Successful Claims Management
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Sample Questions
Q1) When a claims error that could result in inaccurate reimbursement is discovered,a corrected claim should be prepared and submitted according to the payer's guidelines.
A)True
B)False
Q2) If a health insurance professional discovers an error in a claim that could result,or already has resulted,in inaccurate reimbursement,what should be done?
Q3) When a patient signs an assignment of benefits,he or she is authorizing the insurance carrier to send payment directly to the healthcare provider.
A)True
B)False
Q4) The claims process actually starts with the patient's appointment.
A)True
B)False
Q5) Explain how the Health Care Claim Status Inquiry/Response system works.
Q6) The type of Medicare coverage dictates the specific appeal filing process.
A)True
B)False
Q7) List at least 4 ways for optimizing the billing and claims process.
Page 17
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Chapter 16: The Role of Computers in Health Insurance
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Sample Questions
Q1) A standard format used to transfer information electronically between two entities is known as:
A) PHI.
B) EDI.
C) ICD.
D) DHS.
Q2) One of the most important roles of the healthcare industry is _____ management.
A) drug
B) office
C) inventory
D) information
Q3) _____are among the administrative simplifications addressed by HIPAA.Briefly explain the purpose of privacy standards in your own words.
Q4) The record keeping method where some documents are stored electronically and some are kept in paper form is referred to as:
A) combination records.
B) blended registers.
C) sequenced accounts.
D) digital imaging hybrids.
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Chapter 17: Reimbursement Procedures: Getting Paid
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Sample Questions
Q1) A method of payment for healthcare services whereby the provider is paid a fixed amount for each patient regardless of the actual number or nature of services provided is called:
A) UCR.
B) PPG.
C) capitation.
D) fee-for-service.
Q2) List the three types of firms that fall under the umbrella of a "covered entity," as named by HIPAA.
Q3) The biggest challenge in developing an RVS-based payment schedule was patient diversity.
A)True
B)False
Q4) More and more practices are converting to a provider fee schedule that is based on:
A) FFS.
B) RVUs.
C) GPCI.
D) PROs.
Q5) Name the three components that make up a relative value unit (RVU).
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Chapter 18: Hospital Billing and the UB-04
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Q1) All state Medicaid programs use the same method to determine payment for hospital inpatient services.
A)True
B)False
Q2) 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
Q3) All acute care or general hospitals must be licensed by the federal government.
A)True
B)False
Q4) A facility that is certified by Medicare and licensed/approved under state and/or local law to provide 24-hour nursing care and rehabilitation services in addition to other medical services is a/an:
A) acute care hospital.
B) subacute care facility.
C) skilled nursing facility.
D) long-term care facility.
Q5) Discuss the purpose of the new HIPAA edit.
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