Understanding Health Insurance Chapter 1: Mr.
- 1.
The document submitted to the payer requesting reimbursement is called a
- A.
Explanation of benefits
- B.
Health insurance claim
- C.
Remittance advice
- D.
Preauthorization form
Correct Answer
B. Health insurance claimExplanation
A health insurance claim is the document submitted to the payer (such as an insurance company) by a healthcare provider or patient, requesting reimbursement for services rendered. It includes information about the patient, the provider, the services provided, and the associated costs. The payer reviews the claim and determines the amount they will reimburse based on the terms of the insurance policy.Rate this question:
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- 2.
The centers for Medicare and Medical Services (CMS) is an administration within the
- A.
Administration for children and families
- B.
Department of Health and Human Services
- C.
Food and Drug Administration
- D.
Office of The Inspector General
Correct Answer
B. Department of Health and Human ServicesExplanation
The Centers for Medicare and Medical Services (CMS) is an administration within the Department of Health and Human Services. This means that CMS operates under the umbrella of the Department of Health and Human Services, which is responsible for overseeing various health-related programs and initiatives in the United States. CMS specifically focuses on administering the Medicare and Medicaid programs, which provide healthcare coverage for certain eligible individuals. Being part of the Department of Health and Human Services ensures that CMS operates within the broader framework of the federal government's healthcare policies and regulations.Rate this question:
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- 3.
A Healthcare Practitioner is also called a
- A.
Dealer
- B.
Provider
- C.
Purveyor
- D.
Supplier
Correct Answer
B. ProviderExplanation
A Healthcare Practitioner is commonly referred to as a "provider" because they are responsible for providing medical services and care to patients. They offer healthcare services such as diagnosis, treatment, and prevention of illnesses, making them the primary source of medical care for individuals. The term "provider" encompasses various healthcare professionals, including doctors, nurses, therapists, and other licensed practitioners who deliver medical services to patients.Rate this question:
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- 4.
Which is the most appropriate response to a patient who calls the office and asks to speak with the physician?
- A.
Politely state that the Doctor is busy and cannot be disturbed
- B.
Explain that the doctor is with a patient and ask if the patient would like to leave a message
- C.
Transfer the call to the exam room where the Doctor is located
- D.
Offer an appointment for the patient to be seen by the Doctor
Correct Answer
B. Explain that the doctor is with a patient and ask if the patient would like to leave a messageExplanation
The most appropriate response to a patient who calls the office and asks to speak with the physician is to explain that the doctor is with a patient and ask if the patient would like to leave a message. This response acknowledges the patient's request and provides an alternative solution by offering to take a message. It shows professionalism and respect for the doctor's time and the patient's needs.Rate this question:
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- 5.
The Process of assigning diagnoses,procedures and services using numeric and alphanumeric charecters is called?
- A.
Coding
- B.
Data processing
- C.
Programming
- D.
Reimbursement
Correct Answer
A. CodingExplanation
The process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters is called coding. Coding involves translating medical information into standardized codes, such as ICD-10 or CPT codes, which are used for various purposes, including medical billing, record-keeping, and statistical analysis.Rate this question:
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- 6.
If a health insurance plans preauthorization requirements are not met by providers...
- A.
Administrative costs are reduced
- B.
Patients coverage is cancelled
- C.
Payment of the claim is denied
- D.
They pay a fine to the health plan
Correct Answer
C. Payment of the claim is deniedExplanation
If a health insurance plan's preauthorization requirements are not met by providers, the payment of the claim is denied. This means that the insurance company will not reimburse the provider for the services rendered to the patient. Preauthorization is a process where the provider seeks approval from the insurance company before providing certain treatments or procedures. If this requirement is not met, the insurance company has the right to deny payment for the claim.Rate this question:
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- 7.
Which coding system is used to report diagnoses and conditions on claims?
- A.
CPT
- B.
HCPCS
- C.
ICD
- D.
National codes
Correct Answer
C. ICDExplanation
ICD (International Classification of Diseases) is the coding system used to report diagnoses and conditions on claims. It is a standardized system that allows healthcare providers to accurately document and communicate medical diagnoses. ICD codes are used by insurance companies to process claims, track healthcare trends, and analyze population health data. This system helps ensure consistent and reliable reporting of diagnoses, which is essential for effective healthcare management and reimbursement.Rate this question:
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- 8.
The CPT coding system is published by the...
- A.
ADA
- B.
AHIMA
- C.
AMA
- D.
CMS
Correct Answer
C. AMAExplanation
The correct answer is AMA. The CPT coding system, also known as Current Procedural Terminology, is published by the American Medical Association (AMA). CPT codes are used to describe medical procedures and services provided by healthcare professionals. The AMA updates and maintains the CPT coding system to ensure accurate reporting and billing for medical services.Rate this question:
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- 9.
National codes are associated with...
- A.
CDT
- B.
CPT
- C.
HCPCS
- D.
ICD
Correct Answer
C. HCPCSExplanation
National codes, such as HCPCS (Healthcare Common Procedure Coding System), are associated with the identification and billing of medical procedures, services, and supplies provided to patients. These codes are used by healthcare professionals, insurance companies, and government agencies to ensure accurate reimbursement and tracking of healthcare services. HCPCS codes are specifically used for Medicare and Medicaid claims, and they provide a standardized way of documenting and reporting medical procedures and supplies.Rate this question:
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- 10.
Which report is sent to the patient by the payer to clarify the results of claim processing?
- A.
Explanation of benefits
- B.
Health insurance claim
- C.
Preauthorization claim
- D.
Remittence advice
Correct Answer
A. Explanation of benefitsExplanation
Explanation of benefits is the correct answer because it is a report that is sent to the patient by the payer (usually an insurance company) to explain the results of claim processing. This report provides details about the services that were billed, the amount paid by the insurance company, and any remaining balance that the patient may be responsible for. It helps the patient understand how their claim was processed and provides transparency in the billing and payment process.Rate this question:
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- 11.
A remittance advice contains?
- A.
Payment information about a claim
- B.
Provider qualifications and responsibilities
- C.
Detected errors and omissions from claims
- D.
Documentation of medical necessity
Correct Answer
A. Payment information about a claimExplanation
A remittance advice contains payment information about a claim. This means that it provides details regarding the payment made for a claim, such as the amount paid, the date of payment, and any relevant payment reference numbers. The remittance advice serves as a record of the payment transaction and helps the claimant reconcile their accounts. It does not include information about provider qualifications and responsibilities, detected errors and omissions from claims, or documentation of medical necessity.Rate this question:
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- 12.
Which type of insurance guarantees repayment for financial losses resulting from an employees act or failure to act?
- A.
Bonding
- B.
Liability
- C.
Property
- D.
Workers compensaton
Correct Answer
A. BondingExplanation
Bonding insurance guarantees repayment for financial losses resulting from an employee's act or failure to act. This type of insurance provides coverage for dishonest or fraudulent acts committed by employees, such as theft, embezzlement, or other forms of misconduct. It protects the employer from financial harm caused by the actions of their employees and helps to ensure that the employer is reimbursed for any losses incurred due to employee wrongdoing.Rate this question:
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- 13.
Medical malpractice insurance is a type of_____ insurance?
- A.
Bonding
- B.
Liability
- C.
Property
- D.
Workers compensation
Correct Answer
B. LiabilityExplanation
Medical malpractice insurance is a type of liability insurance. Liability insurance provides coverage for legal claims and expenses that may arise if a person or organization is found legally responsible for causing harm or injury to another person or their property. In the case of medical malpractice, this insurance protects healthcare professionals and facilities from financial losses due to claims of negligence or errors in providing medical treatment.Rate this question:
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- 14.
Which mandates workers compensation insurance to cover employees and their dependents against injury and death occurring during the course of employment?
- A.
State
- B.
Federal
- C.
Local
- D.
Workers compensation coverage is optional
Correct Answer
A. StateExplanation
State mandates workers compensation insurance to cover employees and their dependents against injury and death occurring during the course of employment. This means that it is the responsibility of individual states to require employers to provide workers compensation coverage for their employees. The federal government does not have a universal mandate for workers compensation, and it is not a local or optional requirement.Rate this question:
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- 15.
The American Medical Billing Association offers which certification exam
- A.
CCS
- B.
CMRS
- C.
CPC
- D.
RHIT
Correct Answer
B. CMRSExplanation
The American Medical Billing Association offers the CMRS certification exam. This certification is specifically for individuals who work in medical billing and coding. It demonstrates a high level of knowledge and expertise in the field, including understanding of medical terminology, coding systems, insurance processes, and compliance regulations. By obtaining the CMRS certification, individuals can enhance their professional credibility and increase their job opportunities in the medical billing industry.Rate this question:
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- 16.
Which was the first commercial insurance company in the United States to provide private healthcare coverage for injuries not resulting in death?
- A.
Baylor University Health Plan
- B.
Blue Cross and Blue Shield Association
- C.
Franklin Health Assurance Company
- D.
Office of Workers Compensation Program
Correct Answer
C. Franklin Health Assurance CompanyExplanation
The correct answer is Franklin Health Assurance Company. This company was the first to offer private healthcare coverage for non-fatal injuries in the United States.Rate this question:
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- 17.
Which replaced the 1908 workers compensation legislation and provided civilian employees of the federal government with medical care,survivors benefits and compensation for lost wages?
- A.
Black Lung Benefits Reform Act
- B.
Federal Employees Compensation Act
- C.
Longshore and Harbor Workers Compensation Act
- D.
Office of Workers Compensation Programs
Correct Answer
B. Federal Employees Compensation ActExplanation
The Federal Employees Compensation Act replaced the 1908 workers compensation legislation and provided civilian employees of the federal government with medical care, survivors benefits, and compensation for lost wages.Rate this question:
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- 18.
The first Blue Cross policy was introduced by?
- A.
Baylor University in Dallas Texas
- B.
Harvard University in Cambridge, Massachusetts
- C.
Kaiser Permanente in Los Angeles,California
- D.
American Medical Association representatives
Correct Answer
A. Baylor University in Dallas TexasExplanation
Baylor University in Dallas, Texas introduced the first Blue Cross policy.Rate this question:
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- 19.
The Blue Sheild concept grew out of the lumber and mining camps of______ region at the turn of the century
- A.
Great Plains
- B.
New England
- C.
Pacific Northwest
- D.
Southwest
Correct Answer
C. Pacific NorthwestExplanation
The Blue Shield concept grew out of the lumber and mining camps of the Pacific Northwest region at the turn of the century. This suggests that the concept originated in the states of Washington, Oregon, and Idaho, which were known for their abundant natural resources and booming industries during that time. The region's need for healthcare and protection for workers in these hazardous industries likely led to the development of the Blue Shield concept.Rate this question:
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- 20.
Healthcare coverage offered by____ is called group health insurance
- A.
A state
- B.
CMS
- C.
Employees
- D.
Employers
Correct Answer
D. EmployersExplanation
Group health insurance is a type of healthcare coverage that is provided by employers. It is a policy that covers a group of individuals, typically employees of a company, and their dependents. The employer pays a portion of the premium, and the employees may also contribute to the cost. This type of insurance is often more affordable and provides broader coverage than individual health insurance plans.Rate this question:
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- 21.
The Hill-Burton Act provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the great depression and WWII (1929-1945) In return for federal funds.
- A.
Facilities were require to provide services free or at a reduced rates to patients unable to pay for care
- B.
Medical group practices were formed to allow providers to share equipment,supplies and personnel
- C.
National coordinating agencies for physicians-sponsored health plans were created
- D.
Universal Health insurance was provided to those who could not afford private insurance
Correct Answer
A. Facilities were require to provide services free or at a reduced rates to patients unable to pay for careExplanation
The Hill-Burton Act mandated that facilities receiving federal grants for modernization had to provide services either free or at a reduced cost to patients who were unable to afford medical care. This provision aimed to ensure that healthcare services were accessible to all individuals, regardless of their financial situation. By requiring facilities to offer discounted or free services, the Act sought to address the issue of affordability and provide healthcare options for those who could not afford private insurance.Rate this question:
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- 22.
Third party administrators (TPAs) administer healthcare plans and process claims,serving as a...
- A.
Clearing house for data submitted by government agencies
- B.
Medicare administrative contractor(MAC) for business owners
- C.
System of checks and balances for labor management
- D.
Third party payer(insurance company) for employers
Correct Answer
C. System of checks and balances for labor managementExplanation
The correct answer is "system of checks and balances for labor management". Third party administrators (TPAs) play a crucial role in managing and overseeing various aspects of labor management. They ensure that there is a fair and transparent process in place by verifying and validating information related to employee benefits, payroll, and compliance with labor laws. TPAs act as intermediaries between employers and employees, ensuring that both parties adhere to the established rules and regulations. This system of checks and balances helps maintain a harmonious relationship between labor and management, promoting fairness and accountability in the workplace.Rate this question:
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- 23.
Major medical insurance provides coverage for______ illness and injuries,incorporating large deductibles and lifetime maximum amounts.
- A.
Acute care
- B.
Catastrophic or prolonged
- C.
Recently diagnosed
- D.
Work-related
Correct Answer
B. CatastropHic or prolongedExplanation
Major medical insurance provides coverage for catastrophic or prolonged illness and injuries. This type of insurance is designed to protect individuals from high medical expenses that may arise from serious or long-term health conditions. It typically includes large deductibles, meaning that the insured individual is responsible for paying a significant portion of their medical costs before the insurance coverage kicks in. Additionally, major medical insurance often has lifetime maximum amounts, which limit the total amount of coverage that an individual can receive throughout their lifetime.Rate this question:
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- 24.
The government health plan that provides healthcare services to Americans over the age of 65 is called...
- A.
Medicare
- B.
Medicaide
- C.
CHAMPUS
- D.
TRICARE
Correct Answer
A. MedicareExplanation
Medicare is the government health plan that provides healthcare services to Americans over the age of 65. It is a federal program that helps cover the costs of hospitalization, medical visits, and prescription drugs for eligible individuals. Medicare is different from Medicaid, which is a separate program that provides healthcare services to low-income individuals and families. CHAMPUS and TRICARE are health insurance programs specifically for military personnel and their families.Rate this question:
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- 25.
The percentage of cost a paitent shares with the health plan(e.g plan pays 80% of costs and patient pays 20%,is called?
- A.
Coinsurance
- B.
Copayment
- C.
Deductable
- D.
Maximum
Correct Answer
A. CoinsuranceExplanation
Coinsurance refers to the percentage of healthcare costs that a patient shares with their health plan. In this case, the health plan pays 80% of the costs, while the patient is responsible for paying the remaining 20%. Coinsurance is different from copayment, which is a fixed amount that a patient pays for each medical service, and deductible, which is the amount a patient must pay out of pocket before the insurance coverage begins. Maximum refers to the maximum amount that a health plan will pay for covered services during a specific period.Rate this question:
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- 26.
The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) enacted the _____ prospective payment systems (PPS)
- A.
Ambulatory payment classifications
- B.
Diagnosis related groups
- C.
Fee-for-service reimbursement
- D.
Resource based relative value scale system
Correct Answer
B. Diagnosis related groupsExplanation
The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) enacted the diagnosis related groups (DRGs) prospective payment systems (PPS). DRGs are a classification system used by Medicare to categorize patients into groups based on similar diagnoses and treatments. This system determines the reimbursement amount that hospitals receive for providing care to Medicare patients. Under the DRG PPS, hospitals are paid a fixed amount for each case based on the assigned DRG category, regardless of the actual costs incurred. This system was implemented to control healthcare costs and promote efficiency in the delivery of services.Rate this question:
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- 27.
The Clinical Laboratory Improvement Act (CLIA) established quality standards for all laboratory testing to ensure the accuracy reliability and timeliness of patient test results
- A.
Only at hospitals and other large institutions
- B.
Regardless of where the test was performed
Correct Answer
B. Regardless of where the test was performedExplanation
The correct answer is "regardless of where the test was performed." The explanation for this answer is that the Clinical Laboratory Improvement Act (CLIA) established quality standards for all laboratory testing, meaning that these standards apply to all types of laboratories, including hospitals and other large institutions, as well as smaller independent laboratories or point-of-care testing sites. The goal is to ensure that all patient test results are accurate, reliable, and timely, regardless of the location where the test is performed.Rate this question:
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- 28.
The National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and eliminates improper coding NCCI edits are based on coding conventions defined in_____, current standards of medical and surgical coding practice input from specialty societies and analysis of current coding practice
- A.
CPT
- B.
ICD
- C.
HCPCSII
- D.
NDC
Correct Answer
A. CPTExplanation
The National Correct Coding Initiative (NCCI) edits are based on coding conventions defined in CPT, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practice. CPT is the Current Procedural Terminology, which is a standardized medical coding system used to report procedures and services performed by healthcare providers. Therefore, the correct answer is CPT as it is one of the sources used to determine the correct coding methodologies and eliminate improper coding.Rate this question:
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- 29.
The primary intent of HIPPA Legislation is to...
- A.
Combine healthcare financing and quality assurance programs into a single agency
- B.
Create better access to health insurance limit fraud and abuse and reduce administrative cost
- C.
Provide health assistance to uninsured,low income children by expanding Medicaid program
- D.
Protect all employees against injuries from occupational hazards in the workplace
Correct Answer
B. Create better access to health insurance limit fraud and abuse and reduce administrative costExplanation
The primary intent of HIPPA Legislation is to create better access to health insurance, limit fraud and abuse, and reduce administrative costs. This legislation aims to improve the efficiency and affordability of healthcare by implementing measures to protect patient privacy, standardize electronic transactions, and ensure the security of health information. By doing so, it aims to increase access to health insurance coverage, prevent fraudulent activities in the healthcare system, and streamline administrative processes, ultimately improving the overall quality of healthcare delivery.Rate this question:
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- 30.
Utilization and quality control review of healthcare furnished, or to be furnished, to Medicare beneficiaries is currently performed by_____
- A.
Consumer driven Health Plus
- B.
Peer review organizations
- C.
Professional standards review organizations
- D.
Quality improvement organizations
Correct Answer
D. Quality improvement organizationsExplanation
Quality improvement organizations are responsible for the utilization and quality control review of healthcare provided to Medicare beneficiaries. These organizations ensure that the healthcare services meet the required standards and are delivered efficiently. They work to improve the quality of care and outcomes for Medicare beneficiaries by identifying areas for improvement and implementing strategies to enhance the delivery of healthcare services.Rate this question:
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- 31.
Which is the primary purpose of the paitent record?
- A.
Ensure continuity of care
- B.
Evaluate quality of care
- C.
Provide data for use in research
- D.
Submit data to third party payers
Correct Answer
A. Ensure continuity of careExplanation
The primary purpose of the patient record is to ensure continuity of care. This means that the record serves as a comprehensive and accurate documentation of the patient's medical history, treatments, and outcomes. It allows healthcare providers to have access to all relevant information about the patient's health, enabling them to make informed decisions and provide appropriate and consistent care. The patient record also facilitates communication and coordination among different healthcare professionals involved in the patient's care, ensuring that there is a seamless transition between different healthcare settings or providers.Rate this question:
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- 32.
The Problem Oriented Record (POR) includes the following four components
- A.
A chief complaint,review of systems,physical examinations,laboratory data
- B.
Database,problem list,initial plan,progress notes
- C.
Diagnostic plan,management plans, therapeutic plans,patient education plans
- D.
Subjective,objective assessment plans
Correct Answer
B. Database,problem list,initial plan,progress notesExplanation
The correct answer is "database, problem list, initial plan, progress notes". The Problem Oriented Record (POR) is a method of organizing and documenting medical information. The database component includes all relevant patient information such as medical history, demographics, and previous test results. The problem list is a list of the patient's active medical issues or concerns. The initial plan outlines the initial treatment plan or management approach for each problem on the list. Progress notes document the ongoing progress and changes in the patient's condition, as well as any updates to the treatment plan.Rate this question:
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- 33.
The Electronic Health Record (EHR) allows patient information to be created at different locations according to a unique patient identifier or identification number,which is called
- A.
Evidence based decision report
- B.
Health data management
- C.
Record linkage
- D.
Surveillance and reporting
Correct Answer
C. Record linkageExplanation
The correct answer is record linkage. The Electronic Health Record (EHR) system allows patient information to be created at different locations using a unique patient identifier or identification number. This record linkage enables healthcare providers to access and share patient data across different healthcare settings, ensuring continuity of care and improving patient outcomes.Rate this question:
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- 34.
When a patient states "I have not been able to sleep for weeks" the provider that uses the SOAP format documents that statement in the_____ portion of the clinic note
- A.
Assesment
- B.
Objective
- C.
Plan
- D.
Subjective
Correct Answer
D. SubjectiveExplanation
In the SOAP format, the subjective portion of the clinic note is where the provider documents the patient's statements, symptoms, and concerns. This includes any information that the patient shares about their condition, such as the statement "I have not been able to sleep for weeks." The subjective portion focuses on the patient's perspective and provides important context for the provider's assessment and plan for treatment.Rate this question:
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- 35.
The provider who uses the SOAP format documents the physical examination in the ______ portion of clinic note
- A.
Subjective
- B.
Objective
- C.
Assessment
- D.
Plan
Correct Answer
B. ObjectiveExplanation
The provider who uses the SOAP format documents the physical examination in the "objective" portion of the clinic note. The SOAP format is commonly used in medical documentation and stands for Subjective, Objective, Assessment, and Plan. The objective portion includes the factual and measurable information obtained during the physical examination, such as vital signs, physical findings, and laboratory results.Rate this question:
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Mar 22, 2023Quiz Edited by
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Sep 19, 2012Quiz Created by
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