Reference no: EM131146838

Insurance and Compensation Part 1

Questions 1 to 15: Select the best answer to each question. Note that a question and its answers may be split across a page break, so be sure that you have seen the entire question and all the answers before choosing an answer.

1. The National Center for Competency Testing awards the _______ certificate.

A. Certified Medical Administrative Assistant (CMAA)
B. National Certified Medical Office Assistant (NCMOA)
C. Certified Coding Associate (CCA)
D. Certified Medical Billing Specialist (CMBS)

2. Which of the following is a characteristic of a preferred provider organization (PPO)?

A. The plan is more restrictive than a health maintenance organization (HMO).
B. Members select a primary care physician (PCP) as a gatekeeper.
C. It includes a contracted network of providers.
D. Members must obtain referrals to see a specialist.

3. The contract provision that states a physician can't seek payment from a patient under a managed care contract subsequent to a utilization review dispute is called

A. liability.
B. hold harmless.
C. stoploss coverage.
D. no fault.

4. The purpose of a withhold program is to

A. promote the use of specialty physicians.
B. encourage providers to utilize cost-effective services and procedures.
C. encourage preventive care.
D. reward physicians for ordering extensive tests.

5. The Patient's Bill of Rights was adopted in 1998 by the

A. National Committee for Quality Assurance (NCQA).
B. Centers for Medicare and Medicaid Services.
C. U.S. Surgeon General.
D. U.S. Advisory Commission on Consumer Protection and Quality in the Health Care Industry.

6. COBRA insurance is offered to businesses with _______ or more employees.

A. 5
B. 20
C. 50
D. 100

7. Regularly scheduled payments made to purchase an insurance policy are called

A. premiums.
B. coinsurance.
C. deductibles.
D. managed care.

8. Under a per case or per visit charge arrangement, the provider is compensated for each

A. episode of care.
B. service provided.
C. diagnosis code.
D. day of care.

9. The type of insurance coverage that pays a per diem for each day a patient is in the hospital is

A. medical.
B. major medical.
C. hospital.

D. hospital indemnity.

10. Under a discounted fee-for-service arrangement, covered services are compensated at a

A. per diem rate.
B. discount of negotiated fees.
C. discount of usual and customary charges.
D. per-member-per-month rate.

11. The subscriber in a health maintenance organization (HMO) can also be called the

A. patient.
B. physician.
C. policyholder.
D. user.

12. The job title of the professional who abstracts and compiles data from medical records for appropriate optimal reimbursement for physicians is

A. medical biller.
B. medical coder.
C. payment poster.
D. medical office assistant.

13. Which of the following certifications can coders without much job experience receive?

A. Certified Medical Administrative Assistant (CMAA)
B. Certified Coding Associate (CCA)
C. National Certified Medical Office Assistant (NCMOA)
D. Certified Professional Coder (CPC)

14. A physician's practice with 10 or more physicians would generally be categorized as a _______practice.

A. small-group
B. private
C. large-group
D. solo

15. To determine the amount due from a patient, it's necessary to know the

A. billed amount.
B. diagnostic code.
C. allowed amount.
D. adjusted amount.

Medical Coding Review Part2

1. Hypertension is classified in the hypertension table as

A. benign, malignant, or unspecified only.
B. benign or malignant only.
C. malignant or unknown only.
D. malignant or unspecified only.

2. As of 1948, ICD became known as the International

A. Classification of Diseases.
B. Causes of Diseases.
C. Classification of Deaths.
D. Causes of Death.

3. A concise statement, usually in the patient's words, describing the symptom, problem, condition, or other factor that's the reason for the encounter is called the

A. primary complaint.
B. chief complaint.
C. chief reason.
D. primary diagnosis.

4. The ICD-10 uses codes that are

A. 3 to 7 alphanumeric characters.
B. 3 to 7 numeric only characters.
C. 3 to 7 alphabetic only characters.
D. 3 to 7 symbol characters.

5. The first forms of medical diagnostic coding date back to

A. nineteenth-century France.
B. eighteenth-century America.
C. sixteenth-century England.
D. twelfth-century Rome.

6. The first step in the reimbursement process of health care claims is

A. filling out a claim form.
B. registering the patient.
C. reading and understanding the physician's documentation.
D. calling the insurance carrier.

7. The codes that describe a procedure or service with a five-digit numeric code and descriptor are _______ codes.

A. Category I CPT
B. Category II CPT
C. Category III CPT
D. ICD-9-CM

8. Themost often reported evaluation and management (E/M) services are _______ services.

A. emergency room
B. consultation
C. office and other outpatient
D. hospital (inpatient)

9. _______, Supplementary Classifications of External Causes of Injury and Poisoning, can't stand alone and are coded only for the first occurrence, never for additional follow-up care.

A. Subcategories
B. V Codes
C. E Codes
D. Appendixes

10. A presenting problem in which the risk of morbidity without treatment is low and full recovery is expected would be considered _______ in nature.

A. moderate severity
B. minimal
C. self-limited
D. low severity

11. The transfer of the total care of a patient from one physician to another is called a/an

A. consultation.
B. office visit.
C. authorization.
D. referral.

12. If a provider requests an advisory opinion and fails to follow the advice of the Office of Inspector General (OIG), the provider

A. could be prosecuted.
B. could claim not knowing.
C. would be treated leniently for asking the question.
D. shouldn't change its practices.

13. An examples of an eponym is

A. Hodgkin's disease.
B. cardiovascular disease.
C. pneumopathy.
D. rheumatoid arthritis.

14. Codes to be reported for each day's service are ranked from

A. lowest to highest code number.
B. highest to lowest reimbursement rate.
C. lowest to highest reimbursement rate.
D. highest to lowest code number.

15. An internal audit can be conducted

A. prospectively only.
B. either prospectively or retrospectively.
C. retrospectively only.
D. neither prospectively or retrospectively.

Medical Billing Concepts Part 3

Questions 1 to 15: Select the best answer to each question. Note that a question and its answers may be split across a page break, so be sure that you have seen the entire question and all the answers before choosing an answer.

1. When a Medicare beneficiary selects a Medicare Advantage (MA) plan,

A. Medicare pays the plan a set amount of money every month for the care.
B. the beneficiary must pay the entire cost of the plan.
C. Medicare reimburses the plan for expenses incurred by the beneficiary.
D. Medicare isn't involved in the plan payment.

2. If an individual is covered by both Medicaid and Medicare,

A. Medicare is primary only if the individual is younger than 65.
B. Medicaid is primary if the individual is younger than 65.
C. Medicaid is always primary.
D. Medicare is always primary.

3. The method of reimbursement that pays hospitals before services are rendered is called

A. capitation.
B. per diem.
C. fee-for-service.
D. prospective payment system.

4. Which of the following provides states with grants to be spent on time-limited cash assistance?

A. Temporary Assistance for Needy Families (TANF)
B. Children's Health Insurance Program (CHIP)
C. Programs of All-Inclusive Care for the Elderly (PACE)
D. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

5. Benefits that require patients to pay a deductible (if not previously met) and any applicable coinsurance each time a service is rendered are called

A. fee-for-service benefits.
B. Medigap supplemental insurance.
C. fixed-rate benefits.
D. managed care plan.

6. The Ambulatory Payment Classification (APC) system bases payments on

A. number of days.
B. procedures.
C. fees.
D. diagnoses.

7. Most physicians bill insurance carriers by completing a

A. verification of benefits form.
B. superbill.
C. CMS-1500 claim form.
D. UB-04 form.

8. Which of the following is a comprehensive healthcare program in which the U.S. Department of Veterans Affairs shares the cost of covered healthcare services and supplies with veterans?

A. TRICARE Standard
B. TRICARE Prime Remote
C. CHAMPVA
D. TRICARE Prime

9. Under the access standards of care for TRICARE Prime enrollees, appointment wait-time for wellness/preventive care should not exceed

A. 48 hours.
B. 1 week.
C. 4 weeks.
D. 6 weeks.

10. A physician who chooses not to join a particular government health plan is called a _______ physician.

A. noncontracting
B. nonpracticing
C. nonproviding
D. nonparticipating

11. If a patient has more than one insurance plan, determining how much will be paid by each is regulated by the provisions known as _______ of benefits.

A. coordination
B. verification
C. explanation
D. assignment

12. The method of reimbursement that pays hospitals a fixed rate per day for all services performed is called

A. prospective payment system.
B. capitation.
C. fee-for-service.

D. per diem.

13. The organization responsible for determining the type, amount, and scope of services covered by Medicaid is

A. the Centers for Medicare and Medicaid Services (CMS).
B. contracted insurance carriers.
C. the state government.
D. the federal government.

14. With Medicare Part A, basic days are the first _______ days of acute inpatient care provided to a beneficiary during a benefit period.

A. 90
B. 30
C. 60
D. 150

15. According to HIPAA, covered entities for compliance issues include

A. health plans, clearinghouses, and health care providers only.
B. health plans and clearinghouses only.
C. clearinghouses and billing services only.
D. health plans and health care providers only.

Reimbursement and Introduction to the HER Part 4

Questions 1 to 15: Select the best answer to each question. Note that a question and its answers may be split across a page break, so be sure that you have seen the entire question and all the answers before choosing an answer.

1. The set amount a patient must pay for each service is referred to as a/an

A. coinsurance.
B. deductible.
C. out-of-pocket expense.
D. copay.

2. What does OSHA stand for?

A. Occupational Standards for Health Act
B. Optional Safety and Health Act
C. Occupational Safety and Health Administration
D. Optional Standards for Health Act

3. In SOAP documentation, medications ordered for the patient is considered

A. part of the plan.
B. objective findings.
C. part of the assessment.
D. subjective findings.

4. The largest cost element in determining the resource-based relative value scale (RBRVS) is

A. location of the practice.
B. provider's work.
C. professional liability insurance.
D. practice expense.

5. The documentation that describes the degree of permanent damage done to a worker's entire body because of a workers' compensation injury is called the

A. impairment rating.
B. injury rating.
C. disability rating.
D. degree of injury.

6. If an insurance carrier doesn't reconsider a downcoded claim that has been appealed by the physician's office, the medical office assistant can

A. complain to the Department of Health and Human Services (DHHS).
B. complain to the American Medical Association (AMA).
C. complain to the state insurance commissioner.
D. bill the patient for the remaining balance.

7. The amount of money not paid to providers during a contract year but kept to offset any additional costs incurred for referrals or other services under a plan is called a

A. per member per month (PMPM).
B. withhold.
C. withdrawal.
D. disincentive.

8. If a claim is denied because the physician provided services before the patient's health insurance contract
went into effect, the medical office specialist should

A. change the date of the visit to correspond with the coverage-effective date.
B. wait until the effective date of the coverage, then bill the insurance carrier.
C. bill the patient.
D. write off the entire amount.

9. In all categories of workers' compensation claims, the injured worker will receive compensation for

A. pain and suffering.
B. lost wages.
C. vocational rehabilitation.
D. medical expenses.

10. An examination and verification of claims submitted by a physician is known as a/an

A. appeal.
B. audit.
C. challenge.
D. review.

11. The second level of Medicare appeals is a request for

A. review by the state insurance commissioner.
B. review by an administrative law judge.
C. redetermination by the carrier.
D. review by qualified independent contractors.

12. A record of the patient's financial transactions for an encounter is called a

A. walkout receipt.
B. patient day sheet.
C. batch out.
D. registration form.

13. A health problem that results from exposure to a workplace health hazard such as fumes is called a/an

A. workers' compensation accident.
B. employment disease.
C. workplace injury.
D. occupational disease.

14. Prior to the Omnibus Budget Reconciliation Act (OBRA) of 1989, Medicare payments to providers were based on

A. a reasonable-fee schedule.
B. a capitation arrangement.
C. resources used to perform the procedure or services.
D. physicians' charge-based fees.

15. Under Medicare Part B, reimbursement to a PAR provider will pay the physician _______ percent of the allowed amount after the calendar year deductible has been satisifed.
A. 100
B. 20
C. 80
D. 70

CREATE A TRAINING GUIDE PART 5

Now that you've started to learn about insurance, appeals, and reimbursement, you can complete the following project

Goal: The goal of this project is to apply what you are learning throughout your course.

Scenario

You have been recently hired as the Manager of a Billing and Coding Department in a large physician practice. As the Billing and Coding Manager, you'll be responsible for training new employees. For this project, please develop a training document in a Microsoft Word document. Be sure to discuss the following within your training document.

1. How does incorrect patient information impact a claim?

2. What is correct coding? What is meant by a clean claim?

A.Discuss coding of Evaluation and Management Visits. How must medical documentation support provider billing?

B. discuss use of correct diagnosis codes.

3. Discuss HIPAA and electronic Filing.

4. What is meant by federal compliance?

5. What is workers' compensation?

A.Discuss the types of workers' compensation.

B.Discuss the role of the ombudsman.

6. What is the Center for Medicare Physician fee schedule?

A. What is the Center for Medicare Physician fee schedule?

B.Give an example of an office fee and how you would bill 80/20.

7. When a claim is denied, what is the process for filing an appeal?

8. What is meant by timely filing?

9. What is a recovery audit contractor? Discuss how this can impact a physician practice.

10. You'll need to bring your training to a close. Please summarize your training.

11. Discuss the path of a claim from the time the front desk receptionist receives the superbill when the patient checks out to the final receipt of payment.