(Test Bank) Fordney’s Medical Insurance

Smith, 15

Nursing

Test Bank

15th Edition

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Test Bank for Fordney’s Medical Insurance, The downloadable file consists of 155 pages, and the total size of the file is 1.37 MB. Purchase now only for highly discounted price.

Author(s): Smith

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Fordney’s Medical Insurance 15th Edition Smith Test Bank Chapter 01: Role of an Insurance Billing Specialist Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Administrative medical office responsibilities include a. laboratory analyses. b. claims submission. c. taking x-rays. d. venipunctures. ANS: B DIF: Easy REF: 4 OBJ: 2 2. A claims assistance professional a. works for the consumer. b. helps patients file insurance claims. c. neither works for the consumer nor helps patients file insurance claims. d. works for the consumer and helps patients file insurance claims. ANS: D DIF: Easy REF: 4 OBJ: 2 3. What is “cash flow” in a medical practice? a. The actual money available to a medical practice b. The amount of money received by a medical practice in 1 day c. The amount of money received by a medical practice in 1 month d. The amount of outstanding money on the accounts receivable ANS: A DIF: Moderate REF: 4 OBJ: 2 4. Which level of education is generally required for one who seeks employment as an insurance coder? a. College diploma. b. High school diploma. c. Completion of an accredited program for coding certification. d. No specific level of education is required. ANS: C DIF: Easy REF: 4 OBJ: 4 5. The amount of money an insurance billing specialist earns is dependent on which of the following factors? a. Knowledge b. Experience c. Size of employing institution d. All are correct ANS: D DIF: Moderate REF: 9 OBJ: 5 6. A billing specialist is entrusted with a. holding patients’ medical information in confidence. b. collecting monies. c. being a reliable resource for co-workers. d. all are correct. ANS: D DIF: Moderate REF: 13 OBJ: 7 7. Medical etiquette refers to a. consideration for others. b. moral principles or practices. c. laws. d. the Oath of Hippocrates. ANS: A DIF: Moderate REF: 11 OBJ: 9 8. Professional ethics include a. state laws. b. federal laws. c. standards of conduct. d. civil torts. ANS: C DIF: Moderate REF: 13 OBJ: 9 9. The earliest written code of ethical principles for the medical profession is the a. Oath of Hippocrates. b. Socratic oath. c. Code of Hammurabi. d. Medicolegal oath. ANS: C DIF: Easy REF: 13 OBJ: 9 10. What is the n ame of the mTodEeSrnTcBodAeNoKf SetEhiLcsLtEhRat.thCeOAMmerican Medical Associ ation (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 ANS: B DIF: Easy REF: 13 OBJ: 9 11. A self-employed medical insurance biller who does independent contracting is responsible for a. advertising. b. billing. c. accounting. d. all are correct. ANS: D DIF: Hard REF: 10 OBJ: 10 12. The Internet Health care Coalition has developed a. the AAMA Code of Ethics. b. the eHealth Code of Ethics. c. the AMA Code of Ethics. d. the AHIMA Code of Ethics. ANS: B DIF: Moderate REF: 13 OBJ: 9 13. Reporting incorrect information to government -funded programs is a. unethical. b. illegal. c. abuse. d. fraud. ANS: B DIF: Moderate REF: 13 OBJ: 9 14. The doctrine stating that physicians are legally responsible for both their own conduct and that of their employees is known as a. respondeat superior . b. let the master answer. c. vicarious liability. d. all are correct. ANS: D DIF: Hard REF: 14 OBJ: 10 15. The AHIMA Code of Ethics is appropriate for a. health information specialists. b. coders. c. insurance billing specialists. d. all are correct. ANS: D DIF: Easy REF: 14 OBJ: 9 COMPLETION 1. TisEtSheTtBotAalNiKncSoEmLe LprEoRdu.cCedObMy a health care organization. ANS: Revenue DIF: Moderate REF: 2 OBJ: 1 2. An NPP is a . ANS: non-physician practitioner DIF: Moderate REF: 3 OBJ: 3 3. Charging for services done in hospitals, acute care hospitals, skilled nursing or long -term care facilities, rehabilitation centers, or ambulatory surgical centers is known as billing. ANS: facility DIF: Moderate REF: 3 OBJ: 2 4. Obtaining and recording patient data using a questionnaire before that person’s first visit is known as . ANS: preregistration DIF: Easy REF: 3 OBJ: 3 5. Individuals who are employed by an insurance carrier and whose role is to analyze and process incoming claims, checking them for validity and determining if the services were reasonable and necessary are referred to as , or . ANS: claims examiners claims adjustors claims representatives claims examiners claims representatives claims adjustors claims adjustors claims representatives claims examiners claims adjustors claims examiners claims representatives claims representatives claim s examiners claims adjustors claims representatives claims adjustors claims examiners claims examiners, claims adjustors, claims representatives claims examiners, claims representatives, claims adjustors claims adjustors, claims representatives, claims examiners claims adjustors, claims examiners, claims representatives claims representatives, claims examiners, claims adjustors claims representatives, claims adjustors, claims examiners DIF: Moderate REF: 3 OBJ: 3 6. Patients who do not have any medical insurance and are liable for the entire bill are referred to as patients. ANS: self-pay DIF: Easy REF: T4ESTBANKSOEBLJ:LE3 R.COM 7. Transmitting, receiving, storing, and forwarding of text, voice messages, attachments, or images by computer from one person to another is referred to as mail. ANS: electronic DIF: Moderate REF: 12 OBJ: 3 8. The Greek physician known as the Father of Medicine devised the . ANS: Oath of Hippocrates DIF: Easy REF: 13 OBJ: 2 9. Most health care professionals have a well-defined which easily draws a boundary on things which the professional can do and things they are not supposed to do. ANS: scope of practice DIF: Moderate REF: 13 OBJ: 3 10. The Greek physician known as the Father of Medicine devised the . ANS: Oath of Hippocrates DIF: Easy REF: 13 OBJ: 2 11. Standards of conduct by which an insurance billing specialist determines the propriety of his or her behavior in a relationship are known as medical . ANS: ethics DIF: Moderate REF: 13 OBJ: 9 12. The earliest written code of ethical principles of medicine is called the . ANS: Code of Hammurabi DIF: Easy REF: 13 OBJ: 9 13. In 1980, the AMA adopted a modern code of ethics called the . ANS: Principles of Medical Ethics DIF: Easy REF: 13 OBJ: 9 14. Respondeat superior , which literally means “let the master answer,” is also known as liability. ANS: vicarious DIF: Hard REF: 14 OBJ: 1 15. All insurance billing specialists should check with their physician employers to see whether the specialist is included in the medical professional insurance policy. ANS: liability DIF: Moderate REF: 14 OBJ: 10 TRUE/FALSE 1. The primary goal of an insurance claims assistance professional (CAP) is to assist the consumer in obtaining maximum benefits and to tell the patient what checks to write to providers to make sure there are no overpayments. ANS: T DIF: Moderate REF: 4 OBJ: 11 2. In a medical practice, front office duties have lost importance. ANS: F DIF: Easy REF: 4 OBJ: 3 3. Generally, a high school diploma is not required for an insurance billing specialist. ANS: F DIF: Easy REF: 4 OBJ: 4 4. Working in a physician’s office as an insurance billing specialist carries greater responsibilities than operating a self-owned insurance billing business. ANS: F DIF: Moderate REF: 15 OBJ: 10 5. The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the physician. ANS: F DIF: Moderate REF: 13 OBJ: 9 6. The Centers for Medicare and Medicaid Services, formerly known as the Health Care Financing Administration, adopted the Principles of Medical Ethics in 1980. ANS: F DIF: Easy REF: 13 OBJ: 9 7. Illegal coding practices are subject to penalties, fines, and/or imprisonment. ANS: T DIF: Moderate REF: 13 OBJ: 9 8. At certain times medical office staff members are allowed to make critical remarks about a physician to a patient. ANS: F DIF: Moderate REF: 13 OBJ: 9 9. It is illegal to report incorrect information to government -funded programs such as Medicare, Medica id, and TRICARE. ANS: T DIF: Moderate REF: 13 OBJ: 9 10. The title used for medical billing personnel may depend on the region of the United States where they work. ANS: T DIF: Moderate REF: 3 OBJ: 4 11. Insurance companies never require the patient to submit the claim form. ANS: F DIF: Moderate REF: 4 OBJ: 3 12. Physicians are legally responsible for any actions of their employees performed within the context of their employment; therefore, an employee cannot be sued or brought to trial. ANS: F DIF: Hard REF: 14 OBJ: 10 13. A claims assistance professional (CAP) acts as an informal representative of patients and helps patients interpret insurance contracts. ANS: F DIF: Moderate REF: 4 OBJ: 11 14. In some states, giving an insured client advice on purchase or discontinuance of insurance policies is construed as being an insurance agent. ANS: T DIF: Hard REF: 15 OBJ: 11 15. The best way for an insurance specialist to keep up to date in the profession is to read health care industry association publications, attend seminars on billing and coding, and participate in e-mail listserv discussions. ANS: T DIF: Easy REF: 15 OBJ: 12 Chapter 02: Privacy, Security, and HIPAA Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. The focus on the health care practice setting and reducing administrative costs and burdens are the goals of a. HIPAA Title I Insurance Reform. b. HIPAA Title II Administrative Simplification. c. HIPAA Security Rule Administrative Safeguard. d. HIPAA Security Rule Technical Safeguard. ANS: B DIF: Moderate REF: 18 OBJ: 3 2. The Office of Civil Rights enforces a. code set requirements. b. insurance portability. c. privacy and security rules. d. HIPAA transactions. ANS: C DIF: Hard REF: 18 OBJ: 4 3. Confidential information includes a. everything that is heard about a patient. b. everything that is read about a patient. c. everything that is seen regarding a patient. d. all are correct. ANS: D DIF: Moderate REF: 23 OBJ: 7 4. What is the correct response when a relative calls asking about a patient? a. Document the name of the relative and his or her relationship to the patient before disclosing any information. b. Ask the relative to put the request in writing and include the patient’s signed authorization. c. Have the physician return the telephone call. d. None are correct. ANS: C DIF: Hard REF: 25 | 27 OBJ: 7 5. Non-privileged information about a patie nt consists of the patient’s a. city of residence. b. diagnosis. c. illness. d. treatment. ANS: A DIF: Easy REF: 23 OBJ: 8 6. Confidentiality is automatically waived in cases of a. gunshot wounds. b. child abuse. c. extremely contagious diseases. d. all are correct. ANS: D DIF: Moderate REF: 24-25 OBJ: 7 7. What is the best response when telephoning a patient about an insurance matter and the patient’s voice mail is reached? a. Use care in the choice of words when leaving the message. b. Do not leave a message. c. Leave a complete message so that the patient will know why you called and be able to call you back and respond to anyone in the office. d. Leave your name, the practice’s name, and the practice’s telephone number, but do not leave any other informati on. ANS: A DIF: Hard REF: 27 OBJ: 10 COMPLETION 1. “What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about,” is attributed to . ANS: Hippocrates DIF: Easy REF: 20 OBJ: 5 2. Non-privileged information consists of ordinary _ unrelated to the treatment of the patient. ANS: facts DIF: Easy REF: 23 OBJ: 8 3. Telephone conversations by providers in front of patients should be . ANS: avoided DIF: Easy REF: 35 OBJ: 10 MATCHING Match the positions below with the description of that person or entity. a. Health care provider b. Clearinghouse c. Covered entity d. Business associate e. Privacy officer, privacy official 1. Individual who is designated to help a provider remain in compliance by setting policies and procedures in place, train staff regarding HIPAA Privacy guidelines, and act as the contact person for questions and complaints. 2. A health care coverage carrier, clearinghouse, or physician who transmits health information in electronic form in connection w ith a transaction covered by HIPAA. 3. Individual who renders medical services, furnishes bills, or is paid for health care in the normal course of business. 4. Third -party administrator who receives insurance claims from the physician’s office, performs edits, and redistributes the claims electronically to various insurance carriers. 5. Individual who is hired by a medical practice to process claims to a third -party payer. 1. ANS: E DIF: Moderate REF: 19 OBJ: 21 2. ANS: C DIF: Moderate REF: 18 OBJ: 9 3. ANS: A DIF: Moderate REF: 19 OBJ: 9 4. ANS: B DIF: Moderate REF: 19 OBJ: 9 5. ANS: D DIF: Moderate REF: 19 OBJ: 9 SHORT ANSWER 1. Explain when a physician’s office would be considered a “covered entity.” ANS: If the physician’s office transmits protected health information electronically. DIF: Moderate REF: 19 OBJ: 3 2. Expl ain the difference betwTeEeSn TusBeAanNdKdSisEcLloLsuEreRu.nCdOerMHIPAA Privacy Rules. ANS: Use is the sharing, application, and examination of analysis of information within an organization that holds it. Disclosure is the release, transfer, and provision of access to, or divulging of, information outside of the entity holding the information. DIF: Moderate REF: 20 | 21 OBJ: 6 3. List the six federal rights that patients are granted under the HIPAA Privacy Rules which allow them to be informed about PHI and to control how their PHI is used and disclosed. ANS: Right to notice of privacy practices; right to request restrictions on certain uses and discourses of PHI; right to request confidential communications; right to access PHI; right to request an amendment of PHI; right to receive an accounting of disclosures of PHI. DIF: Mod erate REF: 27-28 OBJ: 9 4. Since April 14, 2003, when privacy regulations became enforceable, providers are required to document which four things? ANS: Date of disclosure; name of entity or person who received PHI including the address; brief description of the PHI disclosed; brief statement of the purposes of the disclosure. DIF: Moderate REF: 28 OBJ: 11 5. List three things that can be done to avoid having a patient hear confidential information regarding other patients. ANS: Any three of the following: privacy glass at the front window; have conversations away from the area where patients are present; move dictation stations away from the patient areas; wait to dictate until no patients are present; avoid telephone conversations in front of patients. DIF: Hard REF: 35 OBJ: 10 6. The security rule that addresses elec tronic protected health information is divided into which three main sections? ANS: Administrative safeguards, technical safeguards, and physical safeguards. DIF: Easy REF: 30 OBJ: 12 TRUE/FALSE 1. Under HIPAA guidelines, an outside billing company that manages claims and accounts for a medi cal clinic is known a sTaEcSovTeBreAdNenKtSityE.LLER.COM ANS: F DIF: Moderate REF: 18 OBJ: 3 2. Under HIPAA guidelines, a chiropractor or dentist’s office would never be considered a covered entity. ANS: F DIF: Easy REF: 18 OBJ: 3 3. To give, release, or transfer information to another entity is called consent. ANS: F DIF: Easy REF: 21 OBJ: 6 4. 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. ANS: T DIF: Moderate REF: 25 OBJ: 5 5. Confidentiality between the physician and the patient is automatically waived when the patient is being treated in a workers’ compensation case. ANS: T DIF: Moderate REF: 25 OBJ: 7 6. Notes, papers, and memos regarding patient information should be disposed of using a shredding device. ANS: T DIF: Easy REF: 27 OBJ: 10 7. A patient has the right to obtain a copy of his or her confidential health information. ANS: T DIF: Easy REF: 27 OBJ: 9 8. The HITECH Act replaced the HIPAA privacy laws. ANS: F DIF: Moderate REF: 32 OBJ: 14 9. Disclosing PHI as authorized by the laws relating to workers’ compensation does not require a signed authorization. ANS: T DIF: Moderate REF: 22 OBJ: 7 10. The Office of Civil Rights’ (OCR) mission is to protect the integrity of the Medicare and Medicaid programs. ANS: F DIF: Moderate REF: 18 OBJ: 4 Chapter 03: Compliance, Fraud, and Abuse Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. To bill Medicare beneficiaries at a higher rate than other patients is considered a. negligence. b. abuse. c. fraud. d. illegal. ANS: B DIF: Moderate REF: 39 OBJ: 20 2. When an insurance billing specialist bills for a physician and completes a Medicare claim form with information that does not reflect the true situation, a. he or she may be subject to fines and imprisonment. b. he or she may be found guilty of insurance abuse and sued. c. only the physician can be held liable. d. the insurance specialist cannot be prosecuted. ANS: A DIF: Moderate REF: 41 OBJ: 20 3. What action could happen if an employee knowingly submits a fraudulent Medicare or Medicaid claim at the direction of the employer and subsequently the medical practice is audited? a. Only the employee could be brought into litigation because it was he or she who actually perfo rmed th eTfrEauSdTuBleAntNaKctS. ELLER.COM b. The employee could be exempt from litigation because the employee acted at the direction of the employer. c. The employee and the employer could be brought into litigation by the state or federal government. d. The employee and the employer could be brought into litigation by the local authorities and court. ANS: C DIF: Hard REF: 40 OBJ: 20 4. Identify which of the following would NOT typically be considered as a form of discipline for situations that involve fraudulent and malicious misconduct. a. Verbal warning b. Termination of employment c. Restitution of any damages d. Referral to federal agencies for criminal prosecution ANS: A DIF: Hard REF: 46 OBJ: 21 COMPLETION 1. Billing for services or supplies not provided is . ANS: fraud, illegal fraud illegal fraud illegal DIF: Hard REF: 39 OBJ: 18 2. A billing practice such as excessive referrals to other providers for unnecessary services is considered . ANS: medical billing abuse DIF: Hard REF: 39 OBJ: 18 3. Stealing money that has been entrusted to one’s care is known as . ANS: embezzlement DIF: Moderate REF: 40 OBJ: 18 4. A health care organization must not conduct business with any health care provider who has been listed as an by OIG. ANS: excluded individual DIF: Hard REF: 42 OBJ: 19 5. Stark laws prohibit the subTmEisSsiTonBAofNcKlaSimEsLfLorE“Rd.esCigOnMated services” if the referring physician has a with the entity that provides the service. ANS: financial relationship DIF: Moderate REF: 42 OBJ: 19 6. Under more recent legislation known as the Affordable Care Act, compliance program requirements were implemented. ANS: mandatory DIF: Moderate REF: 44 OBJ: 19 7. A well-designed compliance program should show a effort to submit claims appropriately. ANS: good faith DIF: Moderate REF: 44 OBJ: 21 8. The key individual who oversees an organization’s compliance program is referred to as the . ANS: compliance officer DIF: Easy REF: 45 OBJ: 21 9. Employees should be required to attend a compliance training session at least . ANS: annually DIF: Moderate REF: 45 OBJ: 21 10. Health care organizations are encouraged to have a(n) policy to allow effective lines of communication, whereby staff feel secure to report questionable or suspicious activities relating to fraud and abuse. ANS: open door DIF: Moderate REF: 45-46 OBJ: 22 11. Employees should be aware of what is expected from them and the consequences of misconduct through well-publicized guidelines. ANS: disciplinary standards DIF: Moderate REF: 46 OBJ: 22 MATCHING Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. a. Abuse b. Fraud 1. Calling patients back for repeated and unnecessary follow -up visits. 2. Failure to make required refunds when services are not reasonable and necessary. 3. Altering medical records to generate more in payment. 4. Charging excessively for services and supplies. 5. Altering fees on an insurance claim form to obtain higher payment. 6. Forgiving the deductible or copayment for a Medicare patient. 7. Changing the date of service. 8. Unbundling or exploding charges. 9. Filing insurance claims for services not medically necessary. 10. Billing Medicare beneficiaries at a higher rate than other patients. 11. Failure to make a refund when services are not reasonable or necessary. 1. ANS: A DIF: Easy REF: 39 OBJ: 18 2. ANS: A DIF: Easy REF: 39 OBJ: 18 3. ANS: B DIF: Easy REF: 39 OBJ: 18 4. ANS: A DIF: Easy REF: 39 OBJ: 18 5. ANS: B DIF: Easy REF: 39 OBJ: 18 6. ANS: B DIF: Easy REF: 39 OBJ: 18 7. ANS: B DIF: Easy REF: 39 OBJ: 18 8. ANS: B DIF: Easy REF: 39 OBJ: 18 9. ANS: A DIF: Easy REF: 39 OBJ: 18 10. ANS: A DIF: Moderate REF: 39 OBJ: 18 11. ANS: A DIF: Moderate REF: 39 OBJ: 18 SHORT ANSWER 1. Define compliance. ANS: 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. DIF: Moderate REF: 38 OBJ: 1 2. List the seven basic components of a compliance plan. ANS: Conducting internal monitoring and auditing; implementing compliance and practice standards; designating a compliance officer or contact; conducting appropriate training and education; responding appropriately to detected offenses and developing corrective action; developing open lines of communication; and enforcing disciplinary standards through well-publicized guidelines. DIF: Moderate REF: T4E5 STBANKSOEBLJ:LE21R.COM 3. List five specific risk areas identified by OIG that an office needs to monitor and follow. ANS: Any five of the following: billing for items or services not rendered or not provided as claimed; submitting claims for equipment, medical supplies, and services that are not reasonable an d necessary; double billing resulting in duplicate payment; billing for uncovered services as if covered; knowing misuse of provider identification numbers, which results in improper billing; unbundling or billing for each component of the service instead of billing or using an all -inclusive code; failure to use coding modifiers properly; clustering; upcoding the level of services provided. DIF: Moderate REF: 47 OBJ: 20 4. The HIPAA amendments to the Criminal False Claims Act cover what four areas? ANS: Theft or embezzlement; false statement relating to health care matters; health care fraud; obstruction of criminal investigations. DIF: Moderate REF: 40-41 OBJ: 19 5. List five of the disciplinary standards resulting from misconduct. ANS: Verbal warning; written warning; written reprimand; suspension or probation; demotion; termination of employment; restitution of any damages; referral to federal agencies for criminal prosecution. DIF: Moderate REF: 46 OBJ: 21 6. What is the goal of the Medicare Integrity Program (MIP)? ANS: Identify and reduce Medicare overpayments. DIF: Moderate REF: 43 OBJ: 20 7. What does “safe harbor” refer to? ANS: Business and service arrangements that are protected from prosecution under the Anti-Kickback statute. DIF: Hard REF: 42-43 OBJ: 20 8. Name three measures that should be taken by a coder who has knowledge of fraud or abuse. ANS: Any three of the following answers: notify the provider both personally and with a dated, written memorandum; document the false statement or representation of the material fact; send a memo randum to theToEffSicTeBmAaNnaKgSerEoLrLemERpl.oyCeOr Mstating your concern if no change is made; maintain a written audit trail with dated memoranda for your files; do not discuss the problem with anyone who is not immediately involved. DIF: Moderate REF: 41 OBJ: 19 TRUE/FALSE 1. The process of meeting regulations, recommendations, and expectations of federal and state agencies that pay for health care services and regulate the industry is known as eHealth information management. ANS: F DIF: Moderate REF: 38 OBJ: 1 2. Submitting a claim for services that is not medically necessary is a violation of the False Claims Act. ANS: T DIF: Moderate REF: 40 OBJ: 19 3. The Stark Law is commonly referred to as the Anti -Kickback statute. ANS: F DIF: Easy REF: 42 OBJ: 19 4. Qui tam suits are those cases in which a private citizen known as a whistleblower reports a fraudulent activity within his or her organization. ANS: T DIF: Easy REF: 41 OBJ: 19 Chapter 04: Basics of Health Insurance Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. When does the physician/patient contract begin? a. After the physician has examined the patient for the first time b. When the patient steps into the examination room to be treated c. When the physician accepts the patient and agrees to treat the patient d. When the patient verbally agrees to accept the advice of the physician ANS: C DIF: Hard REF: 56 OBJ: 5 2. Most physician/patient contracts are a. implied. b. expressed. c. written. d. verbal. ANS: A DIF: Hard REF: 56 OBJ: 5 3. When a patient carries private medical insurance, the contract for treatment exists between the a. patient and the insurance company. b. physician and the patient. c. physician and the insurance company. d. policyholder and the insurance company. ANS: B DIF: Hard REF: 56 OBJ: 5 4. An emancipated minor is a a. person younger than the age of 18 who lives independently. b. person older than the age of 21. c. person younger than the age of 16 who lives with his or her parents. d. person younger than the age of 18 who does not live with his or her parents. ANS: A DIF: Hard REF: 56 OBJ: 5 5. The contract in a workers’ compensation case exists between the a. patient and the insurance company. b. physician and the patient. c. physician and the insurance company. d. policyholder and the insurance company. ANS: C DIF: Hard REF: 56 OBJ: 5 6. Mr. Talili has two medical insurance policies. To prevent duplication of payment for the same medical expense, the policies include a a. coordination of benefits statement. b. basic health insurance statement. c. guaranteed benefit statement. d. conditional benefit statement. ANS: A DIF: Moderate REF: 58 OBJ: 6 7. In cases of divorce, the decision as to which parent should be responsible for payment of the child’s services should be made by the a. parents. b. provider. c. court system. d. claims adjudicator. ANS: C DIF: Moderate REF: 58 OBJ: 6 8. If a child has health insurance coverage from two parents, according to the birthday law a. the father’s insurance is always primary. b. the mother’s insurance is always primary. c. the health plan of the person whose birthday (month and day) falls earlier in the calendar year will pay first. d. it is only in effect if the parents are divorced. ANS: C DIF: Hard REF: 58 OBJ: 6 9. According to the birthday law, if both the mother and the father have the same birthday the a. hour of birth determines who pays first. b. plan of the person who has coverage longer is the primary payer. c. plan that offers the best coverage is the primary payer. d. father’s policy is the primary payer. ANS: B DIF: Moderate REF: 58 OBJ: 6 10. Conditions that existed and were treated before the health insurance policy was issued are called a. accidents. b. illnesses. c. preexisting. d. unforeseen occurrences. ANS: C DIF: Easy REF: 58 OBJ: 6 11. What is the correct term used to determine if a procedure is covered and medically necessary? a. Preauthorization b. Predetermination c. Precertification d. Verification ANS: A DIF: Hard REF: 58 OBJ: 6 12. Mr. Ott was laid off from his job. He is protected by the Consolidated Omnibus Budget Reconciliation Act (COBRA), which requires his employer to a. pay him partial salary for 6 months. b. extend group health insurance coverage for 18 months. c. extend individual health insurance policies for 18 months. d. pay him full salary for 6 months. ANS: B DIF: Hard REF: 61 OBJ: 7 13. Assignment of benefits is a. used only by non -participating physicians. b. never used by participating physicians. c. the transfer of the physician’s right to collect an amount payable to the patient. d. the transfer of one’s legal right to collect an amount payable under an insurance contract. ANS: D DIF: Hard REF: 68 OBJ: 10 14. Under HIPAA guidelines, physicians must send all claims electronically a. if they have fewer than 25 full-time employees. b. if they have more than 25 full-time employees. c. if they have more than 10 full-time employees. d. if they have fewer than 10 full-time employees. ANS: C DIF: Hard REF: 72 OBJ: 11 COMP LETION 1. The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA), together, are commonly referred to as . ANS: The Affordable Care Act DIF: Moderate REF: T5E4 STBANKSOEBLJ:LE3 R.COM 2. A key provision to the Affordable Care Act is the creation of central clearinghouses that offer “one -stop shopping” for purchasing health insurance coverage, which are known as . ANS: Exchanges DIF: Moderate REF: 54 OBJ: 3 3. An insurance policy becomes effective only after the company offers the policy and the person accepts it and then pays the initial . ANS: premium DIF: Moderate REF: 57 OBJ: 4 4. The amount that must be paid each year by the insured before policy benefits begin is known as the . ANS: deductible DIF: Moderate REF: 57 OBJ: 6 5. When the insured is required to pay a percentage of the covered services’ costs, this is referred to as . ANS: coinsurance DIF: Moderate REF: 57 OBJ: 6 6. The cost-sharing amount a managed care patient must pay at the point of arriving in the office is referred to as the . ANS: copayment DIF: Moderate REF: 57 OBJ: 6 7. Electronic billers are permitted to obtain a authorization from the patient to release medical information necessary to process a claim. ANS: lifetime DIF: Moderate REF: 67 OBJ: 11 8. In a managed care plan, the participating provider is also referred to as . ANS: a preferred provider DIF: Moderate REF: 69 OBJ: 6 MATCHING Match each type of health plan to its description. a. Independent practice association (IPA) b. Medicaid c. State disability or Unemployment Compensation Disability (UCD) d. TRICARE e. Workers’ compensation insurance f. CHAMPVA g. Health maintenance organization (HMO) h. Disability income insurance i. Medicare 1. Government -sponsored program that provides hospital and medical services for dependents of active duty uniform service members, military reti rees and their families, and survivors of uniformed services. 2. Provides coverage for spouses and children of veterans with total, permanent, service -connected disabilities or for the surviving spouses and children of veterans who died as a result of service -connected disabilities. 3. A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease. 4. An organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment. 5. A medical capitation plan in which the treatment is delivered via a clinic or independent physician that provides a number of basic medical services for a fixed capitation payment per month. 6. A program sponsored jointly by federal and state governments for medically indigent persons, aged individuals who meet certain financial requirements, and the disabled. 7. The hospital insurance system and supplementary medical insurance for those older than 65 years of age, created by the 1965 Amendments to the Social Security Act. 8. Insurance that covers off -the-job injury or sickness and is paid by deductions from a person’s paycheck. 9. A contract that insures a person against on-the-job injury or illness. 1. ANS: D DIF: Moderate REF: 63 OBJ: 9 2. ANS: F DIF: Moderate REF: 63 OBJ: 9 3. ANS: H DIF: Moderate REF: 63 OBJ: 9 4. ANS: G DIF: Moderate REF: 63 OBJ: 9 5. ANS: A DIF: Moderate REF: 63 OBJ: 9 6. ANS: B DIF: Moderate REF: 63 OBJ: 9 7. ANS: I DIF: Moderate REF: 63 OBJ: 9 8. ANS: C DIF: Moderate REF: 63 OBJ: 9 9. ANS: E DIF: Moderate REF: 64 OBJ: 9 SHORT ANSWER 1. List the reasons that healthTcEarSeTreBfoArNmKisSnEeLceLsEsaRry.iCnOthMe United States. ANS: • A continuing increase in the number of uninsured Americans • Higher health care premiums with less being covered by employers • Increased spending in government -sponsored health care programs • Inflation, expensive high-tech equipment, expensive medications • Inefficiencies in the health care system • Fraud • Overuse of health care services by patients DIF: Moderate REF: 53-54 OBJ: 2 TRUE/FALSE 1. The Supreme Court deemed the Affordable Care Act’s requirement to require individuals to have health insurance coverage or face a penalty as unconstitutional. ANS: F DIF: Moderate REF: 54 OBJ: 3 2. An insurance billing specialist can escape liability by pleading ignorance. ANS: F DIF: Easy REF: 54 OBJ: 4 3. Parents of a college student who is living away from home are liable for the medical expenses incurred by their financially dependent child. ANS: F DIF: Moderate REF: 56 OBJ: 5 4. Basic health insurance coverage includes benefits for skilled nursing facilities. ANS: F DIF: Moderate REF: 56 OBJ: 6 5. The insured may not necessarily be the patient seen for the medical service. ANS: T DIF: Easy REF: 56 OBJ: 6 6. Under the health care reform legislation of 2010, health plans must allow employees to keep their children on their plans until the child is 26 years old. ANS: T DIF: Easy REF: 57 OBJ: 6 7. A coordination of benefits statement in an insurance policy refers to the waiting period. ANS: F DIF: Easy REF: 58 OBJ: 6 8. Information such as the deductible, copayment, preapproval provisions, and insurance company address and telephone number can usually be found on the insurance card. ANS: T DIF: Easy REF: 68 OBJ: 11 9. For M edicaid cases, there iTsEnSo TasBsiAgnNmKeSnEt oLfLbEenRe.fitCsOunMless the patient has other insu rance in addition to Medicaid. ANS: T DIF: Easy REF: 69 OBJ: 11 10. State laws may bar the use of a signature stamp. ANS: T DIF: Moderate REF: 75 OBJ: 11 Chapter 05: The Blue Plans, Private Insurance, and Managed Care Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Private insurance companies must meet the requirements and laws of a. the national state insurance agency. b. the state insurance agency in which they conduct business. c. the federal government. d. the state insurance agency in which they conduct business and the federal government. ANS: B DIF: Hard REF: 80 OBJ: 1 2. The Blue Cross plans were established primarily to cover a. hospital expenses. b. physician services. c. both hospital expenses and physician services. ANS: A DIF: Easy REF: 80 OBJ: 1 3. The Blue Shield plans were established primarily to cover a. hospital expenses. b. physician services. c. both hospital expenses and physician services. ANS: B DIF: TEEasSyTBANKSREEFL:LE80R.COM OBJ: 1 4. Fee-for-service plans offered by private health insurance companies are also referred to as a. traditional insurance plans. b. indemnity insurance plans. c. managed care plans. d. both traditional insurance plans and indemnity insurance plans. ANS: D DIF: Moderate REF: 80 OBJ: 1 5. America’s oldest privately owned, prepaid medical group is the a. Ross -Loos Medical Group. b. INA Healthplan, Inc. c. Kaiser Permanente Medical Care Program. d. Health Net HMO, Inc. ANS: A DIF: Moderate REF: 80 OBJ: 2 6. 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. ANS: C DIF: Moderate REF: 81 OBJ: 2