TEST BANK for Fordney’s Medical Insurance 15th Edition by Linda M. Smith

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

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.

OBJ: 5

d. all are correct.

ANS: D

DIF: Moderate

REF: 13

OBJ: 7

REF: 11

OBJ: 9

REF: 13

OBJ: 9

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

8. Professional ethics include a. state laws. b. federal laws. c. standards of conduct. d. civil torts.

ANS: C

DIF: Moderate

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 name of the mT odEeS rnTcB odAeNoKf S etE hiLcsLtEhR at.thCeOAMmerican Medical Association (AMA)

adopted in 1980? a. The Modern Standards of Conduct Code b. The Principles of Medical Ethics c. The Oath of Hippocrates d. The American Medical Association Code of Ethics 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

TisEtS heTtB otA alNiK ncSoE mL eL prEoR du.cC edObMy a health care organization.

1.

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 claims 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: T4ESTBANKS OE BL J: LE 3 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 policy.

insurance

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,

Medicaid, 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

REF: 18

OBJ: 4

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

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 patient consists of the patient’s a. city of residence. b. diagnosis. c. illness. d. treatment.

ANS: A

DIF: Easy

REF: 23

6. Confidentiality is automatically waived in cases of a. gunshot wounds. b. child abuse.

OBJ: 8

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 information.

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 _

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

unrelated to the

1. Individual who is designated to help a provider remain in compliance by setting policies and

2.

3.

4.

5.

procedures in place, train staff regarding HIPAA Privacy guidelines, and act as the contact person for questions and complaints.

A health care coverage carrier, clearinghouse, or physician who transmits health information in electronic form in connection with a transaction covered by HIPAA. Individual who renders medical services, furnishes bills, or is paid for health care in the normal course of business.

Third-party administrator who receives insurance claims from the physician’s office, performs edits, and redistributes the claims electronically to various insurance carriers.

Individual who is hired by a medical practice to process claims to a third-party payer.

1. ANS: 2. ANS: 3. ANS: 4. ANS: 5. ANS:

E C A B D

DIF: DIF: DIF: DIF: DIF:

Moderate Moderate Moderate Moderate Moderate

REF: REF: REF: REF: REF:

19 18 19 19 19

OBJ: OBJ: OBJ: OBJ: OBJ:

21 9 9 9 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

TESTBANKSELLER.COM

2. Explain the difference between use and disclosure under HIPAA 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: Moderate

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 electronic 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

medical clinic is known asTaEcS ovTeB reA d NenKtS ityE. 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 performed theTfrEauSdTuB leA ntNaK ctS . 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

EsLfLorE“Rd. 5. Stark laws prohibit the subT mEisSsiT onBA ofNcK laS im esC igOnM ated 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.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Calling patients back for repeated and unnecessary follow-up visits.

Failure to make required refunds when services are not reasonable and necessary.

Altering medical records to generate more in payment.

Charging excessively for services and supplies.

Altering fees on an insurance claim form to obtain higher payment.

Forgiving the deductible or copayment for a Medicare patient.

Changing the date of service.

Unbundling or exploding charges.

Filing insurance claims for services not medically necessary.

Billing Medicare beneficiaries at a higher rate than other patients.

Failure to make a refund when services are not reasonable or necessary.

1. ANS: 2. ANS: 3. ANS: 4. ANS: 5. ANS: 6. ANS:

A A B A B B

DIF: DIF: DIF: DIF: DIF: DIF:

Easy Easy Easy Easy Easy Easy

REF: REF: REF: REF: REF: REF:

39 39 39 39 39 39

OBJ: OBJ: OBJ: OBJ: OBJ: OBJ:

18 18 18 18 18 18

.

7. ANS: B 8. ANS: B 9. ANS: A 10. ANS: A 11. ANS: A

DIF: DIF: DIF: DIF: DIF:

Easy Easy Easy Moderate Moderate

REF: REF: REF: REF: REF:

39 39 39 39 39

OBJ: OBJ: OBJ: OBJ: OBJ:

18 18 18 18 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

5 STBANKS OE BL J: LE 21R.COM REF: T4E

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 and 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; ER send a memorandum to theToEffSicTeBmAaN naKgS erEoLr L em pl. oyCeO rM stating 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

REF: 56

OBJ: 5

2. Most physician/patient contracts are a. implied. b. expressed. c. written. d. verbal.

ANS: A

DIF: Hard

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

COMPLETION 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

4 STBANKS OE BL J: LE 3 R.COM REF: T5E

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 retirees 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

6.

7.

8.

9.

physician that provides a number of basic medical services for a fixed capitation payment per month.

A program sponsored jointly by federal and state governments for medically indigent persons, aged individuals who meet certain financial requirements, and the disabled.

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. Insurance that covers off-the-job injury or sickness and is paid by deductions from a person’s paycheck.

A contract that insures a person against on-the-job injury or illness.

1. ANS: 2. ANS: 3. ANS: 4. ANS: 5. ANS: 6. ANS: 7. ANS: 8. ANS: 9. ANS:

D F H G A B I C E

DIF: DIF: DIF: DIF: DIF: DIF: DIF: DIF: DIF:

Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate

REF: REF: REF: REF: REF: REF: REF: REF: REF:

63 63 63 63 63 63 63 63 64

OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ:

9 9 9 9 9 9 9 9 9

SHORT ANSWER 1. List the reasons that healthTcE arSeTreBfoArN mKisSnEeL ceLsE saR ry.iC nO thMe 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

nS oT asB siA gnNm t oLfLbE enRe. fitCs O unMless the patient has other insurance 9. For Medicaid cases, there iTs E KeSnE 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:

EF 80R.COM TEEasSy TBANKSRE L:LE

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

7. How does an HMO receive payment for the services its physicians provide? a. Fee-for-service b. Usual, customary, and reasonable charges c. Allowable charges d. Prepaid health plan ANS: D

DIF: Moderate

REF: 81

OBJ: 3

8. When an HMO is paid a fixed amount for each patient served without considering the actual

number or nature of services provided to each person, this is known as a. fee-for-service. b. capitation. c. usual charges. d. customary fees.

ANS: B

DIF: Moderate

REF: 82

OBJ: 3

9. How are physicians who work for a prepaid group practice model paid? a. Salary paid by independent group b. Salary paid by a health plan c. Fee-for-service d. Usual, customary, and reasonable charges ANS: A

DIF: Moderate

REF: 82

OBJ: 3

10. In an independent practice association (IPA), physicians are a. paid salaries by their own independent group. b. paid salaries by the praT ctE icSeTasBsA ocNiaKtiS onE.LLER.COM c. not employees and are not paid salaries. d. not paid until the end of the year in which services were rendered.

ANS: C

DIF: Moderate

REF: 82

OBJ: 5

11. An organization that gives members freedom of choice among physicians and hospitals and

provides a higher level of benefits if the providers listed on the plan are used is called a/an a. health maintenance organization (HMO). b. managed care organization (MCO). c. preferred provider organization (PPO). d. exclusive provider organization (EPO).

ANS: C

DIF: Moderate

REF: 82

OBJ: 6

12. A program that offers a combination of HMO-style cost management and PPO-style freedom

of choice is a/an a. point-of-service (POS) plan. b. exclusive provider organization (EPO). c. managed care organization (MCO). d. physician provider group (PPG).

ANS: A

DIF: Moderate

REF: 82

OBJ: 8

13. A physician-owned business that has the flexibility to deal with all forms of contract medicine

and also offers its own plans is a/an

a. b. c. d.

IPA. PPO. PPG. POS.

ANS: C

DIF: Moderate

REF: 83

OBJ: 7

14. When a physician sees a patient more than is medically necessary, it is called a. buffing. b. turfing. c. churning. d. stirring.

ANS: C

DIF: Hard

REF: 83

OBJ: 10

15. Referral of a patient recommended by one specialist to another specialist is known as a. primary care. b. secondary care. c. concurrent care. d. tertiary care.

ANS: D

DIF: Hard

REF: 86

OBJ: 13

16. What is the correct procedure to collect a copayment on a managed care plan? a. There is no copayment with a managed care plan. b. Bill the plan for the copayment. c. Bill the patient for the copayment. d. Collect the copayment T wEhS enTtB heApNaK tieSnEt L arL riE veRs .foCrOthMe office visit.

ANS: D

DIF: Hard

REF: 90

OBJ: 15

COMPLETION 1. The Blue Cross/Blue Shield Association petitioned and was allowed to convert their status

from a non-for-profit organization to a for-profit organization in the year

.

ANS: 1994 DIF: Easy

REF: 80

OBJ: 1

2. The name and address of the BCBS home company that should be used for claims submission

can be found on the

.

ANS: back of the patient’s BCBS identification card DIF: Easy 3. The

REF: 80

OBJ: 1

is a specific dollar amount that the patient must pay annually before an insurance plan begins covering health care costs.

ANS: deductible

DIF: Moderate

REF: 80

OBJ: 1

4. Managed care refers to a group of techniques intended to

the cost of providing

health care while improving the access to care and the quality of care.

ANS: reduce DIF: Moderate

REF: 80

OBJ: 2

5. The abbreviation MCO stands for

.

ANS: managed care organization DIF: Easy

REF: 81

OBJ: 2

6. Benefits under the HMO Act fall under two categories:

health

services and supplemental health services.

ANS: basic DIF: Moderate

REF: 81

OBJ: 2

7. The not-for-profit organization that accredits managed care health plans and has a rigorous set

of standards to which health plans must attest to and adhere to is the

.

ANS:

National Committee for Quality Assurance (NCQA) National Committee for QuTaEliS tyTABsA suNraKnS ceELLER.COM NCQA DIF: Moderate

REF: 81

OBJ: 2

8. A primary care physician who controls patient access to specialists is called a/an

.

ANS: gatekeeper DIF: Moderate

REF: 81

OBJ: 3

9. To determine the insurance companies address and telephone numbers used for inquiries and

authorizations, photocopied.

side(s) of the patient insurance identification care should be

ANS: both DIF: Easy 10.

REF: 81

OBJ: 3

health plans allow members to select from HMO, PPO or traditional insurance plans.

ANS: Triple-option DIF: Hard

REF: 83

OBJ: 9

11. Consumer directed health plans, (CDHP) which are becoming more common as individuals

look for more economical health insurance options are also known as

plans.

ANS: high deductible DIF: Hard

REF: 83

OBJ: 3

12. UR is the abbreviation for

, which is necessary to control costs in the

health care setting.

ANS: utilization review DIF: Moderate

REF: 83

OBJ: 10

13. When a managed care plan requires the primary care physician to seek approval before

referring a patient to a specialist, it is called obtaining

.

ANS: preauthorization prior approval DIF: Moderate

REF: 86

OBJ: 13

14. When a capitated patient’s services go over a certain amount and the physician can begin

asking the patient to pay (fee-for-service), this arrangement is provided in a section of the managed care contract or agreement.

ANS: stop-loss DIF: Hard

REF: 90

OBJ: 15

15. When a certain percentage of the monthly capitation payment is held out of the premium fund

to pay for operating an IPA, it is known as a/an

.

ANS: withhold DIF: Hard

REF: 93

OBJ: 15

TRUE/FALSE 1. In times past, physicians in private practice billed indemnity insurance plans and professional

services were reimbursed on a fee-for-service basis.

ANS: T

DIF: Moderate

REF: 80

OBJ: 1

2. Ross-Loos Medical Group, America’s oldest privately owned prepaid medical group, started

in Texas.

ANS: F

DIF: Moderate

REF: 80

OBJ: 1

3. The Health Maintenance Organization Act of 1973 required most employers to offer HMO

coverage to their employees as an alternative to traditional health insurance.

ANS: T

DIF: Hard

REF: 81

OBJ: 2

4. In a staff model HMO, physicians are hired directly by the health plan that pays their salary.

ANS: T

DIF: Hard

REF: 81

OBJ: 3

5. Exclusive provider organizations (EPOs) are regulated by the federal government.

ANS: F

DIF: Moderate

REF: 82

OBJ: 4

6. The difference between an IPA and a PPG is that member physicians may not own an IPA,

whereas a PPG is physician owned.

ANS: F

DIF: Hard

REF: 82 | 83

OBJ: 7

7. In a point-of-service (POS) program, members may choose to use a non-program provider at

any time.

ANS: T

DIF: Moderate

REF: 82

OBJ: 8

8. The term turfing means to transfer the sickest high-cost patients to other physicians so that the

provider appears as a low utilizer.

ANS: T

DIF: Hard

REF: 83

OBJ: 10

9. In certain managed care plans there is an incentive for the gatekeeper to limit patient referrals

to specialists.

ANS: T

DIF: Moderate

REF: 93

OBJ: 13

10. Managed care plans allow laboratory tests to be performed at any facility the patient chooses.

ANS: F

DIF: Hard

REF: 86

OBJ: 13

11. Usually, there are no deductibles for managed care plans.

ANS: T

DIF: Moderate

REF: 89

OBJ: 15

12. A copayment in a managed care plan is usually a fixed dollar amount (predetermined fee).

ANS: T

DIF: Moderate

REF: 90

OBJ: 15

13. Value-based reimbursement programs reward health care providers with incentive payments

for the quantity of patients they can manage.

ANS: F

DIF: Hard

REF: 90

OBJ: 15

14. A bundled reimbursement program is when the health care organization agrees to accept a

single negotiated fee to deliver all medical services for one patient for a specified procedure or condition.

ANS: T

DIF: Hard

REF: 90

OBJ: 15

15. The Patient-Centered Medical Home is an incentive program which consists of multiple

health care teams managing a patient’s medical care.

ANS: F

DIF: Hard

REF: 90

OBJ: 15

16. In a shared savings plan, a health care organization will receive a share of the savings when

they reduce total health care spending on their patients below an expected level set by the payer.

ANS: T

DIF: Hard

REF: 90

OBJ: 15

Chapter 06: Medicare Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. National health coverage for American 65 years and older known as Medicare was signed into

legislation by a. Theodore Roosevelt. b. Harry Truman. c. John F. Kennedy. d. Lyndon B. Johnson.

ANS: D

DIF: Easy

REF: 97

OBJ: 1

2. What is the federal agency that is responsible for implementation of all rules, regulations, and

health-related policies governing the Medicare program? a. CMS b. DHHS c. The Center for Beneficiary Choices d. SSA ANS: A

DIF: Moderate

REF: 97

OBJ: 1

3. Medicare Part A a. physician outpatient medical services. b. blood transfusions. c. physical therapy. d. hospice care.

ANS: D

DIF: Easy

REF: 98

OBJ: 6

REF: 97

OBJ: 1

4. Medicare is a a. state health insurance program. b. federal health insurance program. c. regional health insurance program. d. local health insurance program.

ANS: B

DIF: Moderate

5. A program of income support for low-income aged, blind, and disabled persons a. Medicare Part A b. Medicare Part. B c. Supplemental Security Income d. Hospice ANS: C

DIF: Hard

REF: 97

OBJ: 6

6. For an illegal immigrant to be eligible for benefits under the Medicare program, they must

have lived in the United States as a permanent resident for 5 consecutive years. a. 1 year b. 5 consecutive years

c. 10 consecutive years d. They are never eligible for benefits as an illegal immigrant.

ANS: B

DIF: Moderate

REF: 98

OBJ: 2

7. Medicare identification cards are currently being shifted from social security numbers to

Medicare Beneficiary Identifier (MBI) numbers. Effective from submitted with the patient’s MBI. a. April 1, 2018 b. April 1, 2019 c. December 31, 2019 d. January 1, 2020 ANS: D

DIF: Moderate

REF: 99

, all claims must be

OBJ: 3

8. A short-term inpatient stay that is necessary for a terminally ill patient to give temporary relief

to the person who regularly assists with home care is referred to as a. Hospice care. b. Respite care. c. Caregiver relief. d. Custodial services.

ANS: B

DIF: Moderate

REF: 98

OBJ: 6

9. The frequency of Pap tests that may be billed for a Medicare patient who is low risk is a. once every 12 months. b. every other year. c. once every 24 months. d. once every 5 years.

ANS: C

DIF: Moderate

REF: 102

OBJ: 4

10. Plans that may be offered under a Medicare Advantage Plan include a. HMO. b. POS. c. PPO. d. All are correct.

ANS: D

DIF: Moderate

REF: 104

OBJ: 6

11. Some Medicare Advantage plans may provide services not covered by Medicare, such as a. laboratory and x-ray services. b. vaccines and ambulance services. c. mammograms and Pap smears. d. eyeglasses and prescription drugs.

ANS: D

DIF: Hard

REF: 104

12. Medigap insurance may cover a. all physician and hospital deductibles. b. the deductible not covered under Medicare. c. 80% of the Medicare allowed amount. d. 75% of the Medicare allowed amount.

OBJ: 6

ANS: B

DIF: Hard

REF: 106

OBJ: 6

13. A program that contracts with CMS to review medical necessity and appropriateness of

inpatient medical care is known as a a. QIO. b. PCP. c. HMO. d. HHS. ANS: A

DIF: Moderate

REF: 108

OBJ: 7

14. A participating physician with the Medicare plan agrees to accept a. 80% of the billed amount. b. 80% of the physician’s usual and customary charges. c. 80% of the limiting charge. d. 80% of the Medicare-approved charge.

ANS: D

DIF: Moderate

REF: 109

OBJ: 8

15. In the Medicare program, there is mandatory assignment for a. clinical laboratory tests. b. surgery performed in the physician’s office. c. ECGs. d. E/M services.

ANS: A

DIF: Hard

REF: 110

OBJ: 8

16. When a Medicare patient sT igEnS sT anBaAdN vaKnS ceEbLeL neEfiR ci.arCyOnM otice, the procedure code for the

service provided must be modified using the HCPCS Level II modifier a. –LA. b. –HB. c. –GA. d. –GB. ANS: C

DIF: Moderate

REF: 112

OBJ: 10

17. A Medicare prepayment screen a. identifies claims to review for medical necessity. b. monitors the number of times given procedures can be billed during a specific time

frame. c. identifies claims to review for medical necessity and monitors the number of times

given procedures can be billed during a specific time frame. d. neither identifies claims to review for medical necessity nor monitors the number

of times given procedures can be billed during a specific time frame.

ANS: C

DIF: Moderate

REF: 112

OBJ: 12

18. Under the prospective payment system (PPS), hospitals treating Medicare patients are

reimbursed according to a. a new fee schedule established in 1983. b. preestablished rates for each type of illness treated based on diagnosis. c. preestablished rates for each type of hospital stay based on services.

d. a hospital capitation plan.

ANS: B

DIF: Hard

REF: 114

OBJ: 13

19. A type of value-based program established by Medicare to provide an incentive for hospitals

to reduce hospital acquired conditions, by reducing payments of the worst-performing hospitals. a. HVBP b. HRRP c. HACRP d. PVBM ANS: C

DIF: Hard

REF: 115

OBJ: 15

20. An example of an Advanced Alternative Payment Model is a. Accountable Care Organizations. b. Patient Centered Medical Homes. c. bundled payment models. d. All are correct.

ANS: D

DIF: Hard

REF: 115

OBJ: 15

COMPLETION 1. A legally enforced system of health insurance that insures a countries’ population against the

costs of health care is

health insurance.

ANS: national DIF: Moderate

REF: 97

2. Medicare provides insurance for people

OBJ: 1

years of age or older who are retired on Social

Security.

ANS: 65 DIF: Easy

REF: 97

OBJ: 2

3. An organization that provides pain relief, symptom management, and supportive services to

terminally ill people and their families would submit claims to Medicare Part

.

ANS: A DIF: Moderate

REF: 98

OBJ: 6

4. End-stage renal disease occurs when a patient who has chronic kidney disease has gradual

loss of kidney function and reaches an

state.

ANS: advanced DIF: Easy

REF: 98

OBJ: 2

5. Patients who are entitled to receive benefits are referred to as

.

ANS: beneficiaries DIF: Easy

REF: 98

OBJ: 2

6. Medicare Beneficiary Identifiers, which will be used for claim submission purposes are

characters in length and made up only of numbers and uppercase letters.

ANS: 11 DIF: Moderate

REF: 98

OBJ: 3

7. A Medicare

period begins on the day a patient enters a hospital and ends when the patient has not been a bed patient in any hospital or nursing facility for 60 consecutive days.

ANS: benefit DIF: Easy

REF: 98

OBJ: 4

8. Medicare Part B covers medical services and supplies that are

to treat the patient’s

health condition.

ANS: medically necessary DIF: Moderate

REF: 99

OBJ: 4

9. Under Medicare Part B, deT nE taS l cTaB reAisNcKoS veErL edLoEnR ly.fC orOM or surgery of the jaw.

ANS: fractures DIF: Hard

REF: 99

10. Medicare Advantage plans receive a

OBJ: 4

amount of money from Medicare to spend on

their Medicare members.

ANS: fixed DIF: Hard

REF: 103

OBJ: 6

11. In a Medicare medical savings account (MSA) the patient uses the MSA money to pay

medical expenses until a high deductible is reached. If the MSA money becomes depleted, the patient must pay until the deductible is reached.

ANS: out of pocket DIF: Hard 12. Medicare Part

benefit.

REF: 104

OBJ: 6

offers seniors and people living with disabilities with a prescription drug

ANS: D DIF: Moderate

REF: 104

OBJ: 6

13. The temporary limit on what the Medicare drug plan will cover for drugs is referred to as a

.

ANS: doughnut hole DIF: Hard

REF: 104

OBJ: 6

14. The list of covered drugs that each Medicare drug plan has is referred to as a

.

ANS: formulary DIF: Hard

REF: 104

OBJ: 6

15. After a Railroad Medicare claim has been processed, a

document is generated to the service provider explaining the decision made on the claim and the services for which they paid.

ANS:

remittance advice (RA) remittance advice RA DIF: Hard

REF: 105

OBJ: 6

16. A specialized insurance policy that is predefined by the federal government for the Medicare

beneficiary to cover the deductible and copayment amounts is referred to as .

ANS: Medigap DIF: Moderate

REF: 106

OBJ: 6

17. Every Medicap policy must follow federal and state laws and must be clearly identified as

Medicare

Insurance.

ANS: Supplement DIF: Hard

REF: 106

OBJ: 6

18. MSP rules state that Medicare is the secondary payer when an aged worker has benefits under

a group health plan with more than

covered employees.

ANS: 20 DIF: Hard

REF: 107

OBJ: 6

19. A Medicare non-participating physician may bill no more than the Medicare

.

ANS: limiting charge DIF: Moderate

REF: 109

OBJ: 8

20. An NPI number issued to a provider by CMS is the acronym for

.

ANS: National Provider Identifier DIF: Easy

REF: 117

OBJ: 8

TRUE/FALSE 1. Medicare provides insurance for disabled individuals if they have received Social Security

disability benefits for 24 months.

ANS: T

DIF: Easy

REF: 98

OBJ: 1

2. All person’s age 65 who meet eligibility requirements for Medicare receive Medicare Part B

(outpatient coverage).

ANS: F

DIF: Easy

REF: 98

OBJ: 1

3. Medicare provides insuranT ceEfS orTdBisAaN blK edSw keErsRo.fCaO nyMage.

EoLrL ANS: T

DIF: Easy

REF: 97

OBJ: 1

4. Patients who elect Medicare Part B coverage pay annually increasing basic premium

payments.

ANS: T

DIF: Moderate

REF: 98

OBJ: 2

5. It is possible for an alien to be eligible for Medicare Part A and Part B. ANS: T

DIF: Moderate

REF: 98

OBJ: 2

6. Employee and employer contributions help pay for Medicare Part A health services.

ANS: T

DIF: Moderate

REF: 98

OBJ: 2

7. Each Medicare hospital benefit period consists of 60 consecutive days in a hospital or nursing

facility.

ANS: T

DIF: Moderate

REF: 98

OBJ: 4

8. The number of Medicare benefit periods a patient can have for hospital care is limited.

ANS: F

DIF: Hard

REF: 98

OBJ: 4

9. Funds for Medicare Part B come equally from those who sign up for it and the federal

government.

ANS: T

DIF: Moderate

REF: 99

OBJ: 4

10. In the Medicare program, a physical examination is a covered benefit when performed within

12 months of enrollment.

ANS: T

DIF: Moderate

REF: 101-102

OBJ: 2

11. A Medicare patient with a Medicare Advantage plan does not need a supplemental insurance

policy.

ANS: T

DIF: Moderate

REF: 100 | 104

OBJ: 6

12. When a Medicare recipient chooses a Medicare senior plan, he or she forfeits the Medicare

card.

ANS: F

DIF: Moderate

REF: 103

OBJ: 6

13. Non-participating physicians have an option regarding accepting assignment on the Medicare

patient.

ANS: T

DIF: Easy

REF: 109

OBJ: 8

14. A non-participating physician who is not accepting assignment may bill any fee he or she

wants.

ANS: F

DIF: Easy

REF: 109

OBJ: 8

15. The time limit for sending in Medicare claims is the end of the calendar year in which

professional services were performed.

ANS: F

DIF: Moderate

REF: 117

OBJ: 18

SHORT ANSWER 1. A patient classified with ESRD may be provided benefits from Medicare. What does ESRD

stand for?

ANS:

End-stage renal disease DIF: Easy

REF: 98

OBJ: 1

2. What type of coverage does a Medi–Medi patient have?

ANS:

Medicare and Medicaid

DIF: Moderate

REF: 106

OBJ: 6

3. When a Medicare patient is injured, and the primary insurance is a liability insurance, when

can a claim be filed to Medicare?

ANS:

If the provider has not received a higher combined reimbursement than what Medicare would have paid as the primary payer.

DIF: Hard

REF: 108

OBJ: 6

4. In a situation when liability insurance is primary and Medicare is secondary, how much would

be billed to Medicare if the provider’s full charge is $300, the liability insurance paid $250 and the Medicare allowed amount for the service is $175.

ANS:

None, the liability insurance carrier has paid more than the Medicare allowed amount. The remaining balance would be written off by the service provider.

DIF: Hard

REF: 108

OBJ: 6

5. What does TEFRA stand for?

ANS:

Tax Equity and Fiscal Responsibility Act DIF: Easy

REF: 105

OBJ: 5

6. When Medicare payments are posted to a separate daysheet, what should the daysheet

payment total agree with?

ANS:

The deposit slip total DIF: Moderate

REF: 118

OBJ: 19

Scenario: The following questions pertain to a participating physician who bills Medicare $480; Medicare allows $400, and the patient has met the Medicare deductible for the calendar year.

7. What is the amount of the check that Medicare sends to the physician?

ANS:

$320 DIF: Moderate

REF: 109

OBJ: 19

8. What is the patient’s financial responsibility?

ANS:

$80

DIF: Moderate

REF: 109

OBJ: 19

9. What is the courtesy adjustment?

ANS:

$80 DIF: Moderate

REF: 109

OBJ: 19

Chapter 07: Medicaid and Other State Programs Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. The Medicaid program is funded a. by state government. b. by federal government. c. jointly by state and federal governments. d. by charitable organizations.

ANS: C

DIF: Easy

REF: 124

OBJ: 1

2. The Federal Emergency Relief Administration made funds available to pay for a. food and living expenses of the needy unemployed. b. food and living expenses of the needy employed. c. medical expenses of the needy unemployed. d. medical expenses of the needy employed.

ANS: C

DIF: Moderate

REF: 124

OBJ: 1

3. The Social Security Act of 1935 a. created the public assistance programs. b. made a special provision for medical assistance. c. made a special provision for dental coverage. d. set up the state medical programs.

ANS: A

DIF: Moderate

REF: 124

OBJ: 2

4. The federal aspects of Medicaid are the responsibility of the a. AMA. b. AHA. c. HIAA. d. CMS. ANS: D 5.

DIF: Hard

REF: 124

OBJ: 5

DEFRA and CHAP were responsible for reducing Medicaid-covered services. decreasing the number of people covered by Medicaid. expanding Medicaid eligibility requirements. changing the way the Medicaid program is administered.

a. b. c. d.

ANS: C

DIF: Hard

REF: 125

OBJ: 3

6. Legislation which expanded access for childless adults, non-elderly and non-pregnancy

individuals, including preventive services and long-term care benefits: a. DEFRA b. CHAP c. PPACA d. CHIP

ANS: C

DIF: Hard

REF: 125

OBJ: 3

7. A partnership between the federal and state governments that provides low-cost health

coverage to children in families that earn too much money to qualify for Medicaid. a. DEFRA b. CHAP c. PPACA d. CHIP ANS: D

DIF: Hard

REF: 125

OBJ: 3

8. Programs available to low-income individuals with out-of-pocket costs for Medicare,

including Medicare Part A and Part B premiums, deductibles, copayments, and coinsurance: a. MSP b. SSI c. MCHP d. TANF ANS: A

DIF: Moderate

REF: 126

OBJ: 4

9. The Omnibus Budget Reconciliation Act a. helped set up a Medicaid fund for each state. b. provided assistance for the blind who are below the poverty level and who are

covered under the Medicare program. c. provided assistance for the aged and disabled who are receiving Medicare and

whose incomes are below the poverty level. d. set up counseling centers for those on Medicaid and Medicare.

TESTBANKSELLER.COM ANS: C

DIF: Moderate

REF: 126

OBJ: 3

10. A Medicare Savings Program which only pays for Medicare Part A premiums. a. MSP b. SLMB c. QI d. QDWI ANS: D

DIF: Moderate

REF: 127

OBJ: 4

11. Medicaid is available to the needy and low-income people such as a. the blind. b. the disabled. c. the aged (65 years or older). d. All are correct.

ANS: D

DIF: Moderate

REF: 127

OBJ: 7

12. A Federal government program which provides limited cash assistance to extremely

low-income parents and their children when the parents or other responsible relatives cannot provide for the family’s basic needs. a. MSP b. SSI c. TANF

d. MN ANS: C

DIF: Hard

REF: 127

OBJ: 7

13. Under the Spousal Impoverishment Protection Law, protection does not count a. cash, checking, and savings accounts. b. life insurance policies. c. certificates of deposit. d. burial assets.

ANS: D

DIF: Moderate

REF: 128

OBJ: 7

14. Health care organizations/providers may accept or refuse to treat Medicaid patients, based on a. the individual patient’s personality. b. the individual patient’s medical situation. c. the entire Medicaid program rather than individual’s circumstances. d. All are correct.

ANS: C

DIF: Moderate

REF: 128

OBJ: 8

15. If a physician accepts Medicaid patients, the physician must accept a. the Medicaid-allowed amount. b. the Medicare-allowed amount. c. an amount equal to his or her regular fee schedule. d. the Medicaid-allowed amount plus 20%, which may be collected from the patient.

ANS: A

DIF: Moderate

REF: 128

OBJ: 8

AN 16. Items that should be abstraT ctE edSfTroBm aK paStiE enLt’LsEMRe. diCcO aiM d ID card for claims submission do NOT include a. patient’s name. b. county of residence. c. Medicaid ID number. d. gender.

ANS: B

DIF: Easy

REF: 128

OBJ: 9

17. The Medicaid service for prevention, early detection, and treatment for welfare children is

known as a. CHPS. b. EPSDT. c. EPDT. d. CHAP. ANS: B

DIF: Easy

REF: 130

OBJ: 10

18. The time limit to appeal a claim varies from state to state, but it is usually for a. 30–60 days. b. 90–120 days. c. 6 months. d. 1 year.

ANS: A

DIF: Easy

REF: 133

OBJ: 12

19. To control escalating health care costs by curbing unnecessary emergency department visits

and emphasizing preventive care, Medicaid reform has involved a. increased state funding. b. increased federal funding. c. managed care programs. d. fee-for-service programs.

ANS: C

DIF: Moderate

REF: 130

OBJ: 11

20. There are two types of copayment requirements that may apply to a state, they are: a. capitation copayment or small fixed copayment b. sliding scale copayment or small fixed copayment c. annual copayment or spend down copayment d. small fixed copayment or spend down copayment ANS: D

DIF: Moderate

REF: 131

OBJ: 13

COMPLETION 1. Medicaid was legally established by Title

of the Social Security Act.

ANS: XIX DIF: Easy

REF: 125

OBJ: 2

2. The abbreviation for the Deficit Reduction Act of 1984 is

.

ANS: DEFRA DIF: Easy

REF: 125

OBJ: 2

3. The Patient Protection and Affordable Care Act and the Health Care and Education

Reconciliation Act are federal legislation passed in

.

ANS: 2010 DIF: Easy

REF: 125

OBJ: 3

4. The Medicaid medical assistance program in California is called

.

ANS: Medi-Cal DIF: Easy

REF: 125

OBJ: 2

5. The Medicare Savings Program which was established for elderly individuals whose income

is 20% above the FPL and pays the entire Medicare Part B Premium is called the .

ANS:

Specified Low-Income Medicare Beneficiary Program (SLMB)

Specified Low-Income Medicare Beneficiary Program SLMB DIF: Moderate

REF: 136

OBJ: 6

6. The Medicare Savings Program, known as the QI program, was created for individuals whose

income is at least

but less than

of the FPL.

ANS:

135%, 175% 135% 175% DIF: Moderate

REF: 136

OBJ: 6

7. The two Medicaid eligibility classifications are the

the

needy group and

needy class.

ANS:

categorically; medically categorically, medically categorically; medically DIF: Moderate

REF: 127

OBJ: 7

8. Some Medicaid recipients in the medically needy category must pay a coinsurance payment

and/or deductible, also known as a/an before state benefits may be received.

, within the eligibility month

ANS: share of cost DIF: Moderate

REF: 127

OBJ: 7

9. The

Law prevents the community spouse from being impoverished by his or her spouse’s institutionalization in a nursing facility.

ANS: Spousal Impoverishment Protection DIF: Moderate

REF: 128

OBJ: 7

10. In the Medicaid program, a

is an organization under contract with the state to process claims for a state Medicaid program.

ANS: fiscal agent DIF: Easy

REF: 128

OBJ: 12

11. Medicaid identification cards are usually issued every ANS: month DIF: Easy

REF: 128

OBJ: 9

.

12. Retroactive Medicaid eligibility status must be decided within

days of filing of the

application.

ANS: 90 DIF: Moderate

REF: 128

OBJ: 7

13. The evaluation of a provider’s request for a specific good or service to determine the medical

necessity and appropriateness of the care requested for the patient is known as

.

ANS:

prior approval or prior authorization prior approval prior authorization DIF: Moderate

REF: 131

OBJ: 12

14. Time limits for Medicaid claim submission can vary from

months to 1 year from the date of service depending on the state in which service was provided.

ANS: 2 DIF: Moderate

REF: 131

15. Most states have

OBJ: 12

for Medicaid payments if a patient requires medical

care while out of state.

ANS: reciprocity DIF: Moderate

REF: 131

16. Medicaid is always considered the

OBJ: 10

when the patient is eligible for Medicaid and also

has group health insurance coverage.

ANS: Payer of last resort DIF: Hard

REF: 133

17. The

OBJ: 13

form accompanies all Medicaid payment checks.

ANS: remittance advice DIF: Easy

REF: 133

OBJ: 14

18. The processing of an insurance claim through a series of edits by a fiscal intermediary for

final determination of coverage and possible payment is referred to as ANS:

adjudication or claim settlement adjudication

.

claim settlement DIF: Moderate

REF: 133

OBJ: 13

19. A federally funded state law enforcement entity that employ teams of fraud investigators,

attorneys, and auditors who investigate and prosecute cases of fraud and other violations is known as .

ANS:

Medicaid Fraud Control Unit (MFCU) Medicaid Fraud Control Unit MFCU DIF: Moderate

REF: 134

OBJ: 16

20. The Office of

oversees and assesses state law enforcement for performance and compliance with federal requirements.

ANS: Inspector General DIF: Moderate

REF: 133

OBJ: 16

TRUE/FALSE 1. Medicaid is not so much an insurance program as an assistance program.

ANS: T

DIF:

EF 12R4.COM TEEasSy TBANKSRE L:LE

OBJ: 1

2. Under Medicaid, all recipients will have the same copayment amount that must be collected at

each office visit.

ANS: F

DIF: Moderate

REF: 125

OBJ: 4

3. Under the PPACA legislation, states were given the option to extend Medicaid eligibility to

adults with incomes at or below 120% of the federal poverty level.

ANS: F

DIF: Hard

REF: 125

OBJ: 3

4. CHIP insures children from families whose income is below 200% of the federal poverty level

or whose family has an income 50% higher than the state’s Medicaid eligibility threshold.

ANS: T

DIF: Hard

REF: 125

OBJ: 3

5. It is not possible for an immigrant to have Medicaid coverage in any state.

ANS: F

DIF: Moderate

REF: 127

OBJ: 7

6. Emergency care and pregnancy services are exempt by law from copayment requirements.

ANS: T

DIF: Moderate

REF: 127

OBJ: 10

7. A physician may accept or refuse Medicaid patients on the basis of the individual patient and

his or her circumstances.

ANS: F

DIF: Moderate

REF: 128

OBJ: 8

8. The patient’s Medicaid card must be checked each time the patient visits the physician’s

office to verify eligibility for month of service.

ANS: T

DIF: Easy

REF: 128

OBJ: 9

9. It is possible for a Medicaid patient to be on Medicaid one month and off Medicaid the

following month.

ANS: T

DIF: Moderate

REF: 128

OBJ: 9

10. Medicaid eligibility is verified in all states using a point-of-service machine.

ANS: F

DIF: Moderate

REF: 128

OBJ: 9

11. In some cases the welfare office may grant retroactive eligibility to a patient.

ANS: T

DIF: Hard

REF: 128

OBJ: 9

12. If a service is totally disallowed by Medicaid, a physician is within legal rights to bill the

patient.

ANS: T

DIF: Hard

REF: 130

OBJ: 15

13. The EPSDT is program for prevention, early detection and treatment of children under the age

of 18 and enrolled in Medicaid.

ANS: F

DIF: Hard

REF: 130

OBJ: 4

14. The Medicaid patient may be responsible for a copayment.

ANS: T

DIF: Moderate

REF: 131

OBJ: 14

15. All state Medicaid programs operate with a fee-for-service reimbursement system.

ANS: F

DIF: Hard

REF: 130

OBJ: 5

16. Medicaid patients in managed care plans must go to hospitals participating in their assigned

plan.

ANS: T

DIF: Moderate

REF: 130

OBJ: 11

17. The gatekeeper in a Medicaid managed care program is the specialist to whom the patient is

referred.

ANS: F

DIF: Moderate

REF: 130

OBJ: 11

18. Prior approval or authorization is never required in the Medicaid program.

ANS: F

DIF: Moderate

REF: 130

OBJ: 11

19. All states processing medical claims must bill using the CMS-1500 claim form.

ANS: T

DIF: Easy

REF: 131

OBJ: 12

20. When Medicaid and a third-party payer cover the patient, Medicaid is always the payer of last

resort.

ANS: T

DIF: Moderate

REF: 133

OBJ: 13

21. It is not possible for a person to be eligible for Medicaid benefits and also have additional

group health insurance coverage.

ANS: F

DIF: Moderate

REF: 133

OBJ: 13

Chapter 08: TRICARE and Veterans’ Health Care Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. TRICARE, formerly known as CHAMPUS, is funded through a. the US Congress. b. individual states. c. individual regions. d. military contributions.

ANS: A

DIF: Moderate

REF: 138

OBJ: 1

2. Effective January 1, 2018, TRICARE is available a. in two US regions. b. in three US regions. c. in four US regions. d. in five US regions.

ANS: A

DIF: Moderate

REF: 138

OBJ: 1

3. A service retiree is entitled to TRICARE benefits a. for 30 days after retirement date. b. for one year after retirement date. c. until he/she becomes eligible for the Medicare program. d. until death.

ANS: C

DIF: Easy

REF: 138

OBJ: 2

4. What is the system called that TRICARE claims processors use to verify beneficiary

eligibility? a. CHAMPUS b. Eligibility report c. TRI-CHECK d. DEERS ANS: D

DIF: Easy

REF: 139

OBJ: 2

5. An NAS is a a. certification of the status of a military hospital. b. certification of the status of a civilian hospital. c. certification from a civilian hospital stating specific treatment that was denied. d. certification from a military hospital stating that it cannot provide the necessary

care.

ANS: D

DIF: Easy

REF: 139

OBJ: 3

6. The NAS catchment area is a. defined by ZIP codes. b. determined by the availability of hospitals in the area. c. based on an area of about 40 miles in radius surrounding each USMTF.

d. defined by ZIP codes and based on an area of about 40 miles in radius surrounding

each USMTF. ANS: D

DIF: Easy

REF: 139

OBJ: 3

7. The maximum amount paid by a TRICARE beneficiary each fiscal year for the cost-share and

annual deductible is referred to as a. premium. b. allowable amount. c. copayment. d. catastrophic cap.

ANS: D

DIF: Moderate

REF: 139

OBJ: 2

REF: 140

OBJ: 6

8. The TRICARE fiscal year extends from a. January 1 to December 31. b. April 1 to March 31. c. July 1 to June 30. d. October 1 to September 30.

ANS: D

DIF: Easy

9. A physician who chooses not to participate in TRICARE bills a. the total amount of the usual charge. b. the total amount of the customary charge. c. no more than 100% of the TRICARE allowable charge. d. no more than 115% of the TRICARE allowable charge.

ANS: D

DIF:

TMEoSdeTraBteANKSRE L:LE EF 14R0.COM

OBJ: 4

10. Effective from January 1, 2018, the TRICARE Select program replaced a. TRICARE Standard. b. TRICARE Extra. c. TRICARE Standard Overseas. d. All the above programs.

ANS: D

DIF: Moderate

REF: 140

OBJ: 5

11. Medical care that is cost-shared by both TRICARE Select and a civilian source is known as a. coordination of care. b. conversion of care. c. cooperative care. d. competitive care.

ANS: C

DIF: Hard

REF: 141

OBJ: 5

12. A health care professional, usually a registered nurse, who helps the patient work with his or

her primary care manager to locate a specialist or obtain a preauthorization for care is referred to as a/an a. PCP. b. TSC. c. HCF. d. PCM.

ANS: C

DIF: Moderate

REF: 141

OBJ: 5

13. The health maintenance organization provided for dependents of active duty military

personnel is called a. CHAMPUS. b. TRICARE Prime. c. TRICARE Extra. d. TRICARE Standard.

ANS: B

DIF: Moderate

REF: 143

OBJ: 7

14. Enrollment in TRICARE Prime is for a. 1 month at a time. b. 1 year at a time. c. as long as the beneficiary would like to remain in the plan. d. none are correct.

ANS: B

DIF: Moderate

REF: 143

OBJ: 7

15. The physician who is responsible for coordinating and managing all of the health care for the

TRICARE Prime patient is referred to as a/an a. PCM. b. PCP. c. gatekeeper. d. HCF. ANS: A

DIF: Moderate

REF: 143

OBJ: 7

16. Periodic physical examinations are covered at no charge under a. TRICARE Prime. b. TRICARE Select. c. Neither TRICARE Prime nor TRICARE Select.

ANS: A

DIF: Hard

REF: 143

OBJ: 7

17. A person at a military hospital or clinic who is there to help beneficiaries obtain medical care

needed through the military and TRICARE. a. PCP b. HCF c. HBA d. PCM ANS: C

DIF: Hard

REF: 143

OBJ: 7

18. TRICARE Prime Remote can only be used if both the sponsor’s home and work addresses are

more than a. 50 miles from a military hospital or clinic. b. 100 miles from a military hospital or clinic. c. One hour’s drive from a military hospital or clinic. d. 50 miles from a military hospital or clinic and one hour’s drive from a military hospital or clinic.

ANS: D

DIF: Moderate

REF: 144

OBJ: 8

19. TRICARE Prime Overseas is available to a. active duty service members. b. activated guard/reserve members. c. retirees. d. a and b only.

ANS: D

DIF: Moderate

REF: 144

OBJ: 8

20. TRICARE Prime Remove Overseas is available to a. active duty service members. b. active guard/reserve members. c. retirees. d. a and b only.

ANS: D

DIF: Moderate

REF: 144

OBJ: 8

21. Under the US Family Health Plan, the designated provider for an individual living in northern

Connecticut would be a. John Hopkins Medicine. b. Martin’s Point Health care. c. Brighton Marine Health Center. d. St. Vincent Catholic Medical Centers. e. CHRISTUS Health. f. Pacific Medical Centers (PacMed Clinics).

ANS: C

DIF:

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OBJ: 9

22. To be eligible for TRICARE Retired Reserve, an individual must be a member of the retired

Reserve of a Reserve component of the armed forces and a. under the age of 60. b. under the age of 65. c. eligible for TRICARE Prime/Select. d. under the age of 65 and eligible for TRICARE Prime/Select.

ANS: A

DIF: Moderate

REF: 145

OBJ: 9

23. The TYA program provides coverage of a. medical services. b. pharmacy charges. c. dental care. d. medical services and pharmacy charges.

ANS: D

DIF: Moderate

REF: 145

OBJ: 9

24. TRICARE for Life provides coverage a. to any individual who has been an active duty service member for more than 10

years. b. all retirees and their spouses. c. military survivors under the age of 21. d. TRICARE eligible beneficiaries with Medicare Part A and B.

ANS: D

DIF: Moderate

REF: 145

OBJ: 10

REF: 146

OBJ: 11

25. TRICARE Plus limits coverage to a. primary care. b. specialty care. c. dental care. d. a and b only.

ANS: A

DIF: Moderate

26. The Veterans Health Care Expansion Act of 1973 authorized the a. CHAMPUS program. b. CHAMPVA program. c. TRICARE program. d. VA program.

ANS: B

DIF: Moderate

REF: 147

OBJ: 14

27. The wife of a veteran with total permanent disability resulting from a service-connected injury

is eligible for CHAMPVA benefits a. as long as she is not eligible for TRICARE Standard. b. as long as she is not eligible for Medicare Part A. c. as long as she is not eligible for TRICARE Standard and as long as she is not eligible for Medicare Part A. d. neither as long as she is not eligible for TRICARE Standard nor as long as she is not eligible for Medicare Part A. ANS: C

DIF:

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OBJ: 14

28. The Privacy Act of 1974 establishes an individual’s right to review his or her medical records

maintained by a. a federal medical care facility. b. a VA hospital. c. a US Public Health Service facility. d. all are correct.

ANS: D

DIF: Moderate

REF: 149

OBJ: 15

29. The time limit within which a TRICARE outpatient claim must be filed is a. within 6 months from the date a service is provided. b. within 1 year from the date a service is provided. c. by the end of the year in which a service is provided. d. by the end of the year following the year in which a service is provided.

ANS: B

DIF: Hard

REF: 150

OBJ: 15

30. The time limit within which a TRICARE inpatient claim must be filed is a. within 1 year from the date a service is provided. b. by the end of the year in which the service is provided. c. within 1 year from a patient’s discharge from an inpatient facility. d. by the end of the year following a patient’s discharge from an inpatient facility.

ANS: C

DIF: Hard

REF: 150

OBJ: 15

COMPLETION 1. The active duty service member whose family members are covered under TRICARE is

called the

.

ANS: sponsor DIF: Easy

REF: 138

OBJ: 2

2. Individuals who qualify for TRICARE are known as

.

ANS: beneficiaries DIF: Easy

REF: 138

OBJ: 2

3. A certification from a military hospital stating that it cannot provide the care needed is called

a

.

ANS: Non-availability Statement DIF: Easy

REF: 139

OBJ: 3

4. A specific geographic region defined by zip codes and based on an area of approximately 40

miles in radius surrounding a MTF is referred to as a

area.

ANS: Catchment DIF: Moderate

REF: 139

OBJ: 3

5. The physician who provides medical care at contracted rates to beneficiaries under the

TRICARE Extra program is called a/an

provider.

ANS: network DIF: Hard

REF: 139

OBJ: 4

6. A provider who is non-participating in the TRICARE program may not bill the patient more

than

% of the allowable charge (the limiting charge).

ANS: 115 DIF: Hard

REF: 139

OBJ: 4

7. Health care services which are generally accepted by qualified professionals to be reasonable

and adequate for the diagnosis and treatment of illness, injury, pregnancy, and mental disorders are referred to as .

ANS:

medically (or psychologically) necessary medically necessary

psychologically necessary medically or psychologically necessary DIF: Moderate 8.

REF: 141

OBJ: 4

is the process required to obtain permission for a service or procedure before it is done to determine if the TRICARE regional contractor considers it to be medically necessary.

ANS: Preauthorization DIF: Moderate

REF: 141

OBJ: 5

9. An office staffed by health care professionals and beneficiary service representatives who

work with a beneficiary’s PCP to locate health care specialists and obtain preauthorization for care is referred to as a .

ANS:

TRICARE service center (TSC) TRICARE service center TSC DIF: Easy

REF: 141

OBJ: 5

10. A civilian or military provider who provides the majority of patient care to an individual

enrolled in the TRICARE Prime program is a

.

ANS:

Primary care manager (PCM) Primary care manager PCM DIF: Moderate

REF: 143

OBJ: 7

11. A health care benefits advisor (HBA) is employed by

and is responsible for helping

all MHS beneficiaries to obtain medical care.

ANS: the government DIF: Moderate

REF: 143

OBJ: 7

12. TRICARE Prime Overseas beneficiaries are assigned a

patient’s care.

ANS:

Primary Care Manager (PCM) Primary Care Manager PCM DIF: Moderate

REF: 143

OBJ: 8

who will provide most of the

13. The US Family Health Plan is an additional TRICARE Prime option available in

designated areas of the United States.

ANS: 6 DIF: Hard

REF: 144

OBJ: 8

14. Under the TYA program, an individual may qualify for benefits if they are under the age of

and enrolled in a full-time course of study at an approved institution of higher learning and if the sponsor provides at least % of his/her financial support.

ANS: 21, 50 DIF: Hard

REF: 145

OBJ: 9

15. Beneficiaries who qualify for TRICARE for Life will use

as proof of coverage.

ANS: Military ID DIF: Easy

REF: 145

16. TRICARE Plus does not cover

OBJ: 10

care.

ANS: specialty DIF: Moderate

REF: 146

OBJ: 11

AeNdKFSoE 17. A person who has served iT nE thS eT AB rm rcL esLoEf R th.eCUOnM ited States, especially in a time of war, who is no longer in the service and has received an honorable discharge is called a/an .

ANS: veteran DIF: Moderate

REF: 147

OBJ: 14

18. Dependents of individuals who have died as a result of service-connected injuries qualify to

receive

benefits.

ANS: CHAMPVA DIF: Moderate

REF: 147

OBJ: 14

19. CHAMPVA’s eligibility requirements refer to children as those who are unmarried and

younger than the age of up to the age of educational institution.

ANS:

18; 23 18, 23 18 23

, regardless of whether dependent or not, or if enrolled in a course of instruction at an approved

DIF: Moderate

REF: 147

OBJ: 14

20. An organization under contract to the government that handles insurance claims for care

received under the TRICARE program is known as a/an

.

ANS: regional contractor DIF: Moderate

REF: 149

OBJ: 15

SHORT ANSWER 1. What payment does a participating provider agree to accept when assignment is accepted in a

TRICARE case?

ANS:

The TRICARE-determined allowable or reasonable cost/charge is accepted as payment in full.

DIF: Moderate

REF: 139

OBJ: 4

2. What does the acronym CHAMPVA stand for?

ANS:

Department of Veterans Affairs, formerly known as Civilian Health and Medical Program of the Department of Veterans Affairs.

DIF: Easy

REF: 147

J: 14 TESTBANKSOEBL LER.COM

3. Who determines eligibility in the CHAMPVA program?

ANS:

Department of Veterans Affairs DIF: Moderate

REF: 147

OBJ: 14

4. What does the Computer Matching and Privacy Protection Act of 1988 permit the government

to do?

ANS:

Verifies information regarding Privacy Act requests through computer matches.

DIF: Moderate

REF: 149

OBJ: 15

5. When transmitting TRICARE claims, where would the claim go if the patient is a child who

was treated in New York, but the military sponsor is an ADSM stationed in California?

ANS:

The claim should be transmitted to the TRICARE claims office in the west region (CA), rather than the east region (NY). The medical billing specialist would refer to the TRICARE website to locate the address of the western region’s claims office.

DIF: Hard

REF: 150

OBJ: 15

TRUE/FALSE 1. TRICARE provides comprehensive health coverage, except dental coverage, to all its’

members.

ANS: F

DIF: Moderate

REF: 138

OBJ: 2

2. Humana Military is the TRICARE regional contractor under agreement with the federal

government to handle claims processing for the Eastern United States.

ANS: T

DIF: Moderate

REF: 139

OBJ: 2

3. Only sponsors can add or remove eligible family members from the DEERS computerized

database.

ANS: T

DIF: Moderate

REF: 139

OBJ: 2

4. Military family members and retirees are issued a common access card (CAC) to access health

care benefits.

ANS: F

DIF: Hard

REF: 139

OBJ: 2

5. TRICARE non-network providers can determine whether they are participating or

non-participating on a claim-by-claim basis.

ANS: T

DIF:

TMEoSdeTraBteANKSRE LLER.COM EF: 139

OBJ: 4

6. The catastrophic cap for an active duty family is $3000 per family, per fiscal year.

ANS: F

DIF: Hard

REF: 140

OBJ: 5

7. TRICARE Select beneficiaries may receive urgent care which is a sudden and unexpected

medical condition, or the worsening of a condition, that poses a threat to life, losing a limb, or sight and requires immediate treatment to alleviate suffering.

ANS: F

DIF: Hard

REF: 141

OBJ: 5

8. A partnership program permits TRICARE-eligible people to receive inpatient treatment from

civilian providers of care in a military hospital.

ANS: T

DIF: Moderate

REF: 141

OBJ: 5

9. TRICARE Select beneficiaries are subject to paying annual deductibles and copayments.

ANS: T

DIF: Moderate

REF: 141

OBJ: 5

10. If a beneficiary elects to enroll in TRICARE Prime, the patient may no longer use the

TRICARE Select program.

ANS: T

DIF: Moderate

REF: 143

OBJ: 7

11. Periodic physical examinations are covered at no charge under TRICARE Prime and under

TRICARE Select.

ANS: F

DIF: Moderate

REF: 143

OBJ: 7

12. TRICARE Prime Remote is available to active duty service members and retirees.

ANS: F

DIF: Moderate

REF: 143

OBJ: 8

13. TRICARE Prime Overseas is available to active duty service members and retirees.

ANS: F

DIF: Moderate

REF: 144

OBJ: 9

14. Under the US Family Health Plan, beneficiaries do not get care from military hospital and

clinics or from TRICARE network providers.

ANS: T

DIF: Hard

REF: 144

OBJ: 9

15. TRICARE for Life is available worldwide and offers additional TRICARE benefits as a

supplementary payer to Medicare unless the beneficiary is in an overseas area.

ANS: T

DIF: Moderate

REF: 145

OBJ: 10

16. All services and supplies provided to TRICARE for Life beneficiaries must be preauthorized.

ANS: F

DIF:

14R5.COM TMEoSdeTraBteANKSREFL:LE

OBJ: 10

17. TRICARE Plus patients are allowed to get primary care at their military hospital or clinic or

by a civilian provider and pay nothing out of pocket.

ANS: F

DIF: Moderate

REF: 146

OBJ: 11

18. The Supplemental Health Care Program (SHCP) enables beneficiaries to be referred to a

civilian provider and incur no deductible, copayment, or cost share for services provided by a civilian provider.

ANS: T

DIF: Moderate

REF: 146

OBJ: 12

19. Under the TRICRE hospice program, the patient, PCP or an authorized family can initiate

care without a doctor’s orders.

ANS: F

DIF: Moderate

REF: 147

OBJ: 13

20. Although CHAMPVA is considered to be a service benefit program for veterans, beneficiaries

must pay a monthly premium for coverage.

ANS: F

DIF: Moderate

REF: 147

OBJ: 14

21. A husband, wife, or unmarried child of an individual who died in the line of duty while in

active service is eligible for CHAMPVA benefits as long as they are not eligible for TRICARE Select and not eligible for Medicare Part A. ANS: T

DIF: Hard

REF: 147

OBJ: 14

22. TRICARE is subject to state regulatory agencies that control insurance policies.

ANS: F

DIF: Moderate

REF: 149

OBJ: 15

23. For a CHAMPVA beneficiary, if the physician is non-participating and does not accept

assignment, the patient completes the top portion of the CMS-1500 claim form, attaches an itemized statement from the physician, and submits the claim.

ANS: T

DIF: Moderate

REF: 149

OBJ: 15

24. TRICARE/CHAMPVA is usually the second payer when a beneficiary is enrolled in other

health insurance plans.

ANS: T

DIF: Hard

REF: 150

OBJ: 15

25. TRICARE is considered primary to Medicare for people younger than age 65 who have

Medicare Part A as a result of a disability and who have enrolled in Medicare Part B. ANS: F

DIF: Hard

REF: 151

OBJ: 15

Chapter 09: Workers’ Compensation Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. The statutes for workers’ compensation laws fall under a. federal compensation laws. b. state compensation laws. c. federal and state compensation laws. d. state and county compensation laws.

ANS: C

DIF: Moderate

REF: 156

OBJ: 2

2. Due to widespread legal and medical corruption that had evolved throughout the workers’

compensation system, reform laws have been introduced in a number of states that deal with a. antifraud legislation. b. implementation of medical necessity requirements. c. prosecution of health care organizations, physicians, lawyers and employees who abuse the system. d. all are correct.

ANS: D

DIF: Moderate

REF: 156

OBJ: 2

3. The reason for workers’ compensation laws is a. to ensure a prompt return to work of any injured or ill employee. b. to provide income to the injured or ill worker.

SpTloByAerNiK c. to encourage maximumTeEm ntS erEesLt L inEsR af.etCyO .M d. all are correct.

ANS: D

DIF: Easy

REF: 156

OBJ: 3

4. Premiums for workers’ compensation insurance are paid by the a. employee. b. employer. c. employee and employer in equal amounts. d. state in which the employee works.

ANS: B

DIF: Easy

REF: 157

OBJ: 4

5. ERISA is a federal law which sets minimum requirements for workers’ compensation and

governs a. agricultural companies. b. coal mining companies. c. United States postal workers. d. self-insured employers.

ANS: D

DIF: Moderate

REF: 157

OBJ: 6

6. Captive insurance is a form of self-insurance designed to serve a. smaller companies. b. mid-size companies.

c. large companies. d. a and b. e. b and c.

ANS: D

DIF: Moderate

REF: 157

OBJ: 6

7. One function of the second-injury fund is to a. eliminate hiring of individuals who have a pre-existing injury. b. encourage hiring of the physically disabled. c. provide occupational safety training to prevent second-injuries. d. charge higher premiums to employers who experience repeat injuries at their

workplace.

ANS: B

DIF: Easy

REF: 157

OBJ: 5

8. Which of the following would NOT be entitled to workers’ compensation benefits? a. A firefighter who develops posttraumatic stress disorder due to on the job

experiences. b. An employee who breaks his leg during an official company retreat at a ski resort. c. An employee who is injured on his morning drive to work. d. An employee who amputates his finger while operating a drill press incorrectly at

his place of employment.

ANS: C

DIF: Moderate

REF: 158

OBJ: 7

9. An abnormal condition caused by exposure to environmental factors associated with

employment is termed a/an a. physical injury. b. occupational illness. c. temporary disability. d. permanent disability.

ANS: B

DIF: Hard

REF: 158

OBJ: 7

10. Employees who work for federal agencies are covered by federal workers’ compensation laws

administered through the a. OIG. b. OWCP. c. DWMWC. d. FECA. ANS: B

DIF: Hard

REF: 158

OBJ: 7

11. Private and public employees engaged in maritime work nationwide are protected under the a. b. c. d.

Act. FECA LHWCA EEOICPA RECA

ANS: B

DIF: Moderate

REF: 158

OBJ: 7

12. State compensation laws that require each employer to accept its provisions and provide for

specified benefits are a. compulsory laws. b. elective laws. c. regional laws. d. local laws.

ANS: A

DIF: Hard

REF: 159

OBJ: 7

13. In most states children who are injured on the job are a. entitled to the same workers compensation benefits as other injured workers. b. are provided additional workers’ compensation protection over and above the

standard benefits paid to adults. c. are provided limited workers’ compensation protection. d. not entitled to any workers’ compensation protection until the age of 18.

ANS: B

DIF: Moderate

REF: 159

OBJ: 7

14. When billing workers’ compensation for a truck driver who was injured outside of the state

they are employed in, you should a. follow federal guidelines, rather than state guidelines. b. follow the rules of the state the individual was injured in. c. follow the rules of the state the patient currently resides in. d. follow the rules of the state in which the claim was originally filed.

ANS: D

DIF: Hard

REF: 159

OBJ: 7

15. Workers’ compensation beT nE efS itsTiB ncAluNdKeSELLER.COM a. medical care. b. disability income. c. death benefits. d. all are correct.

ANS: D

DIF: Moderate

REF: 159-160

OBJ: 9

16. The simplest type of workers’ compensation claim is a. temporary disability. b. permanent disability. c. non-disability. d. partial disability.

ANS: C

DIF: Moderate

REF: 160

OBJ: 10

17. If a worker has a work-related injury or illness and is unable to perform the duties of his or her

occupation for 2 months and then returns to modified work for 1 month before returning to full work, the claim is referred to as a a. non-disability claim. b. temporary disability claim. c. permanent disability claim. d. permanent and stationary claim.

ANS: B

DIF: Moderate

REF: 160

OBJ: 10

18. An individualized program of therapy using simulated or real work tasks to build strength and

improve the worker’s endurance toward a full day’s work is known as a. work hardening. b. physical therapy. c. cognitive evaluation. d. occupational therapy.

ANS: A

DIF: Moderate

REF: 161

OBJ: 10

19. In a PD claim, the physician’s final report must include the words a. compromise and stationary. b. permanent and stationary. c. stationary and release. d. stationary and discharge.

ANS: B

DIF: Hard

REF: 161

OBJ: 9

20. When a case is rated for permanent disability and settled, this is called a. withdrawal and discharge. b. relief of duty. c. compromise and release. d. surrender and release.

ANS: C

DIF: Hard

REF: 161

OBJ: 9

21. Final determination involving settlement of an industrial accident is known as a. adjudication. b. settlement. c. release. d. discharge.

ANS: A

DIF: Moderate

REF: 161

OBJ: 9

22. Videotapes made of the patient without his or her knowledge to document the extent of the

patient’s permanent disability are called a. live action tapes. b. case films. c. photoplay documents. d. sub rosa films.

ANS: D

DIF: Moderate

REF: 161

OBJ: 11

23. A proceeding in which an attorney asks a witness questions regarding a case and the witness

answers under oath but not in open court is known as a/an a. arbitration. b. negotiation. c. deposition. d. hearing.

ANS: C

DIF: Easy

REF: 162

OBJ: 13

24. Which is the correct procedure for keeping an industrial patient’s financial and health records

when the same physician is also seeing the patient as a private patient?

a. The same financial record may be used, but a separate health record must be

maintained. b. The same health record may be used, but a separate financial record must be

maintained. c. The same financial and health records may be used. d. Separate financial and health records must be used.

ANS: D

DIF: Moderate

REF: 173

OBJ: 16

25. In an industrial case, if the patient is experiencing pain that can be tolerated but will cause

some handicap in the performance of the activity precipitating the pain, it is classified as a. severe pain. b. moderate pain. c. slight pain. d. minimal or mild pain.

ANS: C

DIF: Hard

REF: 174

OBJ: 16

26. The form that contains authorization for the physician to treat the injured employee is the a. Employer’s Report of Occupational Injury. b. Medical service order. c. Physician’s First Report of Occupational Injury or Illness. d. Supplemental Report.

ANS: B

DIF: Moderate

REF: 174

OBJ: 16

27. OSHA stands for a. Occupational Services T anEdSHTeBalAthNA niL stE raR ti. onC. OM KdSmEiL b. Outpatient Safety and Health Association. c. Occupational Standards and Health Association. d. Occupational Safety and Health Administration.

ANS: D

DIF: Easy

REF: 174

OBJ: 16

28. The First Treatment Medical Report or Physician’s First Report of Occupational Injury or

Illness form should be signed a. in ink by the physician’s representative. b. in ink by the physician. c. using a certified signature stamp. d. both in ink by the physician’s representative and in ink by the physician.

ANS: B

DIF: Moderate

REF: 174

OBJ: 17

29. Supplemental report(s) for patients on temporary disability should be sent to the insurance

carrier a. after treatment is completed. b. after every office visit. c. if there is a change in the diagnosis. d. on the first of every month.

ANS: B

DIF: Moderate

REF: 179

OBJ: 18

30. In a workers’ compensation case, the contract and financial responsibility exists between the

a. b. c. d.

physician and the insurance company. physician and the patient. patient and the insurance company. employer and the patient.

ANS: A

DIF: Moderate

REF: 179

OBJ: 19

COMPLETION 1. A form of self-insurance designed to serve a small manufacturing company is known as

insurance.

ANS: captive DIF: Moderate

REF: 157

OBJ: 1

2. A/An

is an unplanned and unexpected happening traceable to a definite time and place, causing injury (damage or loss) not due to any fault on the part of the person injured.

ANS: accident DIF: Moderate

REF: 158

OBJ: 1

3. Any abnormal condition or disorder caused by exposure to environmental factors associated

with employment, including acute and chronic illnesses or diseases that may be caused by inhalation, absorption, ingeTsE tioSnT, B orAdNirK ecSt E coLnL taEctR, . isCreOfeMrred to as a/an .

ANS: occupational illness DIF: Moderate

REF: 158

OBJ: 1

4. If a worker’s occupation takes a person into another state, most compensation laws are

and effective outside the state by either specific provisions or court decision.

ANS: extraterritorial DIF: Hard

REF: 159

5. The three types of disability claims are

OBJ: 7

,

.

ANS:

non-disability; temporary disability; permanent disability non-disability; permanent disability; temporary disability temporary disability; permanent disability; non-disability temporary disability; non-disability; permanent disability permanent disability;non-disability; temporary disability permanent disability; temporary disability; non-disability

, and

non-disability, temporary disability, permanent disability non-disability, permanent disability, temporary disability temporary disability, permanent disability, non-disability temporary disability, non-disability, permanent disability permanent disability, non-disability, temporary disability permanent disability, temporary disability, non-disability non-disability temporary disability permanent disability non-disability permanent disability temporary disability temporary disability permanent disability non-disability temporary disability non-disability permanent disability permanent disability non-disability temporary disability permanent disability temporary disability non-disability DIF: Moderate

REF: 160

OBJ: 10

6. Sometimes a patient is released to

work to effect a transition between the period of inactivity due to disability and a return to full duty, especially when heavy work is involved.

ANS: modified DIF: Moderate

REF: 161

OBJ: 8

7. Rehabilitation in the form of retraining, education, and job guidance and placement to assist

an injured individual in finding work is called

rehabilitation.

ANS: vocational DIF: Moderate

REF: 161

OBJ: 1

8. An individualized program of therapy using simulated or real work tasks to build up strength

and improve a worker’s endurance toward a full day’s work is called .

ANS: work hardening DIF: Moderate

REF: 161

OBJ: 1

9. A/An

evaluation of the worksite may be performed, and modifications may be instituted to lessen the possibility of future injury.

ANS: ergonomic DIF: Moderate

REF: 161

OBJ: 1

10. A physician hired by the insurance company or appointed by the referee or appeals board to

examine an injured worker and render an unbiased opinion regarding the degree of disability is referred to as a/an .

ANS:

independent medical evaluator (IME)

agreed medical evaluator (AME) qualified medical evaluator (QME) independent medical evaluator agreed medical evaluator qualified medical evaluator DIF: Hard

REF: 162

11. A/An

OBJ: 9

expresses legal claim on the property of another for the

payment of a debt.

ANS: lien DIF: Moderate

REF: 162

OBJ: 14

12. The legal words

mean to substitute one person for another.

ANS:

“third-party subrogation” third-party subrogation DIF: Moderate

REF: 169

OBJ: 15

13. A

report is sent to the insurance carrier after 2–4 weeks of treatment to give information on the current status of the patient.

ANS: supplemental DIF: Easy

REF: 179

OBJ: 18

SHORT ANSWER 1. Which types of employees fall under federal workers’ compensation statutes?

ANS:

Miners, federal employees, and maritime workers.

DIF: Moderate

REF: 156

OBJ: 2

2. Name the five types of workers’ compensation benefits.

ANS:

Medical treatment, temporary disability indemnity, permanent disability indemnity, death benefits, and rehabilitation benefits.

DIF: Moderate

REF: 159-160

OBJ: 9

3. What is the name of the form that authorizes the physician to treat the employee?

ANS:

Medical service order.

DIF: Moderate

REF: 174

OBJ: 16

4. What are the differences in patient care between non-disability claims, temporary disability

claims, and permanent disability claims?

ANS:

Non-disability claims—patient experiences a minor injury and is able to continue working.

Temporary disability claims—occurs when a worker has a work-related injury or illness and is unable to perform the duties of his or her occupation for a specific time.

Permanent disability claim—the patient is usually on temporary disability benefits for a time and then concludes that he or she is unable to return to his or her former occupation.

DIF: Moderate

REF: 160

OBJ: 10

5. What formal report is sometimes required to inform the insurance carrier that the patient is

able to return to work?

ANS:

Physician’s final report.

DIF: Easy

REF: 179

OBJ: 17

TRUE/FALSE 1. Under State and Federal Workers’ Compensation Laws, employees are required to purchase

insurance to provide benefT itsEiS fT thB eyAsNuK ffS erEwLoLrkE-rRe. laC teO dM injuries or illnesses.

ANS: F

DIF: Easy

REF: 156

OBJ: 2

2. Workers’ compensation laws are the same in all states.

ANS: F

DIF: Easy

REF: 156

OBJ: 3

3. Employers with sufficient capital can save money by self-insuring employees for work-related

injuries by setting aside a state-mandated percentage of funding to cover medical expenses, wage compensation, death benefits, and other benefits related to work injuries.

ANS: T

DIF: Moderate

REF: 157

OBJ: 4

4. Some states have adopted laws authorizing employers to contract with managed care

programs to insure their workers against work-related accidents and illnesses.

ANS: T

DIF: Moderate

REF: 157

OBJ: 4

5. An independent contractor, who is not actually an employee, is still covered by the company

they are contracted with if they are injured while working for them.

ANS: F

DIF: Moderate

REF: 158

OBJ: 4

6. Claims for coal miners who receive medical treatment for lung diseases related to

pneumoconiosis are filed under the Coal Miners Benefit Act. ANS: F

DIF: Moderate

REF: 158

OBJ: 4

7. All state workers’ compensation laws are compulsory.

ANS: F

DIF: Moderate

REF: 159

OBJ: 4

8. Volunteer workers are covered under workers’ compensation in most states.

ANS: F

DIF: Moderate

REF: 159

OBJ: 4

9. Waiting periods affect workers’ compensation medical and hospital benefits.

ANS: F

DIF: Easy

REF: 159

OBJ: 8

10. Chiropractic care is a medical benefit offered with state workers’ compensation.

ANS: T

DIF: Easy

REF: 159

OBJ: 9

11. Workers’ compensation benefits are subject to income tax.

ANS: F

DIF: Moderate

REF: 161

OBJ: 9

12. Beginning in the 1990s, increases in fraudulent workers’ compensation claims have been

noted throughout many large metropolitan cities.

ANS: T

DIF: Moderate

REF: 162

OBJ: 11

13. A medical evaluator is an employee of the federal government who examines an individual,

independent from the attending physician and renders an unbiased opinion about the degree of disability of an injured worker.

ANS: F

DIF: Moderate

REF: 162

OBJ: 11

14. If a physician is subpoenaed to give medical testimony in a workers’ compensation case, he or

she must appear in court.

ANS: T

DIF: Moderate

REF: 162

OBJ: 13

15. If an individual is asked by her employer to go to the bank to deposit company money and she

is injured when another automobile rear-ended her at the drive up window. Related medical services for the injury will be covered under workers’ compensation insurance.

ANS: T

DIF: Hard

REF: 169

OBJ: 15

16. If a patient is treated by her regular physician for a work-related injury, a separate health

record and financial record should be set up for the work-related injury.

ANS: T

DIF: Moderate

REF: 173

OBJ: 16

17. Workers’ compensation programs are included under the definition of a “health plan” under

HIPAA and must comply with all HIPAA standards.

ANS: F

DIF: Hard

REF: 173

OBJ: 20

18. Authorization to treat a patient with an industrial injury may be obtained over the telephone.

ANS: T

DIF: Moderate

REF: 174

OBJ: 16

19. Progress reports subsequent to the initial report for workers’ compensation patients may be

narrative and are not necessarily completed on the special forms available in most states.

ANS: T

DIF: Moderate

REF: 179

OBJ: 18

20. A narrative industrial medical report should include only objective findings and not subjective

factors.

ANS: F

DIF: Hard

REF: 191

OBJ: 18

21. In an industrial case, the physician’s office may collect all amounts not covered by the

workers’ compensation fee schedule.

ANS: F

DIF: Hard

REF: 179

OBJ: 19

22. A date of injury is a requirement for all workers’ compensation insurance claims.

ANS: T

DIF: Easy

REF: 181

OBJ: 19

Chapter 10: Disability Income Insurance and Disability Benefit Programs Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Coverage that provides a specific monthly or weekly income when a person is unable to work

because of an illness or injury is known as a. guaranteed income insurance. b. disability income insurance. c. supplemental insurance. d. extended income insurance.

ANS: B

DIF: Moderate

REF: 189

OBJ: 2

2. In 1956, the US Congress established a program under Title II of the Social Security Act for

long-term disability known as a. Civil Service Retirement System. b. Federal Employees Retirement System. c. Social Security Disability Insurance. d. Supplemental Security Income.

ANS: C

DIF: Moderate

REF: 190

OBJ: 1

3. Disability income insurance is available from a. private insurance companies. b. employer-sponsored plans. c. government-funded proTgE raSmTsB . ANKSELLER.COM d. all are correct.

ANS: D

DIF: Moderate

REF: 190

OBJ: 2

4. The maximum amount of time for which benefits will be paid to the injured or ill person for a

disability is called the a. waiting period. b. elimination period. c. benefit period. d. payment period.

ANS: C

DIF: Easy

REF: 190

OBJ: 2

5. Residual benefits pay a a. partial benefit when the insured is not totally disabled. b. partial benefit when the insured is totally disabled. c. total sum based on the type of illness. d. total payment based on the type of past employment.

ANS: A

DIF: Moderate

REF: 190

OBJ: 2

6. A policy that offers an insured person protection when loss of sight or loss of limb(s) occurs is

called a. double indemnity.

b. residual benefits. c. dismemberment benefit. d. amputee protection.

ANS: C

DIF: Moderate

REF: 190

OBJ: 2

7. When an illness or injury prevents an insured person from performing one or more of the

functions of his or her regular job, the disability is called a. partial disability. b. residual disability. c. total disability. d. partial disability and residual disability.

ANS: D

DIF: Moderate

REF: 190

OBJ: 2

8. The term guaranteed renewable means that the insurer is a. required to renew the policy as long as premium payments are made, and the

premium may be increased. b. required to renew the policy as long as premium payments are made, and the

premium may not be increased. c. not required to renew the policy if the premium is increased. d. not required to renew the policy.

ANS: A

DIF: Moderate

REF: 191

OBJ: 2

9. Provisions written into the insurance contract denying coverage or limiting the scope of

coverage are called a. exceptions. b. exclusions. c. preexisting conditions. d. denied benefits.

ANS: B

DIF: Moderate

REF: 191

OBJ: 2

10. Disability income benefits vary from one plan to another, but short-term disability is usually: a. up to 6 weeks b. 6 weeks to 24 months c. 13 weeks to 24 months d. 24 weeks to 24 months ANS: C

DIF: Moderate

REF: 191

OBJ: 2

11. Which two programs managed by the Social Security Administration pay monthly disability

benefits to people younger than age 65 who cannot work for at least a year because of a severe disability? a. CCRS and FERS b. Armed Services Disability and Veterans Affairs (VA) disability program c. SSDI and SSI d. SSI and FERS ANS: C

DIF: Hard

REF: 191

OBJ: 4

12. The Supplemental Security Income (SSI) program under Title XVI of the Social Security Act

provides a. monthly income benefits to workers and those self-employed who meet certain conditions. b. disability payments to needy people with limited income and few resources. c. for those who have worked for Civil Service and who become totally disabled. d. income for those injured on the job.

ANS: B

DIF: Hard

REF: 191

OBJ: 5

13. What is the correct order in the appeals process? a. Reconsideration, hearing, review by the Appeals Council, review by the federal

court b. Hearing, reconsideration, review by the Appeals Council, review by the federal

court c. Review by the Appeals Council, reconsideration, hearing, review by the federal

court d. Review by the Appeals Council, review by the federal court, hearing, reconsideration ANS: A

DIF: Hard

REF: 192

OBJ: 5

14. The Armed Services Disability benefits program is available to a. anyone who has served in the armed services. b. anyone who has served during a time of war. c. all civilian and military personnel. d. members of the armed services on active duty.

ANS: D

DIF: Moderate

REF: 193

OBJ: 6

15. What is the time limit for a veteran to file a claim to receive outpatient treatment at VA

expense for a service-connected disability? a. Within 6 months of sustaining the injury b. Within 1 year of sustaining the injury c. Within 3 years of sustaining the injury d. Within 18 months of receiving an honorable discharge ANS: B

DIF: Easy

REF: 193

OBJ: 6

16. The first state to provide a successful State Disability Insurance program was a. Alabama. b. California. c. Iowa. d. Rhode Island.

ANS: D

DIF: Easy

REF: 195

OBJ: 7

17. State Disability Insurance (SDI) is also known as a. Unemployment Compensation Disability (UCD). b. Temporary disability insurance (TDI). c. Social Security Disability Insurance (SSDI). d. Unemployment Compensation Disability (UCD) and temporary disability

insurance (TDI).

ANS: D

DIF: Moderate

REF: 195

OBJ: 8

18. Funding for State Disability Insurance is usually a small percentage of the employee’s wage

that a. b. c. d.

is deducted from employees’ paychecks each month. the employer may elect to pay a portion of. the employer may elect to pay as a fringe benefit. all are correct.

ANS: D

DIF: Hard

REF: 195

OBJ: 8

19. State Disability Insurance benefits begin after the a. third consecutive day of disability. b. fifth consecutive day of disability. c. seventh consecutive day of disability. d. tenth consecutive day of disability.

ANS: C

DIF: Moderate

REF: 195

OBJ: 8

20. Persons under a voluntary insurance plan who become ill or disabled will receive a fixed or

monthly income for approximately a. 3 months. b. 6 months. c. 12 months. d. 24 months.

ANS: B

DIF:

TEEasSy TBANKSRE L:LE EF 19R6.COM

OBJ: 9

COMPLETION 1. For a disability income insurance case, the time period from the beginning of disability to

receiving the first payment of benefits is called a/an

period.

ANS:

elimination waiting DIF: Moderate

REF: 190

OBJ: 2

2. In regard to disability income insurance, the

period is the maximum amount of time for which benefits will be paid to the injured or ill person for a disability.

ANS: benefit DIF: Moderate

REF: 190

OBJ: 2

3. In a life insurance policy, a feature that provides for twice the face amount of the policy to be

paid if death results from accidental causes is called

.

ANS: double indemnity DIF: Moderate

REF: 190

OBJ: 2

4. In an insurance contract, a/an

of premiums means that while disabled the employee does not have to pay any premiums because they are paid by the policy.

ANS: waiver DIF: Moderate

REF: 191

OBJ: 2

5. A

team composed of a physician/psychologist and disability examiner makes the determination regarding disability for the SSDI and SSI programs.

ANS:

Disability Determination Services (DDS) Disability Determination Services DDS DIF: Moderate

REF: 192

OBJ: 2

6. If a claimant does not agree with the determination of disability, a

-level appeal process is available.

ANS: four DIF: Moderate

REF: 192

OBJ: 2

7. The number of years of service required before benefits can be paid under CSRS is

.

ANS: five DIF: Hard

REF: 193

OBJ: 3

8. The physician must obtain prior authorization from the nearest VA facility in disability cases

if the treatment costs more than

per month.

ANS: $40 DIF: Moderate

REF: 193

OBJ: 6

9. If the validity of a State Disability Insurance case is in question, a/an

may be asked by the insurance company to examine the disabled individual.

ANS:

independent medical examiner (IME) independent medical examiner

IME DIF: Moderate

REF: 196

OBJ: 8

10. People residing in states that do not provide State Disability Insurance may elect to contact a

local private insurance carrier to arrange for coverage under a/an disability insurance plan.

ANS: voluntary DIF: Moderate

REF: 196

OBJ: 9

SHORT ANSWER 1. What are six major government disability programs?

ANS:

SSDI, SSI, CSRS, FERS, Veterans Affairs (VA) disability program, and Armed Services Disability DIF: Moderate

REF: 191

OBJ: 3

2. Which two programs managed by the Social Security Administration pay disability benefits to

people younger than 65?

ANS:

Social Security Disability ITnE suSraTnB ceA(NSK SD em SIE) LanLdESRu.ppClO Mental Security Income (SSI) DIF: Moderate

REF: 191

OBJ: 4

3. What are the four levels of the appeal process used if disagreement with determination of

disability occurs?

ANS:

Reconsideration, hearing, review by the Appeals Council, and review by the federal court DIF: Hard

REF: 192

OBJ: 5

4. Who are the eight types of workers not covered by state disability?

ANS:

School district employees, community college employees, church employees, state workers, federal employees, interstate employees, non-profit organization employees, and domestic workers DIF: Hard

REF: 195

OBJ: 8

TRUE/FALSE 1. Disability income policies do not provide medical expense benefits.

ANS: T

DIF: Easy

REF: 190

OBJ: 2

2. Disability income insurance provides benefits for work-related disability.

ANS: F

DIF: Easy

REF: 190

OBJ: 2

3. A disabled individual is eligible to receive benefits from the beginning of disability.

ANS: F

DIF: Easy

REF: 190

OBJ: 2

4. The definition of total disability varies from policy to policy because there is no standard

definition.

ANS: T

DIF: Easy

REF: 190

OBJ: 2

5. Temporary disability exists when an illness or injury prevents a person from performing one

or more of the functions of his or her regular job.

ANS: F

DIF: Easy

REF: 191

OBJ: 2

6. Disability insurance may be denied or may only provide limited coverage if the individual

was injured while legally intoxicated.

ANS: T

DIF: Moderate

REF: 191

OBJ: 2

7. When an employer provides disability income insurance and the employee leaves the

company, the insurance terminates unless the employee is disabled.

ANS: T

DIF: Moderate

REF: 191

OBJ: 3

8. Medical requirements are the same for both the SSDI and SSI programs.

ANS: T

DIF: Moderate

REF: 191

OBJ: 4

9. Disabled workers younger than 65 years of age are eligible for SSDI. ANS: T

DIF: Moderate

REF: 191

OBJ: 5

10. No prior employment is necessary for SSDI eligibility.

ANS: F

DIF: Moderate

REF: 192

OBJ: 5

11. The amount of disability benefit paid to an individual will depend upon the worker’s past

earning records.

ANS: T

DIF: Moderate

REF: 192

OBJ: 5

12. For people trying to qualify for SSDI or SSI, determination is made by the physician.

ANS: F

DIF: Moderate

REF: 192

OBJ: 5

13. The Civil Service Retirement System (CSRS) is a program that combines federal disability

and Social Security disability.

ANS: T

DIF: Easy

REF: 193

OBJ: 3

14. For patients receiving VA medical care, travel expenses to and from the facility are a benefit.

ANS: T

DIF: Moderate

REF: 193

OBJ: 6

15. Non-industrial disability insurance programs exist in only five states and Puerto Rico.

ANS: T

DIF: Moderate

REF: 195

OBJ: 7

16. If a state has State Disability Insurance, all types of workers are covered.

ANS: F

DIF: Moderate

REF: 195

OBJ: 8

17. After a state disability claim is approved, basic benefits become payable on the eighth day of

disability or the third day of hospital confinement, whichever comes first.

ANS: F

DIF: Hard

REF: 195

OBJ: 8

18. California allows for state disability benefits in a normal routine pregnancy.

ANS: T

DIF: Hard

REF: 196

OBJ: 7

19. A reason for denial of disability income benefits is insufficient medical information.

ANS: T

DIF: Moderate

REF: 197

OBJ: 11

20. One of the most important items on a state disability claim form is the claimant’s Social

Security number.

ANS: T

DIF: Moderate

REF: 197

OBJ: 11

Chapter 11: Medical Documentation and the Electronic Health Record Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. The key to substantiating procedure and diagnostic code selections for proper reimbursement

is a. b. c. d.

the information on the daysheet. supporting documentation in the electronic health record. the data on the patient’s information sheet. the data checked off on the patient’s encounter form.

ANS: B

DIF: Moderate

REF: 203

OBJ: 1

2. An advantage of electronic medical records is a. increased confidentiality and security. b. ease in learning and using the technology. c. low start-up costs. d. greater standardization in clinical medical terminology.

ANS: D

DIF: Moderate

REF: 204

OBJ: 2

3. When each entry in the medical record is worded similar to the previous entries, this is

considered a. correct documentation. b. current documentation. c. cloned documentation. d. legal documentation.

ANS: C

DIF: Moderate

REF: 204

OBJ: 2

4. Reasons for documentation include a. defense of a professional liability claim. b. insurance carriers require accurate documentation that supports procedure and

diagnostic codes. c. both defense of a professional liability claim and insurance carriers require

accurate documentation that supports procedure and diagnostic codes. d. none are correct.

ANS: C

DIF: Moderate

REF: 206

OBJ: 4 | 7

5. The SOAP in patient medical record charting may be defined as a. S—symptoms, O—observations, A—actual findings, P—procedures. b. S—subjective, O—objective, A—assessment, P—plan. c. S—signs, O—observations, A—auscultation, P—percussion. d. S—standardized, O—original, A—assessment, P—plan.

ANS: B

DIF: Moderate

REF: 218

OBJ: 7

6. When a patient fails to return for needed treatment, documentation should be made a. in the patient’s medical record.

b. in the appointment book. c. on the financial record or ledger card. d. all are correct.

ANS: D

DIF: Moderate

REF: 219

OBJ: 7

7. How should an entry in a patient’s electronic medical record be corrected? a. Input a note of which section is in error and enter correct data with details of why

the correction is necessary and authenticate with electronic signature, date, and time. b. Key over the incorrect entry, substitute the correct information, date, and electronically initial the entry. c. Delete the incorrect entry, substitute the correct information, date, and electronically initial the entry. d. Substitute the correct information by inserting an amendment keyed over the incorrect information.

ANS: A

DIF: Moderate

REF: 219

OBJ: 2 | 7

8. A concise statement describing the symptom, problem, condition, diagnosis,

physician-recommended return, or other factor that is the reason for the encounter is abbreviated as a. CC. b. HPI. c. ROS. d. PFSH. ANS: A

DIF:

EF 22R0.COM THEarSdTBANKSRE L:LE

OBJ: 8

9. A diseased condition or state is known as a. pathology. b. morbidity. c. mortality. d. complication.

ANS: B

DIF: Moderate

REF: 224

OBJ: 9

10. What does comorbidity mean? a. The act of identifying a disease from its signs and symptoms b. A forecast of the course of a disease c. Underlying diseases or other conditions present at the time of the visit d. Continuity of care ANS: C

DIF: Hard

REF: 226

OBJ: 9

11. A new patient is one who a. has not received any professional services from another physician of the same

specialty within the past 4 years. b. has not received any professional services from a physician who belongs to a group practice within the past 2 years. c. has not received any professional services from the physician within the past 3 years.

d. has not received any professional services from the physician within the past 5

years.

ANS: C

DIF: Moderate

REF: 209

OBJ: 9

12. In dealing with managed care plans, a referral is a. the same as a consultation. b. the transfer of the total or specific care of a patient from one physician to another. c. the term used when requesting an authorization for the patient to receive services

elsewhere. d. the transfer of the total or specific care of a patient from one physician to another

and the term used when requesting an authorization for the patient to receive services elsewhere.

ANS: D

DIF: Hard

REF: 210

OBJ: 9

13. The official American Hospital Association policy states, “Abbreviations should be totally

eliminated from the more vital sections of the record, such as the” a. final diagnosis. b. operative notes. c. discharge summaries. d. all are correct.

ANS: D

DIF: Moderate

REF: 211

OBJ: 7

14. Preservation of health records is governed by a. federal law. b. state law. c. local law. d. both state law and local law.

ANS: D

DIF: Moderate

REF: 216

OBJ: 13

COMPLETION 1. Incentive programs for adoption of EHR will transition into

for those who

do not adopt HER over the next several years in the form of adjustments.

ANS: disincentives DIF: Moderate 2.

REF: 204

OBJ: 3

is a term used to define those providers or hospitals that have the capabilities and processes in place to actively use certified electronic health record technology.

ANS:

Meaningful use (MU) Meaningful use MU DIF: Moderate

REF: 204

OBJ: 4

3. It is the responsibility of the

to handwrite or dictate the

documentation for medical transcription.

ANS: physician provider DIF: Easy

REF: 205

OBJ: 7

4. If a professional liability claim is filed by a patient, good

helps

establish a strong defense.

ANS: documentation DIF: Hard

REF: 215

OBJ: 12

5. Criteria used by insurance companies when making decisions to limit or deny payment in

which medical services or procedures must be justified by the patient’s symptoms and diagnosis are called .

ANS: medical necessity DIF: Hard

REF: 206

OBJ: 7 | 8

6. Most insurance companies perform routine

on practices with

unusual billing patterns or excessive payment amounts.

ANS: audits DIF: Moderate

REF: 207

OBJ: 11

7. A statement describing symptoms and problems as a reason for the office visit is known as the

patient’s

.

ANS: chief complaint DIF: Moderate

REF: 220

OBJ: 7

8. The abbreviation HPI stands for

.

ANS: history of present illness DIF: Moderate

REF: 220

OBJ: 7

9. An inventory of body systems obtained through a series of questions that are used to identify

signs and/or symptoms of the patient is known as a/an

.

ANS: review of systems DIF: Moderate

REF: 220

10. PFSH is the abbreviation for

OBJ: 7

.

ANS: past family and social history DIF: Moderate

REF: 220

OBJ: 7

11. The documentation of the patient’s previous experiences with illnesses, operations, injuries,

and treatments is known as the

.

ANS: past history DIF: Easy

REF: 222

OBJ: 7

12. Review of medical events in the patient’s family, including diseases that may be hereditary, is

known as a/an

.

ANS: family history DIF: Easy

REF: 222

OBJ: 7

13. An age-appropriate review of past and current activities of the patient (e.g., smoking or use of

alcohol) is known as a/an

.

ANS: social history DIF: Easy

REF: 222

OBJ: 7

14. If you are in doubt about the documentation in any health record, to obtain the most specific

and accurate terminology, you should

the physician.

ANS: query DIF: Moderate

REF: 205

OBJ: 9

15. A disease that runs a short but relatively severe course is referred to as

.

ANS: acute DIF: Moderate

REF: 210

16. The term

OBJ: 9

refers to a disease that persists over a long time.

ANS: chronic DIF: Moderate

REF: 211

OBJ: 9

17. An internal review known as a

is done after billing

insurance carriers.

ANS: retrospective review DIF: Moderate

REF: 211

OBJ: 11

MATCHING

Match these types of physicians with the description of the services each provides. a. Attending physician b. Consulting physician c. Ordering physician d. Referring physician e. Treating or performing physician 1. Provider who sends the patient for tests or treatment.

2. Provider whose opinion is requested by another physician about evaluation and management

of a specific problem.

3. Provider who is the medical staff member legally responsible for the care and treatment given

to a patient.

4. Individual who directs the selection, preparation, or administration of tests, medications, or treatment.

5. Provider who renders a service to a patient.

1. ANS: 2. ANS: 3. ANS: 4. ANS: 5. ANS:

D B A C E

DIF: DIF: DIF: DIF: DIF:

Moderate Moderate Moderate Moderate Moderate

REF: REF: REF: REF: REF:

205 205 205 205 205

OBJ: OBJ: OBJ: OBJ: OBJ:

5 5 5 5 5

Match each of these terms, as they are used in a medical office, with the correct definition. a. b. c. d. e. f. g. h.

6.

7.

8.

9.

10.

11.

12.

13.

Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms

Situation associated with the pain/symptom.

Area of the body in which the symptom is occurring.

When the pain/symptom occurs.

Character of the symptom/pain (burning, gnawing).

How long the symptom/pain has been present and how long it lasts when the patient has it.

Symptom/pain and other changes that are noted when the symptom/pain occurs.

Degree of symptom and/or pain on a scale from 1 to 10.

Things done to make the symptom/pain worse or better.

6. ANS: F 7. ANS: A 8. ANS: E 9. ANS: B 10. ANS: D

DIF: DIF: DIF: DIF: DIF:

Hard Moderate Moderate Moderate Moderate

REF: REF: REF: REF: REF:

220 220 220 220 220

OBJ: OBJ: OBJ: OBJ: OBJ:

9 9 9 9 9

11. ANS: H 12. ANS: C 13. ANS: G

DIF: Moderate DIF: Moderate DIF: Moderate

REF: 221 REF: 220 REF: 221

OBJ: 9 OBJ: 9 OBJ: 9

Match each of these types of medical services to the correct definition. a. Concurrent care b. Consultation c. Continuity of care d. Counseling e. Critical care f. Emergency g. Referral 14. Services rendered by a physician whose opinion is requested by another physician for 15.

16.

17.

18.

19.

20.

evaluating a patient’s illness.

Transfer of the total care of a patient from one physician to another.

Providing similar services to the same patient by more than one physician on the same day.

Providing treatment for a patient and subsequent referral by the treating physician to another physician for treatment of the same condition.

Discussion with a patient, family, or both about diagnostic results and instructions for treatment.

Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician.

Care provided during a life-threatening condition in the hospital emergency department.

14. ANS: B 15. ANS: G 16. ANS: A 17. ANS: C 18. ANS: D 19. ANS: E 20. ANS: F

DIF: Moderate REF: 210 T E S T B ANKS L:LE RE EF 21R0.COM DIF: Moderate DIF: Moderate REF: 210 DIF: Moderate REF: 210 DIF: Moderate REF: 210 DIF: Moderate REF: 210 DIF: Moderate REF: 210

OBJ: 9 OBJ: 9 OBJ: 9 OBJ: 9 OBJ: 9 OBJ: 9 OBJ: 9

SHORT ANSWER 1. Explain the methods for disposing of both paper and electronic records.

ANS:

Paper records are usually shredded.

Electronic records stored on CD-ROMs, floppy disks, or flash drives may be disposed of through physical destruction such as burning, shredding, degaussing, or zeroization programs.

DIF: Easy

REF: 217

OBJ: 14

2. Identify three ways that a physician may withdraw formally from further provision of care to a

patient when the patient is non-compliant.

ANS:

(1) Send a letter of withdrawal by certified mail, (2) send a letter of confirmation of discharge when the patient states that he or she no longer desires care, and (3) send a letter confirming that the patient did not follow the advice of the physician.

DIF: Moderate

REF: 208

OBJ: 15

TRUE/FALSE 1. The key to substantiating procedure and diagnostic code selections for appropriate

reimbursement is a supporting electronic health record.

ANS: T

DIF: Easy

REF: 203

OBJ: 2

2. Private insurance carriers have the right to claim refunds in the event of accidental miscoding.

ANS: T

DIF: Moderate

REF: 220

OBJ: 7

REF: 210

OBJ: 9

3. A referral is the same as a consultation.

ANS: F

DIF: Moderate

4. The acceptance of a subpoena by an authorized person is the equivalent of a subpoena being

served personally.

ANS: T

DIF: Hard

REF: 215

OBJ: 13

Chapter 12: Diagnostic Coding Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Diagnostic codes on an insurance claim explain a. the patient’s condition that was treated during the visit. b. the professional services provided during the visit. c. the supplies that were provided to the patient. d. the provider’s identification.

ANS: A

DIF: Easy

REF: 232

OBJ: 1

2. What is the consequence when a medical practice does not use diagnostic codes? a. It affects the physician’s level of reimbursement for inpatient claims. b. Claims can be denied. c. Fines or penalties can be levied. d. All are correct.

ANS: D

DIF: Moderate

REF: 232

OBJ: 2

3. Diagnoses that relate to a patient’s previous medical problem and that have no bearing on the

patient’s present condition should be when coding. a. handled according to specific insurance guidelines b. included c. excluded d. disclosed ANS: C

DIF: Hard

REF: 232

OBJ: 3

4. Why is the correct sequence of codes on an insurance claim important? a. To make the chronology of patient care events understood. b. To make the severity of disease understood. c. It is not important as long as the correct indicator is used for each line of service. d. To make the chronology of patient care events understood and to make the severity

of disease understood.

ANS: D

DIF: Moderate

REF: 232

OBJ: 3

5. The diagnosis listed first in submitting insurance claims for patients seen in a physician’s

office is the a. principal diagnosis. b. primary diagnosis. c. secondary diagnosis. d. patient’s presenting complaint.

ANS: B

DIF: Hard

REF: 232

OBJ: 3

6. The diagnosis obtained following review of studies for the condition that prompted inpatient

hospitalization is the a. secondary diagnosis.

b. principal diagnosis. c. primary diagnosis. d. procedure diagnosis.

ANS: B

DIF: Hard

REF: 232

OBJ: 3

7. The International Classification of Diseases, Tenth Revision, Clinical Modification

(ICD-10-CM), was published by the World Health Organization in a. 1986. b. 1992. c. 2001. d. 2009.

ANS: B

DIF: Moderate

REF: 233

OBJ: 5

8. In locating a diagnosis, look up the main term, which is the a. disease. b. anatomic part. c. injury. d. disease and injury.

ANS: D

DIF: Moderate

REF: 236

OBJ: 10

9. The first three characters of an ICD-10-CM code are composed as a. Character 1 (alpha), Character 2 (numeric), Character 3 (numeric). b. Character 1 (alpha character), Character 2 (alpha), Character 3 (numeric). c. Character 1 (numeric), Character 2 (numeric), Character 3 (alpha). d. Character 1 (numeric),TCEhS arT acBteArN2K(aSlpEhLa)L, E CR ha.raCcO teM r 3 (alpha).

ANS: A

DIF: Moderate

REF: 236

OBJ: 9

10. The sixth character of an ICD-10-CM code can signify a. etiology. b. anatomic site. c. severity. d. trimester of pregnancy.

ANS: D

DIF: Moderate

REF: 237

OBJ: 9

11. In ICD-10-CM, a placeholder for future code expansion is shown as a. X character. b. O character. c. (underline symbol). d. ? symbol.

ANS: A

DIF: Easy

REF: 237

OBJ: 9

12. In ICD-10-CM, a code with a fourth digit 9 or fifth digit 0 for diagnosis codes means a. data in the medical record are specified. b. information in the health record is unspecified. c. data in the medical record show right side is affected. d. information in the medical record shows left side is involved.

ANS: B

DIF: Moderate

REF: 238

OBJ: 9

13. Terms enclosed in parentheses following the main term are referred to as a. non-essential modifiers. b. essential modifiers. c. exclusions. d. fifth digits.

ANS: A

DIF: Hard

REF: 240

OBJ: 9

14. Codes that are used principally by tumor or cancer registries are a. neoplasm codes. b. default codes. c. morphology codes. d. manifestation codes.

ANS: A

DIF: Moderate

REF: 244

OBJ: 11

15. Which of the following is the correct order of steps to take in ICD-10-CM coding? a. Locate the main term in the Alphabetic Index, verify the code in the Tabular List,

read any instructions in the Tabular List, check for exclusion notes, and assign the code. b. Locate the main term in the Tabular List, verify the code in the Alphabetic Index, read any instructions in the Alphabetic Index, and assign the code. c. Locate the diagnosis by the adjective in the Alphabetic Index, verify the code in the Tabular List, and assign the code. d. Locate the diagnosis by the main term in the Alphabetic Index, read any instructions pertaining T toEtS heTtB erAmN, K anSdEaL ssLigEnRth.eCcO odMe. ANS: A

DIF: Moderate

REF: 241

OBJ: 7

16. Codes that describe symptoms and signs are acceptable for reporting purposes a. any time they are documented. b. when a definitive diagnosis has not been established. c. if the sign or symptom is an integral part of the disease process. d. under no circumstances.

ANS: B

DIF: Moderate

REF: 241

OBJ: 10

17. Combination codes are a single code used to report a. two diagnoses. b. a diagnosis with an associated manifestation. c. a diagnosis with an associated complication. d. all are correct.

ANS: D

DIF: Moderate

REF: 243

OBJ: 9

18. Diagnosis codes for body mass index (BMI) reported by a clinician who is not the patient’s

provider in the medical record must be accompanied by a. an associated diagnosis such as obesity by the clinician. b. an associated diagnosis such as obesity by the patient’s provider. c. the patient’s weight record.

d. the attending physician’s attestation of BMI with signature.

ANS: B

DIF: Moderate

REF: 243

OBJ: 3

19. Asymptomatic HIV infection status is reported as a. B20. b. B21. c. Z11.4. d. Z21.

ANS: D

DIF: Moderate

REF: 241

OBJ: 11

20. Which statement is true regarding neoplasms? a. They are new growths. b. They may be malignant. c. They may be benign. d. All are correct.

ANS: D

DIF: Moderate

REF: 244

OBJ: 11

21. Carcinoma in situ is used to describe a. metastatic cancer. b. a secondary tumor. c. cancer that is confined to the site of origin. d. none are correct.

ANS: C

DIF: Hard

REF: 244

OBJ: 11

TBusAeNoKf S 22. Diagnosis code Z79.4 (lonT g-E teSrm inE suLliL n)EiR s. usCeO dM to describe a. the patient who routinely takes insulin. b. the patient who has taken insulin for more than 2 years. c. the patient who has taken insulin for more than 10 years. d. any patient who takes insulin, even on a temporary basis.

ANS: A

DIF: Moderate

REF: 245

OBJ: 11

23. What is the table that contains a classification of substances for identifying poisoning states

and external causes of adverse effects? a. Table of Drugs and Chemicals b. Table of Neoplasms c. Table of Hypertension d. Table of Morphology ANS: A

DIF: Easy

REF: 248

OBJ: 9

24. External cause codes are used a. when a person who is not currently sick encounters health services for some

specific purpose. b. to show cause of injury. c. to code neoplasms. d. to code hypertension.

ANS: B

DIF: Moderate

REF: 249

OBJ: 11

25. Which of the following is NOT a reason why medical practices have adopted

computer-assisted coding? a. Shortage of coders b. Adoption of electronic health records c. Constant changes in code numbers and rules d. Future elimination of coding staff ANS: D

DIF: Easy

REF: 253

OBJ: 6

COMPLETION 1. A working knowledge of

and a course in anatomy and physiology are essential to becoming a top-notch coder of diagnoses.

ANS: medical terminology DIF: Moderate

REF: 232

2. ICD-10-CM classifies

OBJ: 1

and

information for statistical purposes.

ANS:

morbidity; mortality morbidity mortality mortality, morbidity mortality morbidity morbidity, mortality mortalit;y morbidity DIF: Moderate

REF: 233

OBJ: 5

3. Annual updates to the ICD-10-CM coding system are published in the

,

by the US Government Printing Office.

ANS: Federal Register DIF: Moderate

REF: 233

OBJ: 5

4. A term used as the name of a disease, structure, operation, or procedure, usually derived from

the name of a place or a person who discovered or described it first, is called a/an ANS: eponym DIF: Moderate

REF: 236

OBJ: 9

5. Symbols, punctuation marks, indentations, and other similar rules for determining the

appropriate diagnosis code are referred to as ANS: conventions DIF: Easy

REF: 238

OBJ: 9

.

.

6. Alphabetic Index entries with the acronym

indicate that there is no further classification

of the disease in ICD-10-CM. ANS: NEC DIF: Moderate

REF: 238

OBJ: 8

7. The convention

_ used after a code indicates the need to report another code in the same sequence as indicated in the index.

ANS:

[ ] (Slanted brackets) [] Slanted brackets DIF: Moderate

REF: 238-239

OBJ: 9

8. Certain codes that should never be reported at the same time are indicated by the convention

.

ANS: excludes 1 DIF: Moderate

REF: 240

OBJ: 9

9. Always code to the highest level of

.

ANS: specificity DIF: Easy

REF: 241

OBJ: 2

10. When a neoplasm has been analyzed by the pathologist but has not been confirmed as benign

or malignant, it would be coded from the column labeled

.

ANS: uncertain behavior DIF: Hard

REF: 245

OBJ: 11

11. When coding multiple injuries, the diagnosis for the conditions treated should be sequenced in

the order of _

.

ANS:

importance/severity importance severity DIF: Moderate

REF: 247

OBJ: 3

SHORT ANSWER 1. Provide the appropriate ICD-10-CM code for eczematous dermatitis.

ANS:

L30.9 DIF: Hard

REF: N/A

OBJ: 11

2. Provide the appropriate ICD-10-CM code for bursitis of the elbow.

ANS:

M70.30 DIF: Hard

REF: N/A

OBJ: 11

3. Provide the appropriate ICD-10-CM code for a cellulitis of the anus.

ANS:

K61.0 DIF: Hard

REF: N/A

OBJ: 10

4. How should an insurance billing specialist list the diagnostic codes on an insurance form

when a specific condition is stated as both acute and chronic?

ANS:

Sequence the acute first DIF: Hard

REF: 242

OBJ: 3

5. A 67-year-old man consults the physician because of his concern over symptoms of weight

loss and hemoptysis. The impression is “rule out bronchogenic carcinoma.” The patient is referred to another physician for bronchoscopy. What ICD-10-CM code(s) will the office of the physician who initially examined the patient list on the insurance claim form?

ANS:

R04.2 hemoptysis, R63.4 abnormal weight loss.

DIF: Hard

REF: 242

OBJ: 10

6. A patient was seen for a fever of unknown origin. List the appropriate ICD-10-CM code(s) for

this condition.

ANS:

R50.9 fever of unknown origin (FUO) DIF: Hard

REF: N/A

OBJ: 10

7. List the ICD-10-CM code(s) for a patient with glaucoma with recurrent iridocyclitis.

ANS:

H40.46 glaucoma secondary to eye inflammation unspecified eye, H20.029 recurrent acute iridocyclitis, unspecified eye.

DIF: Hard

REF: N/A

OBJ: 10

8. A patient was diagnosed with diverticulosis and diverticulitis of the colon. List the appropriate

ICD-10-CM code(s) for these conditions.

ANS:

K57.30 diverticulosis of large intestine without perforation or abscess without bleeding.

DIF: Hard

REF: N/A

OBJ: 10

9. Where does the Alphabetic Index of the ICD-10-CM coding manual instruct the coder to go

when looking up the condition leiomyosarcoma?

ANS:

See also neoplasm, connective tissue malignant DIF: Hard

REF: N/A

OBJ: 8

10. List the ICD-10-CM code(s) for a patient seen in the medical facility with diabetic retinopathy

(insulin-dependent, not stated as uncontrolled) with retinal detachment.

ANS:

E13.319 other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema, H35.9 unspecified retinal disorder, H33.20 serous retinal, detachment, unspecified eye.

DIF: Hard

REF: N/A

OBJ: 10

11. What ICD-10-CM code would be reported on the insurance claim form for an old myocardial

infarction that is healed?

ANS:

I25.2 (old myocardial infarction, healed) DIF: Hard

REF: N/A

OBJ: 10

12. A patient is seen in the emergency department with arteriosclerotic cardiovascular disease

with congestive heart failure. List the ICD-10-CM code(s) required for these two conditions.

ANS:

I25.10 atherosclerotic heart disease and I50.9 heart failure (congestive heart failure NOS).

DIF: Hard

REF: N/A

OBJ: 10

Chapter 13: Procedural Coding Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. What is the name of the book used in the physician’s office to code procedures? a. Clinical Procedure Terminology (CPT) b. Current Procedural Terminology (CPT) c. International Classification of Diseases, Tenth Revision, Clinical Modifications

(ICD-10-CM) d. Systematized Nomenclature of Human and Veterinary Medicine (SNOMED International) ANS: B

DIF: Moderate

REF: 256

OBJ: 2

2. The CPT publication is updated and revised a. annually. b. biannually. c. every 3 years. d. every 5 years.

ANS: A

DIF: Moderate

REF: 256

OBJ: 2

3. What is the name of the book that contains a coded listing of procedures with unit values that

indicate the relative value of various services? a. ICD-10-CM b. CPT c. RVS d. HCPCS ANS: C

DIF: Moderate

REF: 281

OBJ: 5

4. The resource-based relative value scale (RBRVS) was developed for a. the Centers for Medicare and Medicaid Services. b. Blue Cross and Blue Shield. c. managed care organizations. d. workers’ compensation insurance plans.

ANS: A

DIF: Hard

REF: 282

OBJ: 5

5. The key components that determine an evaluation and management code are documented by a. the medical assistant. b. the physician. c. the insurance billing specialist. d. none are correct.

ANS: B

DIF: Moderate

REF: 262

OBJ: 7

6. The surgical package for non-Medicare cases includes the a. operation, local infiltration, digital block or topical anesthesia, and normal

uncomplicated postoperative care.

b. preoperative visit, operation, local infiltration, digital block or topical anesthesia,

and normal uncomplicated postoperative care. c. operation, local infiltration, digital block or topical anesthesia, and all

postoperative care. d. operation, local infiltration, digital block or topical anesthesia, and normal

uncomplicated postoperative care occurring outside the hospital.

ANS: B

DIF: Hard

REF: 268

OBJ: 9

7. Included in a global surgery policy and a surgical package is/are a. postoperative visits in and out of the hospital. b. digital block or topical anesthesia. c. preoperative visit and complications after surgery. d. both postoperative visits in and out of the hospital and digital block or topical

anesthesia.

ANS: D

DIF: Hard

REF: 268

OBJ: 9

8. The largest section in the CPT book is the a. surgery section. b. musculoskeletal section. c. evaluation and management section. d. medicine section.

ANS: A

DIF: Moderate

REF: 259

OBJ: 3

9. When a service is rendered that is not listed in the CPT codebook, a. list 00000 on the insuraTnE ceScTlaBim mE sL anLdEsR en.dC sO suM pporting documentation that ANfoKrS

clearly identifies the procedure that was done.

b. write the description of service on the claim form in place of the code. c. you cannot bill for unlisted services. d. use a code with a description stating “unlisted.”

ANS: D

DIF: Moderate

REF: 262

OBJ: 3

10. What does bundling mean? a. When the code system used on a claim submitted to an insurance carrier does not

match the code system used by the company receiving the claim. b. Deliberate manipulation of CPT codes for increased payment. c. Coding and billing numerous CPT codes to identify procedures that are usually

described by a single code. d. Grouping codes that are related to a procedure.

ANS: D

DIF: Hard

REF: 279

OBJ: 11

COMPLETION 1. CPT uses a basic

physicians, plus ANS:

five; two

-digit system for coding services rendered by -digit add-on modifiers.

five, two five two DIF: Moderate

REF: 257

OBJ: 3

2. A listing of accepted charges or established allowances for specific medical procedures is

called a/an

.

ANS: fee schedule DIF: Moderate

REF: 280

OBJ: 5

3. Coding and billing numerous CPT codes to identify procedures that are usually described by a

single code is called

.

ANS: unbundling DIF: Hard

REF: 278

OBJ: 11

4. Deliberate manipulation of CPT codes for increased payment is called

.

ANS: upcoding DIF: Hard

REF: 280

OBJ: 11

SHORT ANSWER 1. A 46-year-old new patient is seen in an internal medicine office for a routine annual checkup.

The patient is asymptomatic, with no complaints. A comprehensive history is taken, and a comprehensive physical examination is performed. A chest x-ray (two views), an ECG, an automated urinalysis with microscopy, and an automated CBC with manual differential WBC count are obtained in the office. List the code(s) required to complete the Health Insurance Claim Form.

ANS:

99386, 71046, 93000, 36415, 81001, 85004 DIF: Hard

REF: N/A

OBJ: 11

2. A patient required arthroplasty of the tibial plateaus of both knees. Code this procedure for the

surgeon.

ANS:

27440, 27440-50 bilateral arthroplasty or 27440-LT and 27440-RT indicating left and right arthroplasty DIF: Hard

REF: N/A

OBJ: 11

3. Mrs. Burke is a 54-year-old patient seen by her physician for an annual routine physical

examination. She has no complaints or symptoms. A non-automated urinalysis with microscopy and bilateral screening mammography were done. Code for the office visit, urinalysis, and mammography.

ANS:

99396, 81000, 77067 DIF: Hard

REF: N/A

OBJ: 11

4. A patient appears at an outpatient medical facility with extensive lacerations. Simple repair of

wounds measuring 2.5, 4.6, and 3.5 cm on the hands, along with complex repair of a 1.5-cm wound on the nose and intermediate repair of wounds measuring 7.3 and 4.6 cm on the scalp, are performed. List the code(s) required for the repairs.

ANS:

12004, 13151, 12034-51 DIF: Hard

REF: N/A

OBJ: 11

TRUE/FALSE 1. Some managed care plans develop “internal codes” for use by the plan only to code specific

procedures.

ANS: T

DIF: Easy

REF: 263

OBJ: 3

2. The Health care Common Procedure Coding System (HCPCS) consists of two levels of codes.

ANS: T

DIF: Easy

REF: 256

OBJ: 5

3. Some private insurance companies may or may not accept HCPCS codes.

ANS: T

DIF: Easy

REF: 257

OBJ: 5

4. A medical practice can have more than one fee schedule unless specific state laws restrict this

practice.

ANS: T

DIF: Moderate

REF: 280

OBJ: 5

5. UCR (usual, customary, reasonable) is used mostly in reference to managed care services.

ANS: F

DIF: Moderate

REF: 281

OBJ: 2

6. Private health insurance plans using the UCR system may pay a physician’s full charge if it

does not exceed UCR charges.

ANS: T

DIF: Hard

REF: 281

OBJ: 4

7. When a new CPT code is used, it may take as long as 6 months before an insurance company

has a mandatory value assignment.

ANS: T

DIF: Moderate

REF: 260

OBJ: 5

8. In coding a surgical procedure, postoperative care and follow-up visits may not be coded

separately if they fall within the global period for the procedure.

ANS: T

DIF: Hard

REF: 268

OBJ: 3

9. When there is a choice of two or three somewhat similar codes, the insurance claims examiner

will choose the highest-paying code.

ANS: F

DIF: Moderate

REF: 280

OBJ: 11

Chapter 14: The Paper Claim CMS-1500 Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. The CMS-1500 is known as the a. COMB-1. b. basic paper claim. c. attending physician’s statement. d. electronic claim.

ANS: B

DIF: Easy

REF: 290

OBJ: 2

2. ASCA required a. all claims sent to Medicaid be submitted electronically. b. all claims sent to Medicare be submitted electronically. c. all claims sent to Blue Shield plans be submitted electronically. d. All are correct.

ANS: B

DIF: Moderate

REF: 290

OBJ: 2

3. The uniform claim form task force was replaced by a. Health Care Financing Administration. b. Centers for Medicare and Medicaid Services. c. Health Insurance Association of America. d. National Uniform Claim Committee.

ANS: D

DIF: Moderate

REF: 291

OBJ: 2

4. When completing a claim form, if any question is unanswerable a. leave the space blank. b. use DNA (does not apply). c. use N/A (not applicable). d. use NA (not applicable).

ANS: A

DIF: Moderate

REF: 295

OBJ: 6

5. The appropriate method for entering the date of service (January 4, 2xxx) on a claim form is a. 1/4/xx. b. 01042xxx. c. 01-04-xx. d. 01 04 xx.

ANS: B

DIF: Moderate

REF: 295

OBJ: 6

6. Office visits may be grouped on the insurance claim form if each visit a. is consecutive and uses the same procedure code. b. is consecutive, uses the same procedure code, and results in the same fee. c. uses the same diagnosis code. d. occurs during the same month.

ANS: B

DIF: Moderate

REF: 295

OBJ: 12

7. The number issued to physicians by the Internal Revenue Service for income tax purposes is

known as a. TIN. b. PIN. c. UPIN. d. NPI. ANS: A

DIF: Easy

REF: 295

OBJ: 8

8. Which of the following is a lifetime 10-digit number issued to physicians that replace all other

numbers assigned by various health plans? a. TIN b. PIN c. UPIN d. NPI ANS: D

DIF: Moderate

REF: 295

OBJ: 8

9. OCR guidelines for the CMS-1500 claim form state a. it can be photocopied by the physician’s office to save the expense of buying huge

quantities. b. it can be submitted with handwritten information. c. it should not be photocopied because it cannot be scanned. d. enter all information in lowercase letters.

ANS: C

DIF: Hard

REF: 300

OBJ: 12

10.1 To conform to CMS-1500 OCR guidelines, 0 a. do not fold insurance claim forms when mailing. . b. do not use symbols with data on insurance claim forms. c. do not strike over errors when making a correction on an insurance claim form. d. All are correct.

ANS: D

DIF: Moderate

REF: 300-301

OBJ: 10

COMPLETION 1. The objective of the Administrative Simplification Compliance Act was to improve the

administration of the Medicare program by increased efficiencies resulting from .

ANS: electronic claim submissions DIF: Moderate

REF: 290

OBJ: 2

2. Health insurance specialists should be familiar with the paper claim, as there may be

occasions where the practice experiences technical claims electronically.

ANS: downtime

and is unable to submit

DIF: Moderate

REF: 291

OBJ: 1

3. The NUCC is charged with the task of

national instructions for completion of

the CMS-1500 claim form.

ANS: standardizing DIF: Moderate

REF: 291

OBJ: 2

4. The paper claim form was revised in 1990 and printed in red ink to allow

of claims.

ANS: optical scanning DIF: Moderate

REF: 291

OBJ: 2

5. The CMS-1500 paper claim can be purchased through a medical office supply company or

through the

.

ANS: AMA DIF: Easy

REF: 292

OBJ: 2

6. A claim that is submitted to the insurance carrier via Internet connection is referred to as

.

ANS: electronic DIF: Easy

REF: 292

7. A clean claim has no

OBJ: 3

and passes all electronic edits.

ANS: deficiencies DIF: Moderate

REF: 292

OBJ: 4

8. Abstraction of technical information from patient records may be necessary to support

medical

.

ANS: necessity DIF: Moderate

REF: 293

OBJ: 5

9. When submitting a letter to an insurance company to explain unusual circumstances that

should be considered when processing the claim, it should be sent to the attention of the .

ANS: claims supervisor DIF: Hard

REF: 293

OBJ: 5

10. When completing a claim form for a patient who has group insurance coverage, it is important

to complete all information regarding the patient’s

.

ANS: employer DIF: Hard

REF: 294

OBJ: 6

11. Copies of submitted claim forms should be maintained in a ticker file and followed up on

every

days.

ANS: 30 DIF: Moderate

REF: 297

OBJ: 12

MATCHING

Match the type of insurance claim with the correct description. a. Clean claim b. Dirty claim c. Electronic claim d. Incomplete claim e. Invalid claim f. Paper claim g. Pending claim h. Rejected claim An insurance claim that is T suEbS mTitB teA dN onKS paEpL erL , iE ncRl. udCinOgMoptically scanned claims.

A Medicare claim that is missing required information.

An insurance claim held in suspense due to review or other reason.

An insurance claim that requires investigation and needs further clarification.

An insurance claim that is submitted within the program or policy time limit and correctly completed.

6. An insurance claim that is submitted via a dial-up modem or direct data entry.

7. An insurance claim that is submitted with errors.

8. A Medicare claim that contains complete, necessary information but is illogical or incorrect.

1.

2.

3.

4.

5.

1. ANS: 2. ANS: 3. ANS: 4. ANS: 5. ANS: 6. ANS: 7. ANS: 8. ANS:

F D G H A C B E

DIF: DIF: DIF: DIF: DIF: DIF: DIF: DIF:

Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate

REF: REF: REF: REF: REF: REF: REF: REF:

290 292 292 292 292 290 292 292

OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ:

4 4 4 4 4 4 4 4

Match the reason that the insurance claim was rejected with the possible solution to the problem. a. Proofread numbers carefully from source documents. b. Check for Sr., Jr., correct birth date, and verify the insured.

c. Refer to an updated diagnostic codebook and review the patient record. d. Verify with the patient’s medical record that all dates of service are listed and

accurate. e. Verify that the place of service is correct for the submitted procedure code(s) and

fill in correct service code.

Refer to the current procedure codebooks and verify the coding system used by the insurance company. g. Verify and submit valid modifiers with the correct procedure codes for which they are valid. h. Total all charges on each claim, recheck the math, and verify amounts with the patient account. i. Obtain data from patient during the first office visit on which company is the primary insurer. j. Submit all attachments with patient’s name and insurance identification number. f.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Missing place of service code.

The insurance claim was submitted to the secondary instead of the primary insurer.

Patient’s name and insured’s name are entered as the same when the patient is a dependent.

The patient’s insurance number is incorrect.

Incorrect modifier.

Operative report is missing from the insurance claim.

Procedure code is invalid.

Diagnostic code is missing.

Total amounts do not equal itemized amounts charged.

Duplicate dates of service listed.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

ANS: E ANS: I ANS: B ANS: A ANS: G ANS: J ANS: F ANS: C ANS: H ANS: D

DIF: DIF: DIF: DIF: DIF: DIF: DIF: DIF: DIF: DIF:

Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate

REF: REF: REF: REF: REF: REF: REF: REF: REF: REF:

298 298 298 298 299 298 299 294 299 299

OBJ: 11 OBJ: 11 OBJ: 11 OBJ: 11 OBJ: 11 OBJ: 11 OBJ: 11 OBJ: 11 OBJ: 11 OBJ: 11

Chapter 15: The Electronic Claim Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Data that is made unintelligible to unauthorized parties is referred to as a. coded. b. decoded. c. encoded. d. encrypted.

ANS: D

DIF: Easy

REF: 337

OBJ: 1

2. Insurance claims transmitted electronically are usually paid in a. 1 day. b. 2 weeks or less. c. 3–4 weeks. d. 4–6 weeks.

ANS: B

DIF: Moderate

REF: 337

OBJ: 2

3. A clearinghouse is a/an a. regional office that “clears” the signal for electronic insurance claim transmission. b. entity that receives transmission of insurance claims, separates the claims, and

sends each one electronically to the correct insurance payer. c. corporation hired by the insurance company to review claims for payment.

ESthTaBt cAaNn KbeSpEuLrcLhEasRe. d. computer software systT em dC byOtMhe physician’s office for

electronic insurance claims transmission.

ANS: B

DIF: Hard

REF: 337

OBJ: 3

4. ASC X12 Version 5010 allows providers to submit claims a. with HCPCs codes, as needed. b. with CPT-4, Category II, and Category III codes. c. with ICD-10-CM/PCS codes. d. with NPI numbers for referring physicians.

ANS: C

DIF: Moderate

REF: 341

OBJ: 4

5. A transmission report which identifies the most common reasons for claim denial is the a. send and receive file reports. b. scrubber report. c. transaction transmission summary. d. rejection analysis report.

ANS: D

DIF: Easy

REF: 354

OBJ: 13

COMPLETION 1. The implementation of standard formats, procedures, and data content into the electronic data

interchange process is the result of

regulations.

ANS: HIPAA DIF: Moderate

REF: 337

OBJ: 1

2. One advantage of electronic claim submission is the ability to build a/an

which provides a chronologic record of submitted data that can be traced to the source to determine the place of origin.

ANS: audit trail DIF: Moderate

REF: 337

OBJ: 2

3. Medical data which are compiled and produced in the specific format used throughout the

health care industry and sent in electronic files are HIPAA

transactions.

ANS: standard DIF: Moderate

REF: 339

OBJ: 5

4. The three-digit standard transaction for transmission of the electronic claim is referred to in

the physician’s office as

.

ANS: 837P DIF: Easy

REF: 339

OBJ: 5

5. HIPAA requires employerT s tEoSoT btB aiA nNKSnEuL mLbE erR s. toCidOeMntify themselves during the process

of enrolling employees into a health plan.

ANS: employer identification DIF: Moderate 6.

REF: 347

OBJ: 7

allows third-party payers to deposit funds into the physician’s bank account automatically and eliminates the need for personal handling of checks.

ANS:

Electronic funds transfer (EFT) Electronic funds transfer EFT DIF: Moderate

REF: 352

OBJ: 16

7. An online transaction concerning the status of an insurance claim is called a/an ANS:

electronic remittance advice (ERA) electronic remittance advice ERA

.

DIF: Moderate

REF: 352

OBJ: 16

SHORT ANSWER 1. Name three advantages of using a clearinghouse to bill insurance companies.

ANS:

Translation of various formats to the HIPAA-compliant standard format; reduction in time of claims preparation; cost-effective method through loss prevention; fewer delays in processing and quicker response time; more accurate coding with claims edits; and consistent reimbursement DIF: Moderate

REF: 337

OBJ: 3

2. Why was the HIPAA Transaction Code Set developed?

ANS:

To introduce efficiencies into the health care system DIF: Moderate

REF: 338

OBJ: 4

3. What are medical code sets?

ANS:

Data elements used uniformly to document why patients are seen.

DIF: Moderate

REF: 338

J: 4 TESTBANKSOEBL LER.COM

4. Identify common claim attachments that provide additional medical information to a claims

processor.

ANS:

Certificate of Medical Necessity, discharge summaries, and operative reports.

DIF: Moderate

REF: 341

OBJ: 6

5. What is an encoder?

ANS:

Add-on software for a practice management system that can reduce the time it takes to build or review a claim before batching.

DIF: Moderate

REF: 351

OBJ: 10

6. List common electronic claim submission errors that have resulted from the upgrade to

Version 5010 of the electronic claims submission standards.

ANS:

Billing provider address, Zip code, anesthesia minutes, primary identification code qualifiers, billing provider ID number, and National drug code errors

DIF: Moderate

REF: 354

OBJ: 15

MATCHING

Match the frequency with which each of the procedures described below should be done with the word correctly describing that frequency. a. Daily b. Weekly c. End of month d. Daily or weekly 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Post payments in practice management system.

Note any problematic claims and resolve outstanding files.

Batch, scrub, edit, and transmit claims.

Review all claim rejection reports.

Audit claims batched and transmitted with confirmation reports.

Make follow-up calls to resolve reasons for rejections.

Review clearinghouse/payer transmission reports.

Correct rejections and resubmit claims.

Update practice management system with payer information.

Research unpaid claims.

1. ANS: A 2. ANS: B 3. ANS: D 4. ANS: C 5. ANS: A 6. ANS: B 7. ANS: A 8. ANS: A 9. ANS: C 10. ANS: B

DIF: Easy REF: 358 DIF: Moderate REF: 358 DIF: Moderate REF: 358 deTraBteANKS REF 35R8.COM DIF: TMEoS L:LE DIF: Moderate REF: 358 DIF: Moderate REF: 358 DIF: Moderate REF: 358 DIF: Moderate REF: 358 DIF: Moderate REF: 358 DIF: Moderate REF: 358

OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ: OBJ:

18 18 18 18 18 18 18 18 18 18

TRUE/FALSE 1. The exchange of data in a standardized format through computer systems is known as

electronic data interchange.

ANS: T

DIF: Easy

REF: 337

OBJ: 1

2. Encrypted data often look like gibberish to unauthorized users.

ANS: T

DIF: Easy

REF: 337

OBJ: 1

3. A disadvantage of electronic claim submission is more time spent processing claims, which

requires additional staffing.

ANS: F

DIF: Moderate

REF: 337

OBJ: 2

4. The objective of HIPAA Transaction and Code Set regulations was to standardize code sets,

claim forms, and processes used in health care facilities which would reduce administrative costs.

ANS: T

DIF: Moderate

REF: 337

OBJ: 4

5. Any provider who submits claims to Medicare is considered a covered entity.

ANS: F

DIF: Moderate

REF: 338

OBJ: 4

6. CPT, ICD-10, and HCPCS codes are referred to as medical code sets and are standardized

under HIPAA. ANS: T

DIF: Moderate

REF: 339

OBJ: 4

7. Certain data elements are required when submitting a HIPAA standard transaction, whereas

others are only necessary in specific situations.

ANS: T

DIF: Moderate

REF: 338

OBJ: 5

8. The American Medical Association (AMA) developed the standards for electronic data

exchange.

ANS: F

DIF: Moderate

REF: 341

OBJ: 6

9. The 837P is the National Standard Format for electronic claims submission by physicians,

which replaces the paper CMS-1500 form.

ANS: T

DIF: Moderate

REF: 341

OBJ: 5

10. For insurance claims to be submitted electronically, a signed agreement by the physician with

the carriers involved is necessary.

ANS: T

DIF: Easy

REF: 354

OBJ: 11

Chapter 16: Receiving Payments and Insurance Problem Solving Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Guidelines for claims submission, such as which services are covered, and reimbursement

rates is dictated by a. the insurance company. b. the health care provider. c. the insured. d. the insured’s employer.

ANS: A

DIF: Easy

REF: 363

OBJ: 1

2. If an insured is in disagreement with the insurer for settlement of a claim, a suit must begin

within a. 1 year. b. 2 years. c. 3 years. d. 5 years.

ANS: C

DIF: Easy

REF: 363

OBJ: 2

3. The document together with the payment voucher that is sent to a physician who has accepted

assignment of benefits is referred to as an a. EOB. b. EOMB. c. MRA. d. MPS. ANS: A

DIF: Easy

REF: 335

OBJ: 3

4. The maximum dollar value that the insurance company assigns to each medical service is

referred to as a. charge. b. allowed amount. c. adjustment amount. d. paid amount.

ANS: B

DIF: Moderate

REF: 364

OBJ: 4

5. All of the following are responsibilities of the insurance payment poster EXCEPT a. posting insurance reimbursements for every code submitted in the insurance claim. b. adjusting the amount charged to match the allowable charge. c. filing the appeal for denial. d. sending statements for patient deductibles and coinsurance balances.

ANS: B

DIF: Moderate

REF: 364

OBJ: 3

6. If the insurance billing specialist posts a payment and there is a remaining balance, they

should always

a. b. c. d.

send an appeal to the insurance company for the balance. write off the remaining balance. bill the patient for the balance. determine the appropriate course of action.

ANS: D

DIF: Hard

REF: 364

OBJ: 3

7. Delinquent claims are claims that have not been paid a. within 15 days of the service date. b. within 13–30 days of the service date. c. within 30–45 days of the service date. d. within 45–60 days of the service date.

ANS: C

DIF: Moderate

REF: 366

OBJ: 3

8. A listing of outstanding accounts that have not been paid is referred to as a. A claims submission report. b. A backlog report. c. A purge report. d. An aging report. e. A rebill report.

ANS: D

DIF: Moderate

REF: 366

OBJ: 5

9. A follow-up effort made to an insurance company to locate the status of an insurance claim is

called a/an a. inquiry. b. tracer. c. rebill. d. inquiry and tracer.

ANS: A

DIF: Moderate

REF: 367

OBJ: 5

10. When billing secondary insurances, which of the following is NOT true. a. The secondary insurance is billed at the same time the primary insurance is. b. Blocks 9a–d of the CMS 1500 claim form must be completed. c. Block 30 of the CMS 1500 claim form must be completed. d. If the MAC automatically forwards the claim to the secondary insurance, there is

no need to bill the secondary insurance.

ANS: A

DIF: Hard

REF: 364-365

OBJ: 4

11. The listing of outstanding accounts that have not been paid, which can be generated by most

billing systems is referred to as a a. purged report. b. outstanding accounts report. c. software report. d. account aging report.

ANS: D

DIF: Moderate

REF: 366

OBJ: 5

12. If an insurance claim has been lost by the insurance carrier, the procedure(s) to follow is to a. ask if there is a backlog of claims at the insurance office.

b. submit a copy of the original claim. c. verify the correct mailing address. d. All are correct.

ANS: A

DIF: Moderate

REF: 369

OBJ: 6

13. An insurance claim for a service that has been bundled with other services would be a. paid. b. rejected. c. suspended. d. denied.

ANS: D

DIF: Easy

REF: 369

OBJ: 7

14. A submitted claim that does not follow specific third-party payer instructions or contains a

technical error is referred to as a. paid. b. rejected. c. suspended. d. denied.

ANS: B

DIF: Easy

REF: 399

OBJ: 7

15. The total number of levels of redetermination that exist in the Medicare program is a. two. b. three. c. five. d. six.

ANS: C

DIF: Easy

REF: 374

OBJ: 10

16. The first level of appeal in the Medicare program is a. redetermination. b. inquiry. c. fair hearing. d. appeals council review.

ANS: A

DIF: Easy

REF: 374

OBJ: 10

17. The correct method to send documents for a Medicare reconsideration (Level 2) is by a. certified mail with return receipt requested. b. certified mail. c. standard mail. d. overnight mail.

ANS: A

DIF: Easy

REF: 376

OBJ: 10

18. A request for a Medicare administrative law judge hearing can be made if the amount in

controversy is at least a. $160. b. $250. c. $350. d. $500.

ANS: A

DIF: Moderate

REF: 376

OBJ: 10

19. If a payment problem develops with an insurance company and the company ignores claims

and exceeds time limits to pay a claim, it is prudent to contact the a. federal insurance commissioner. b. state insurance commissioner. c. state insurance federation. d. department of public service.

ANS: B

DIF: Moderate

REF: 384

OBJ: 12

20. Which statement is true of the insurance commission of the state? a. To maintain all complaints confidential every year. b. To make sure that all organizations authorized to transact insurance including

agents and brokers are in compliance with the insurance laws of that state. c. To bring insurance claim submissions to court when there are disputes about

payments. d. To monitor activities of policyholders and to ensure the interests of insurance

companies.

ANS: C

DIF: Hard

REF: 384

OBJ: 12

COMPLETION 1. The process that health care organizations use to track services provided to patients from the

time they register to the final payment of associated fees is referred to as

.

ANS:

revenue cycle management (RCN) revenue cycle management RCN DIF: Moderate

REF: 363

2. Revenue is the

OBJ: 5

produced by a health care organization.

ANS: total income DIF: Moderate

REF: 363

OBJ: 5

3. Once a claim has been successfully submitted to an insurance carrier, the next step is to

the claim until a response is received from the responsible party and the service has been paid in full.

ANS: track DIF: Moderate

REF: 363

4. An insurance company may

paying or denying it.

OBJ: 5

a claim to investigate the details of the claim before

ANS: suspend DIF: Easy

REF: 363

OBJ: 7

5. The management of the reimbursement process and insurance company denials is often

referred to as claim

.

ANS: follow-up DIF: Easy

REF: 363

OBJ: 7

6. If inadequate payment was received from an insurance company for a complicated procedure,

the insurance billing specialist should file a/an physician.

on behalf of the

ANS: appeal DIF: Easy

REF: 363

OBJ: 9

7. An insured person cannot bring legal action against an insurance company until

days after a claim is submitted to the insurance company.

ANS:

60 sixty DIF: Moderate

REF: 363

OBJ: 2

8. Documentation from private insurance carriers sent to participating providers that

accompanies payment and describes the response to a claim is referred to by the acronym .

ANS: EOB DIF: Easy

REF: 364

OBJ: 3

9. A

claim is the refusal of an insurance carrier to honor a request to pay for health care services.

ANS: denied DIF: Easy

REF: 364

OBJ: 7

10. A delinquent insurance claim may be easily located by reviewing the

.

ANS: insurance claims register DIF: Moderate

REF: 366

OBJ: 5

11. Overdue payment on an insurance claim is referred to as

.

ANS: delinquent DIF: Moderate

REF: 366

OBJ: 7

12. An insurance claim that is pending because of the need for additional information is also

referred to as being in

.

ANS: suspense DIF: Moderate

REF: 368

OBJ: 7

13. The account aging report which categorizes outstanding claims as current,

,

,

, and

days, should be generated each month.

ANS:

30 60 90 120 30, 60, 90, 120 DIF: Moderate

REF: 366

OBJ: 6

14. An insurance claim that is processed without following specific insurance carrier instructions

is considered a/an

claim.

ANS: rejected DIF: Moderate

REF: 369

OBJ: 7

15. If the medical practice receives payment from an insurance company that is more than the

contract rate, it is called a/an

.

ANS: overpayment DIF: Moderate

REF: 373

OBJ: 3

16. A request for a hearing before an administrative law judge (in a Medicare case) may be made

if the amount still in question is

or more.

ANS: $160 DIF: Easy

REF: 375

OBJ: 10

17. Monitoring the activities of insurance companies and making sure that the interests of the

policyholders are protected are the jobs of the insurance ANS: commission DIF: Moderate

REF: 384

OBJ: 12

.

18. The

manages complaints about delays in settling insurance claims, illegal cancellations or terminations of an insurance policy, and problems about insurance premium rates.

ANS: insurance commissioner DIF: Moderate

REF: 383

OBJ: 13

19. Requests to the insurance commissioner must be submitted

.

ANS: online DIF: Moderate

REF: 384

OBJ: 13

20. All requests of the insurance commissioner must be submitted in writing and include the

signature.

ANS: patient’s DIF: Moderate

REF: 384

OBJ: 13

TRUE/FALSE 1. The patient’s health insurance card specifies all benefits and coverages.

ANS: F

DIF: Easy

REF: 363

OBJ: 1

2. The explanation of benefits (EOB), which details the amount allowable, the amount that needs

to be adjusted, and the reason why, is issued by the health insurance company.

ANS: T

DIF: Easy

REF: 364

OBJ: 3

3. There is standardization of format for the explanation of benefits document for all private

insurance carriers.

ANS: F

DIF: Easy

REF: 364

OBJ: 3

4. The insurance payment poster is responsible for submitting appeals for denied claims.

ANS: F

DIF: Easy

REF: 364

OBJ: 3

5. The status of electronic insurance claims may be accessed quickly through online health

insurance physician web portals.

ANS: T

DIF: Moderate

REF: 366

OBJ: 6

6. A rejected insurance claim should be corrected and sent for review or appeal.

ANS: F

DIF: Moderate

REF: 370

OBJ: 6

7. Approximately 50% of individuals pursue appeals on a denied insurance claim.

ANS: F

DIF: Moderate

REF: 371

OBJ: 6

8. If you have a denied insurance claim, you should change the information and resubmit the

claim.

ANS: F

DIF: Moderate

REF: 371

OBJ: 7

9. In any type of overpayment situation, always cash the third-party payers check and write a

refund check payable to the originator of the overpayment.

ANS: T

DIF: Hard

REF: 373

OBJ: 7

10. A Level 1 Medicare redetermination (appeal) may be made by telephone, in writing, or by

submitting a CMS-20027 form.

ANS: T

DIF: Moderate

REF: 376

OBJ: 10

11. Appeal decisions on Medicare unassigned insurance claims are sent to the patient.

ANS: T

DIF: Moderate

REF: 376

OBJ: 10

12. The highest level of a Medicare redetermination is with an administrative law judge hearing.

ANS: F

DIF: Easy

REF: 376

OBJ: 10

13. If a claim has not been paid within a reasonable amount of time, the most effective method to

follow-up on it, is to automTaE tiS caT llB yA reN biKllSitEtL heLtE heRt. hiCrdO-M party payer.

ANS: F

DIF: Easy

REF: 366

OBJ: 8

14. Prior to appealing a claim, the health care provider should determine that there is sufficient

information to back up the claim.

ANS: T

DIF: Moderate

REF: 374

OBJ: 9

15. The process for filing appeals is the same for all insurance carriers and should be performed in

writing.

ANS: F

DIF: Moderate

REF: 374

OBJ: 9

16. Insurance companies are rated according to the number of complaints received about them.

ANS: T

DIF: Moderate

REF: 384

OBJ: 12

17. A qualified independent contractor (QIC) conducts Medicare level 1 appeals.

ANS: F

DIF: Moderate

REF: 376

OBJ: 10

18. The third level of appeals for Medicare claims with an Administrative Law Judge must be

made within 30 days of receiving the reconsideration officer’s decision (Level 2 appeals).

ANS: F

DIF: Moderate

REF: 376

OBJ: 10

19. There are no requirements regarding the amount of money in controversy for the fourth level

of Medicare appeals through the Medicare Appeals Council.

ANS: T

DIF: Moderate

REF: 376

OBJ: 10

20. In 2018, the minimum dollar amount for a judicial review in federal district court which must

be met is $1500.

ANS: F

DIF: Moderate

REF: 376

OBJ: 10

21. Expedited TRICARE appeals must be filed within 3 days of the receipt of the initial denial.

ANS: T

DIF: Moderate

REF: 383

OBJ: 11

22. Insurance companies are regulated by a federal regulatory agency.

ANS: F

DIF: Moderate

REF: 383

OBJ: 12

23. Only unorganized and poorly managed health care organizations will experience claim

denials.

ANS: F

DIF: Moderate

REF: 384

OBJ: 15

24. The reason for a claim denial is usually identified on the remittance advice with a reason code

that translates to a specific denial description.

ANS: T

DIF: Moderate

REF: 384

OBJ: 15

Chapter 17: Collection Strategies Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Cash flow is a. the amount of money available in the cash drawer. b. the amount of money taken into the office in a given period of time. c. the ongoing availability of cash in the medical practice. d. the amount of money in accounts receivable.

ANS: C

DIF: Easy

REF: 388

OBJ: 1

2. What does the insurance billing specialist need to monitor to be able to evaluate the

effectiveness of the collection process? a. Number of statements sent b. Number of claims processed c. Accounts payable d. Accounts receivable ANS: D

DIF: Easy

REF: 388

OBJ: 2

3. What is the biggest change medical offices can expect from the Affordable Care Act? a. A reduction in the cost of medications b. The number of self-pay patients will decrease c. Young adults under 26 can remain under their parent’s health care plan d. The elimination of the T prEeS exTisB tiA ngNcKoS ndEiL tioLnEbRar.riCerOM ANS: C

DIF: Moderate

REF: 389

OBJ: 3

4. What should be done to inform a new patient of office fees and payment policies? a. Send a patient information brochure. b. Send a confirmation letter. c. Discuss fees and policies at the time of the initial contact. d. All are correct.

ANS: D

DIF: Moderate

REF: 389-390

OBJ: 4

5. The patient is likely to be the most cooperative in furnishing details necessary for a complete

registration process a. before any services are provided. b. right after services are provided. c. at the time of the first statement. d. in a follow-up telephone call.

ANS: A

DIF: Easy

REF: 391

OBJ: 4

6. Medical offices can take the following steps to prevent missed appointments EXCEPT a. establish a missed appointment fee of $35–50. b. set a 24–48-hour appointment cancellation policy. c. call patients to confirm appointment the day before.

d. all of the above are acceptable strategies to prevent missed appointments.

ANS: D

DIF: Easy

REF: 391

OBJ: 5

7. The reason for a fee reduction must be documented in the patient’s a. financial accounting record. b. health record. c. insurance file. d. registration form.

ANS: B

DIF: Easy

REF: 391

OBJ: 6

8. When collecting fees, your goal should always be to a. leave the impression that you are a nice person. b. collect at least one half the fee. c. collect the full amount. d. collect as much as possible.

ANS: C

DIF: Easy

REF: 397

OBJ: 7

9. All of the following are examples of why accepting credit/debit cards in the medical office is

beneficial EXCEPT a. credit/debit terminals charge a per service fee to the medical office. b. lower risk of embezzlement from medical office staff. c. staff does not need to leave the office to deposit checks. d. convenient for patients.

ANS: A

DIF: Easy

REF: 401

OBJ: 8

10. A medical practice has a policy of billing only for charges in excess of $50. When the medical

assistant requests a $45 payment for the office visit, the patient states, “Just bill me.” How should the medical assistant respond? a. Say “All right” and bill the patient. b. State the office policy and ask for the full fee. c. Indicate that because it is such a small sum, it can be paid later. d. Ask that the payment be mailed to the office.

ANS: B

DIF: Moderate

REF: 396

OBJ: 8

11. What is a card called that permits bank customers to make cashless purchases from funds on

deposit without incurring revolving finance charges for credit? a. Private-label card b. Credit card c. Debit card d. VeriFone card ANS: C

DIF: Easy

REF: 401

OBJ: 8

12. When the physician’s office receives notice that a check was not honored, the first thing to do

is to a. send an NSF demand letter. b. file a claim in small claims court. c. call the bank or the patient.

d. notify the patient that future payments need to be in the form of cash or money

orders.

ANS: C

DIF: Moderate

REF: 402

OBJ: 8

13. Accounts receivable are usually aged in time periods of a. 1, 4, 6, and 8 weeks. b. 30, 60, 90, and 120 days. c. 1, 2, 3, and 6 months. d. 30, 60, 90, 120, and 180 days.

ANS: B

DIF: Easy

REF: 403

OBJ: 9

14. Accounts that are 90 days or older should not exceed a. 5%–11% of the total accounts receivable. b. 10%–15% of the total accounts receivable. c. 15%–18% of the total accounts receivable. d. 20%–25% of the total accounts receivable.

ANS: C

DIF: Hard

REF: 403

OBJ: 9

15. Messages included on statements to promote payment are called a. billing messages. b. statement slogans. c. dun messages. d. payment prompters.

ANS: C

DIF: Easy

REF: 403

OBJ: 10

16. Contracting a medical billing service for insurance claim submission is called a. statement service. b. centralized billing. c. outsourcing. d. cycle billing.

ANS: C

DIF: Moderate

REF: 406

OBJ: 10

17. Which group of accounts would a collector target when he or she begins making telephone

calls? a. 30–60 day accounts b. 60–90 day accounts c. 90–120 day accounts d. Accounts older than 120 days ANS: B

DIF: Moderate

REF: 409

OBJ: 9

18. In making collection telephone calls to a group of accounts, how should the accounts be

organized to determine where to begin? a. Organize the accounts alphabetically and start with the letter A. b. Organize the accounts by account number and start with number 1. c. Organize the accounts according the number of days past the date of service the account is delinquent. d. Determine which patient you think may be easier to collect from and start with that

account.

ANS: C

DIF: Moderate

REF: 409

OBJ: 9

19. How many installments (excluding a down payment) must a payment plan have to require full

written disclosure? a. Three or more b. Four or more c. Five or more d. Six or more ANS: B

DIF: Moderate

REF: 407

OBJ: 14

REF: 410

OBJ: 14

20. All collection calls should be placed a. after 9 AM and before 9 PM. b. after 8 AM and before 9 PM. c. after 8 AM and before 8 PM. d. after 9 AM and before 8 PM. ANS: B

DIF: Moderate

21. When writing a collection letter a. do not try to be friendly; just get to the point. b. use a friendly tone and ask why payment has not been made. c. do not suggest that the patient has overlooked a previous statement. d. do not imply that the patient has good intentions to pay.

ANS: B

DIF: Moderate

REF: 412

OBJ: 13

22. If an insurance company seems to be ignoring all efforts to trace a claim, send a copy of the a. history and physical. b. operative report. c. claim. d. history of the account.

ANS: D

DIF: Moderate

REF: 414

OBJ: 14

23. What is the name of the act designed to address the collection practices of third-party debt

collectors and attorneys who regularly collect debts for others? a. Equal Credit Opportunity Act b. Fair Credit Billing Act c. Truth in Lending Act d. Fair Debt Collection Practices Act ANS: D

DIF: Hard

REF: 417

OBJ: 11

24. The part of the legal system that allows laypeople to settle a legal matter without use of an

attorney is the a. people’s court. b. justice court. c. small claims court. d. All are correct.

ANS: C

DIF: Easy

REF: 418

OBJ: 16

25. What is the name of the federal act that prohibits discrimination in all areas of granting credit? a. Equal Credit Opportunity Act b. Fair Credit Reporting Act c. Fair Debt Collection Practices Act d. Truth in Lending Act ANS: A

DIF: Hard

REF: 408

OBJ: 11

26. Requires businesses to explain all interest charges, late charges, collection fees, finance

charges up front, before the time of service. a. Equal Credit Opportunity Act b. Fair Credit Reporting Act c. Fair Credit Billing Act d. Truth in Lending Consumer Credit Cost Disclosure ANS: D

DIF: Hard

REF: 409

OBJ: 11

27. In a bankruptcy case, most medical bills are considered a. secured debt. b. unsecured debt. c. nonexempt assets. d. exempt assets.

ANS: B

DIF: Hard

REF: 421

OBJ: 11

28. Which type of bankruptcy is considered “wage earner’s bankruptcy?”

TESTBANKSELLER.COM a. Chapter 7 b. Chapter 11 c. Chapter 12 d. Chapter 13 ANS: D

DIF: Hard

REF: 521

OBJ: 11

29. The first patient account statement should be a. presented at the time of service. b. mailed right after the date of service. c. mailed 2 weeks after the date of service. d. mailed 30 days after the date of service.

ANS: A

DIF: Moderate

REF: 406

OBJ: 14

30. The first telephone call to the patient to try to collect on an account should be made a. the month following the date of service. b. after there is no response from the first statement. c. after there is no response from the second statement. d. after there is no response from the third statement.

ANS: D COMPLETION

DIF: Moderate

REF: 406

OBJ: 14

1. The amount expected based on physician charges from third-party insurance companies and

patients for services that have been rendered is called

.

ANS: accounts receivable DIF: Easy

REF: 388

OBJ: 2

2. The relationship of the amount of money owed to a physician and the amount of money

collected on the physician’s accounts receivable is called the

.

ANS: collection ratio DIF: Easy

REF: 388

OBJ: 2

3. All discounted fees need to be noted on the patient’s

.

ANS: financial accounting record ledger card DIF: Moderate

REF: 391

OBJ: 6

4. Assets or debts that have been determined to be uncollectible and are therefore taken off

(debited) the accounting books as a loss are called

.

ANS: write-off or courtesy adjustments DIF: Moderate

REF: 393

OBJ: 6

5. The amount due listed on the patient’s financial accounting record is also referred to as the

account

.

ANS: balance DIF: Moderate

REF: 396

OBJ: 2

6. A/An

is a patient payment option in which the check is deposited into the physician’s account at the time of service.

ANS: e-check DIF: Moderate

REF: 401

OBJ: 8

7. If the endorsement on the back of the payment check does not match the name on the front,

there may be a case of

.

ANS: forgery DIF: Moderate

REF: 401

OBJ: 8

8. The statement “This bill is now 30 days past due. Please remit payment” is called a

.

ANS: dun message DIF: Easy 9.

REF: 403

OBJ: 10

are another way of offering the patient a way of paying off an account by spreading out the amount due over a period of time.

ANS: Payment plans DIF: Moderate

REF: 407

OBJ: 14

10. A formal regulation or law setting time limits on legal action is known as a

.

ANS: statute of limitations DIF: Moderate

REF: 407

OBJ: 12

11. The collection abbreviation TTA means

.

ANS: turned to agency DIF: Moderate

REF: 414

OBJ: 15

12. The collection abbreviation OOT means

.

ANS: out of town DIF: Moderate

REF: 414

OBJ: 17

13. When dealing with managed care contracts, do not sign contracts that use the

clause because this is a way for one party to shift financial responsibilities to another party.

ANS:

“hold harmless” hold harmless DIF: Hard

REF: 415

OBJ: 18

14. Patients’ accounts turned over to a collection agency should have a/an

sent by certified mail.

ANS: letter of withdrawal DIF: Hard

REF: 417

OBJ: 15

15. In filing a claim in small claims court, the physician’s office is referred to as the

.

ANS: plaintiff

DIF: Moderate

REF: 418

OBJ: 16

16. A patient who owes a balance on his or her account and moves but leaves no forwarding

address is called a/an

.

ANS: skip DIF: Moderate

REF: 419

OBJ: 17

17. In dealing with an estate claim, a call to the

can be made

periodically to check on the status of the estate.

ANS: executor DIF: Moderate

REF: 422

18. A/An

OBJ: 18

is a claim on the property of another as security for a debt.

ANS: lien DIF: Moderate

REF: 422

OBJ: 16

19. All insurance billers, all claim assistance professionals, and anyone who handles checks or

cash should be

.

ANS: bonded DIF: Hard 20.

REF: T4E 23STBANKS OE BL J: LE 11R.COM

The truth in lending consumer credit cost disclosure requires businesses to disclose all and costs related to granting credit.

ANS:

direct; indirect indirect; direct direct indirect indirect direct DIF: Hard

REF: 409

OBJ: 11

21. According to the FDCPA, do not contact a third party more than

unless requested to do so by the party or the response was erroneous or incomplete.

ANS: once DIF: Hard 22. The term

the month.

ANS: cycle billing

REF: 410

OBJ: 11

is used when accounts are billed at spaced intervals during

DIF: Moderate

REF: 406

OBJ: 14

TRUE/FALSE 1. A large percentage of reimbursement in the physician’s office is generated from third-party

payers.

ANS: T

DIF: Easy

REF: 388

OBJ: 2

2. A collection rate of 80%–85% should be a goal for the practice administrator in charge of

collections in the physician’s office.

ANS: F

DIF: Moderate

REF: 388

OBJ: 2

3. Information provided on the patient registration form will prove critical to any billing and

collection efforts.

ANS: T

DIF: Easy

REF: 390

OBJ: 3

4. A helpful tip in assisting patients’ complete necessary paperwork is to use a yellow

highlighter blocking all necessary information.

ANS: T

DIF: Easy

REF: 391

OBJ: 3

5. When no business or home telephone number is listed on the patient registration form, this

may be an indication of a fT utEuS reTnB onA-N paKyS inEgLpL atE ieR nt.. COM ANS: T

DIF: Easy

REF: 391

OBJ: 3

6. Most medical practices operate with a set of fees that must be applied to all patients in the

practice.

ANS: T

DIF: Moderate

REF: 391

OBJ: 7

7. Under federal regulations, a list of the most common services the physician offers, including

procedure code numbers with a description of each service and its price, must be posted in the office waiting room.

ANS: F

DIF: Moderate

REF: 391

OBJ: 7

8. When a physician offers a discount, it must apply to the total bill, not just the portion that is

paid by the patient.

ANS: T

DIF: Moderate

REF: 391

OBJ: 6

9. It is legal to offer patients a cash discount when the entire fee is paid at the time of service.

ANS: T

DIF: Moderate

REF: 391

OBJ: 6

10. In most situations, both private insurers and the federal government ban waiving the

copayment portion of the patient’s fee.

ANS: T

DIF: Moderate

REF: 395

OBJ: 6

11. Standard policy should be to reduce fees of any patient who dies after receiving medical care.

ANS: F

DIF: Moderate

REF: 395

OBJ: 6

12. You should not give patients the option of whether they would like to pay now or have a bill

sent.

ANS: T

DIF: Moderate

REF: 396

OBJ: 8

13. In trying to collect an unpaid balance, a telephone interview is preferred to a personal

interview.

ANS: F

DIF: Moderate

REF: 397

OBJ: 10

14. A medical practice cannot refuse to let an established patient see the doctor because of a debt.

ANS: T

DIF: Hard

REF: 397

OBJ: 11

15. Refunds may be made by check on accounts in which payment was made by credit card.

ANS: F

DIF: Hard

REF: 401

OBJ: 8

anEteSeToB f pAaNyK mS enEt.LLER.COM 16. A personal check is a guarT ANS: F

DIF: Moderate

REF: 401

OBJ: 8

17. If a patient writes “paid in full” on a check against an account that will not be paid in full with

the check, the acceptance of the check indicates an acceptance of the “paid in full” remark.

ANS: F

DIF: Hard

REF: 401

OBJ: 8

18. One person or one department should handle all billing questions.

ANS: T

DIF: Moderate

REF: 403

OBJ: 10

19. The best and most effective collection statements include a handwritten note.

ANS: T

DIF: Moderate

REF: 403

OBJ: 13

20. Using an aging report is the most organized approach to do collection calls to target accounts

that are in the 60–90-day categories.

ANS: T

DIF: Moderate

REF: 403

OBJ: 9

21. Medicare accounts may not be written off until sequential statements have been sent with an

increasing intensity in the collection message and a genuine collection effort has been made.

ANS: T

DIF: Moderate

REF: 415

OBJ: 6

22. All accounts older than 120 days should go to a collection agency.

ANS: F

DIF: Moderate

REF: 416

OBJ: 15

23. Statements should not be sent to a patient who has filed for bankruptcy.

ANS: T

DIF: Hard

REF: 421

OBJ: 18

24. Insurance billing specialists who handle checks or cash should be bonded and insured.

ANS: T

DIF: Moderate

REF: 423

OBJ: 11

25. The Fair Credit Reporting Act states that a patient has 60 days from the date a statement is

mailed to complain about an error.

ANS: F

DIF: Hard

REF: 408

OBJ: 11

26. When a physician continues to treat a patient with an overdue account, the courts have viewed

this as an extension of credit; therefore, patients who fall into this delinquent status should be referred elsewhere.

ANS: T

DIF: Moderate

REF: 409

OBJ: 15

27. According to the FDCPA, debtors can never be contacted at work.

ANS: F

DIF:

41R0.COM THEarSdTBANKSREFL:LE

OBJ: 11

28. In a telephone collection call, the first 2 minutes will set the scene for your relationship with

the patient.

ANS: F

DIF: Moderate

REF: 411

OBJ: 13

29. In a telephone collection call, if a patient does not respond, it probably means “no.”

ANS: F

DIF: Moderate

REF: 411

OBJ: 13

Chapter 18: Ambulatory Surgical Center Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Ambulatory surgical centers are health care facilities focused on providing a. surgical services on a walk-in basis. b. surgical services for patients with orthopedic issues. c. same-day surgical care. d. overnight surgical care.

ANS: C

DIF: Easy

REF: 429

OBJ: 2

2. Common ASC specialties include all but which of the following: a. Dermatology b. Orthopedics c. Gynecological d. Gastroenterology ANS: C

DIF: Easy

REF: 429

OBJ: 2

3. The accrediting body for ambulatory surgical centers is a. AAAHC. b. AHA. c. AMA. d. ASCQR. ANS: A

DIF: Moderate

REF: 430

OBJ: 2

4. Providers furnishing services to Medicare Part B patients, are reimbursed via a. DRG payment methodology. b. APC payment methodology. c. Medicare Physician Fee Schedule. d. None are correct.

ANS: C

DIF: Moderate

REF: 431

OBJ: 12

5. Medicare makes facility payments to ASCs a. for all surgical procedures performed. b. for all surgical and ancillary services. c. for all orthopedic procedures performed. d. for only specific ASC covered surgical procedures.

ANS: D

DIF: Moderate

REF: 431

OBJ: 12

6. Payments made to ASC facilities from private insurers are based on a. the Medicare fee schedule. b. APC payment methodology. c. the contract the facility has negotiated with the payer. d. None are correct.

ANS: C

DIF: Hard

REF: 432

OBJ: 12

7. ASC facility services which are covered under Part B include all but the following: a. The physician’s professional service for performing the procedure b. Surgical supplies, nursing services and equipment c. Drugs, biologicals, intravenous fluids, and tubing d. Simple diagnostic and preoperative testing performed by the ASC on the date of

surgery ANS: A

DIF: Hard

REF: 432

OBJ: 12

8. Under the MPFS, payment rate is assigned by relative value units which take are calculated

using the following three factors: a. Location of the service, amount of physician work involved, practice expense b. Location of the service, amount of physician work involved, malpractice expense c. Amount of physician work involved, malpractice expense, practice expense d. Amount of physician work involved, complexity of aftercare, practice expense ANS: C

DIF: Moderate

REF: 434

OBJ: 5

9. For screening flexible sigmoidoscopy and screening colonoscopy performed in an ASC,

Medicare will pay a. 70 b. 80 c. 100 d. None are correct

% of the allowed amount for the service.

ANS: D

(they pay 75%) DIF: Hard

REF: 434

OBJ: 2

10. When multiple surgical procedures are performed in the same operative session at an ASC,

the second surgery a. will not be paid; only the primary procedure is paid. b. will be subject to a multiple procedure discount of 50%. c. will be subject to a multiple procedure discount of 75%. d. will be paid at 100%.

ANS: B

DIF: Hard

REF: 435

OBJ: 9

COMPLETION 1. The first ASC facility was launched in Phoenix, AZ in the year

.

ANS: 1970 DIF: Easy

REF: 429

OBJ: 2

2. According to Medicare, an ASC is a distinct entity that provides outpatient surgical services

and operate either

or are operated by a

ANS: independently, hospital

.

DIF: Easy

REF: 429-430

OBJ: 2

3. When a hospital-based surgery center is not certified as an ASC, the

payment rules

apply.

ANS: hospital outpatient or HOPPS DIF: Moderate

REF: 430

OBJ: 4

4. The Medicare

list refers to procedures and services that CMS has identified as those typically only provided in the inpatient setting because they are complex, complicated or require the care and coordinated services provided in the inpatient setting of a hospital.

ANS: Inpatient-Only DIF: Hard

REF: 432

OBJ: 4

5. Medicare makes a single payment is made to an ASC facility for a covered surgical procedure.

Related services provided during the surgical session are bundled together and paid in one lump sum.

, which means they are

ANS: Packaged DIF: Moderate

REF: 436

OBJ: 4

6. ASC claims are submitted to Medicare and Medicaid using the

claim form.

ANS: CMS 1500 DIF: Moderate

REF: 436

OBJ: 2

7. Hospital outpatient surgery claims are submitted using the

claim form.

ANS: UB04 DIF: Moderate

REF: 436

OBJ: 2

8. The revenue cycle of an ASC starts with

.

ANS: patient registration/scheduling DIF: Easy 9.

REF: 436

OBJ: 1

is a fixed amount of money per patient per unit of time paid in advance to the ASC for the delivery of health care services.

ANS: Capitation DIF: Moderate

REF: 439

OBJ: 2

10. The initial diagnosis documented by the surgeon which determined that surgery was necessary

is referred to as the

diagnosis.

ANS: preoperative DIF: Moderate

REF: 441

OBJ: 6

11. Conditions that co-exit during the episode of care and affect the treatment provided to the

patient are referred to as

diagnosis(es).

ANS: secondary DIF: Moderate 12. Modifier

REF: 441

OBJ: 6

is used when an ASC procedure was discontinued after prep for surgery.

ANS: 73 DIF: Easy 13. Modifier

REF: 442

OBJ: 9

is required by Medicaid to identify an ASC facility service.

ANS: SG DIF: Easy

REF: 442

14. CMS developed the

OBJ: 9

to promote national correct coding and to control

ErSoT KeSnEt L improper coding leading toTw ngBpAaN ym inLPEarRt .

BCcO laM ims.

ANS:

NCCI (National Correct Coding Initiative) NCCI National Correct Coding Initiative DIF: Moderate

REF: 442

OBJ: 7

15. In the absence of an NCD, an item or service may be covered at the discretion of the Medicare

Administrative Contractor (MAC) based on

.

ANS:

LCD (Local Coverage Determination) LCD Local Coverage Determination DIF: Moderate

REF: 443

OBJ: 11

16. CMS developed the standardized survey,

, to measure and assess the experience of care for patients who have a surgical procedure performed in and ASC. ANS:

OAS CAHPS (Consumer Assessment of Health care Providers and Systems Outpatient and Ambulatory Surgery Survey) OAS CAHPS Consumer Assessment of Health care Providers and Systems Outpatient and Ambulatory Surgery Survey DIF: Moderate

REF: 444

OBJ: 13

SHORT ANSWER 1. Describe the reasons for significant growth of the number of ASCs and utilization of services

at ASCs have increased over the past 40 years.

ANS:

• Reduced health care costs for patients, providers and payers • Expansion of the types of surgeries and services that can be performed at ASCs • Technological advancements DIF: Moderate

REF: 429

OBJ: 2

2. Identify the two different types of ASCs and describe the difference between them.

ANS:

• Independent: not part of any other facility or hospital; freestanding • Hospital: Owned, licensed, and controlled by a hospital DIF: Moderate

29S-4T3B 0 ANKS OE BL J: LE 2 R.COM REF: T4E

3. Describe the criteria which must be met for a service to be considered medically necessary.

ANS:

• The service must match the diagnosis.

• The service must not be experimental or investigational.

• The service must be necessary.

• The service must be provided at the most appropriate level that is safe and effective.

• The service is not elective.

DIF: Moderate

REF: 432

OBJ: 6

4. List the criteria which Medicare considers to be an exclusion for payment and will not allow

payment of a surgical procedure if any of the criteria are met.

ANS:

• Is on the inpatient only list • Poses a significant safety risk to the beneficiary • Typically requires active medical monitoring and care past midnight • Directly involved major blood vessels • Requires major or prolonged invasion of body cavities • Generally results in extensive blood loss

• Is emergent in nature • Is life-threatening in nature • Commonly requires systemic thrombolytic therapy • Can only be reported using an unlisted surgical procedure code DIF: Hard

REF: 433

OBJ: 12

5. Using your CPT manual (Appendix A), list the “Modifiers Approved for ASC Hospital

Outpatient Use.” ANS:

• 25 • 27 • 33 • 50 • 52 • 58 • 59 • 73 • 74 • 76 • 77 • 78 • 79 • 91 DIF: Easy

REF: 436 | Appendix A

OBJ: 9

6. List the survey measures used by OAS CAHPS to assess the experience of care for patients

who have had a surgery performed at an ASC or in a hospital outpatient department.

ANS:

• Communication and care provided by health care providers and office staff • Preparation for the surgery or procedure • Postsurgical care coordination • Patient-reported outcomes DIF: Moderate

REF: 444

OBJ: 13

Chapter 19: Hospital Outpatient and Inpatient Billing Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. The revenue cycle is divided into three periods: a. Scheduling of services, patient care, and discharge b. Preadmission, patient care, and posthospitalization c. Preadmission, patient care, and reimbursement d. Scheduling of services, billing of services, and reimbursement ANS: B

DIF: Easy

REF: 446

OBJ: 1

2. The rule stating that when a patient receives outpatient services within 72 hours of admission,

then all outpatient services are combined with inpatient services and become part of the diagnostic-related group rate for admission, is called the a. preop rule. b. preadmission rule. c. Medicare 72-hour rule. d. PAT. ANS: C

DIF: Easy

REF: 446

OBJ: 3

3. Preadmission testing performed a day or two before admission for surgery often includes all

of the following EXCEPT a. blood and urine testing. b. radiology imaging. c. pulmonary function testing. d. electrocardiogram.

ANS: C

DIF: Moderate

REF: 447

OBJ: 1

4. Utilization management is a process performed in order to a. control health care cost and ensure patient care is medically necessary. b. ensure patient care is provided quickly and ensure patient care is medically

necessary. c. improve access to care and control health care cost. d. ensure health care services are billed correctly and control the cost of health care.

ANS: A

DIF: Moderate

REF: 447

OBJ: 4

5. An examination of a patient’s health record to determine whether or not a patient should stay

in the hospital or can be discharged. a. admission review b. continued stay review c. inpatient stay review d. discharge review ANS: B

DIF: Moderate

REF: 447

OBJ: 4

6. A listing of all charges for supplies, procedures, room and board, equipment, medications, etc.

provided in the hospital setting a. charge database. b. fee schedule. c. chargemaster. d. revenue code listing.

ANS: D

DIF: Moderate

REF: 448

OBJ: 5

7. The charge for an x-ray service which covers the costs of the x-ray itself, the radiology

technician performing the procedure and other supplies necessary to perform the x-ray. a. technical charge b. professional charge c. facility fee d. global fee ANS: A

DIF: Moderate

REF: 448

OBJ: 5

8. The ICD-10-PCS coding system is used to report a. Outpatient and Inpatient diagnosis codes. b. Inpatient diagnosis codes. c. Outpatient and inpatient procedure codes. d. Inpatient procedure codes.

ANS: D

DIF: Moderate

REF: 448

OBJ: 7

9. The significant reason for patient admission to the hospital is coded as the a. primary diagnosis. b. secondary diagnosis. c. main diagnosis. d. principal diagnosis.

ANS: D

DIF: Moderate

REF: 448

OBJ: 7

REF: 449

OBJ: 6

10. ICD-10-PCS codes contain a. at least two digits. b. three to five characters. c. seven characters. d. five digits.

ANS: C

DIF: Easy

11. The ICD-10-PCS coding system and coding guidelines are a. maintained by NCHS and updated each October. b. maintained by WHO and updated each January. c. maintained by CMS and updated each October. d. maintained by AHA and updated each January.

ANS: C

DIF: Easy

REF: 449

OBJ: 6

12. Which of the following code sets were mandated for use under HIPAA’s Transactions and

Code Set Rule a. ICD-10-CM, ICD-10-PCS, HCPCs Level II, CPT?

b. HCPCs Level II and CPT? c. ICD-10-CM and ICD-10-PCS? d. CPT, ICD-10-CM? ANS: A

DIF: Moderate

REF: 450

OBJ: 6

13. The claim form transmitted to the insurance carrier for reimbursement for inpatient hospital

services is called the a. UB-82. b. CMS 1450 (UB-04). c. CMS-1500. d. standard hospital billing form.

ANS: B

DIF: Moderate

REF: 450

OBJ: 1

14. The claim form used for outpatient hospital procedure billing is the a. CMS-1500 claim form. b. CMS 1450 (UB-04) claim form. c. HOP claim form. d. standard outpatient claim form (SOCF).

ANS: B

DIF: Moderate

REF: 450

OBJ: 1

Hospital acquired conditions are a. not reimbursed by Medicare. b. are reimbursed by Medicare. c. dependent upon the condition acquired. d. dependent upon the nuT mE beSrToB f dAaN ysKrSeqEuLirL edEfRo. r tCreOaM tment of the condition.

15.

ANS: A

DIF: Hard

REF: 450

OBJ: 7

COMPLETION 1. The revenue cycle is the process of how patient financial and health information moves into,

through and out of the health care facility, culminating with the facility receiving services provided.

for

ANS: reimbursement DIF: Easy 2.

REF: 446

OBJ: 1

is the process of preparing for the patient’s care by collecting demographic information and insurance information.

ANS: Preadmission DIF: Moderate

REF: 446

OBJ: 1

3. To be an inpatient who receives nursing and other care around the clock, there must be a

admitting the patient to the hospital.

ANS: physician order

DIF: Moderate

REF: 446

OBJ: 1

4. PAT is an abbreviation for

.

ANS: preadmission testing DIF: Easy

REF: 447

OBJ: 1

5. Conditions such as administration of wrong blood type during a hospital stay or foreign body

left in patient during surgery are referred to as

conditions.

ANS: hospital acquired DIF: Hard

REF: 450

OBJ: 7

6. A claim that has not been submitted to the insurer because it is missing data and is not coded

would be listed on the

report.

ANS: Discharge Not Final Billed DIF: Moderate 7.

REF: 451

OBJ: 2

is the reimbursement method frequently used in managed care in which the hospital or health care provider is given a set amount of money each month to provide all care for a patient over a period of time.

ANS: Capitation DIF: Moderate

REF: 453

OBJ: 11

8. The federal law that prohibits pregnant patients without insurance from being transferred to

another hospital if they are in active labor is the

.

ANS: Emergency Medical Treatment and Labor Act DIF: Moderate

REF: 453

OBJ: 11

9. The MS-DRG-based system is a complex

-tiered system.

ANS: three DIF: Moderate 10.

REF: 454

OBJ: 7

is a preexisting condition that will, because of its effect on the specific principal diagnosis, require more intensive therapy or cause an increase in length of stay by at least 1 day in approximately 75% of cases.

ANS: Comorbidity DIF: Moderate

REF: 454

OBJ: 7

are DRG cases that cannot be assigned properly because of an

11.

atypical situation.

ANS: Cost outliers DIF: Moderate

REF: 454

OBJ: 7

12. The amount of reimbursement for the assigned MS-DRG is based on

as assigned by

CMS. ANS: relative weight DIF: Moderate

REF: 454

OBJ: 7

13. An unethical practice of upcoding a patient’s DRG category for a more severe diagnosis to

increase reimbursement is called

.

ANS: DRG creep DIF: Moderate

REF: 455

OBJ: 7

14. APC reimbursement to the hospital is

if the patient is prepared for surgery, taken to the operating room, anesthesia was administered and the surgery was cancelled just prior the surgery being started.

ANS: reduced or discounted DIF: Hard

55STBANKS OE BL J: LE 8 R.COM REF: T4E

15. Hospitals that provide services to patients who no longer need acute care, but their level of

care is still significant, are reimbursed under the _ System

Prospective Payment

ANS:

Long Term Care Hospital (LTCH PPS) Long Term Care Hospital LTCH PPS DIF: Hard

REF: 455

OBJ: 11

16. A

bed is a bed in an acute care hospital that can be used for either acute care or for skilled nursing facility care.

ANS: swing DIF: Moderate

REF: 456

OBJ: 11

17. The IPF PPS reimbursement system is used for hospitals that provide ANS: psychiatric

care.

DIF: Moderate

REF: 456

OBJ: 11

18. Payment to ambulance transport services is a base rate plus

to the closest appropriate

facility.

ANS: mileage DIF: Moderate

REF: 456

OBJ: 11

SHORT ANSWER 1. What is QIO an abbreviation for?

ANS:

Quality improvement organization peer review organization DIF: Moderate

REF: 453

OBJ: 11

2. What does the abbreviation CC indicate when used with DRGs? ANS:

Complication and comorbidities DIF: Moderate

REF: 454

OBJ: 7

3. What are the 13 conditions that qualify rehabilitation hospitals for reimbursement under the

Inpatient Rehabilitation Facility Prospective Payment System if 60% of their patients are treated for one of the conditions?

ANS:

Stroke, spinal cord injury, congenital anomaly, amputation of limb, multiple trauma, fracture of femur, injury to the brain, specified neurological disorders such as Parkinson’s Disease, burns, specific arthropathies causing difficulty with activities of daily living, systemic vasculitides with inflammation of the joints, causing difficulty with activities of daily living, osteoarthritis (severe), knee, and/or hip replacement (procedure must be bilateral, patient obese or patient 85 years of age or older).

DIF: Hard

REF: 456

OBJ: 11

TRUE/FALSE 1. The technical portion of diagnostic x-ray services related to an inpatient admission and

provided within 72 hours of admission to the same hospital is bundled with the inpatient service claim.

ANS: T

DIF: Moderate

REF: 446

OBJ: 3

2. Ambulance services related to an inpatient admission and provided within 72 hours of

admission are bundled with the inpatient service claim.

ANS: F

DIF: Moderate

REF: 447

OBJ: 3

3. Open heart surgery is on Medicare’s IPO list of procedures as it is considered to be too risky

to be performed on an outpatient basis.

ANS: T

DIF: Hard

REF: 447

OBJ: 1

4. Patients are admitted to either observation or inpatient care, depending upon what rooms the

hospital has available.

ANS: F

DIF: Moderate

REF: 447

OBJ: 1

5. A retrospective review is an evaluation of health care services to determine medical necessity

and appropriateness of the care provided during the time services are being provided.

ANS: F

DIF: Moderate

REF: 447

OBJ: 1

6. Revenue codes are five-digit codes on a chargemaster used to group similar types of services,

supplies, equipment, and so forth provided by the hospital.

ANS: F

DIF: Moderate

REF: 448

OBJ: 5

7. The discharge disposition is the order a physician writes, releasing a patient from the hospital.

ANS: F

DIF: Moderate

REF: 448

OBJ: 1

rvS icT esB, A thN eK coSdEinLgLsE ysRte.mCuOsM ed for procedures depends on if the 8. When coding for hospital sTeE patient is an outpatient or inpatient.

ANS: T

DIF: Moderate

REF: 448

OBJ: 7

9. If a patient presents to the hospital with chest pain, and after running test, the physician

determines that the chest pain is caused by an acute myocardial infarction, the chest pain is the principal diagnosis.

ANS: F

DIF: Moderate

REF: 448

OBJ: 7

10. The seventh character of an ICD-10-PCS code is the approach which identifies how the

surgery was performed (open, laparoscopically, endoscopically).

ANS: F

DIF: Easy

REF: 449

OBJ: 6

11. On the UB-04, there are 81 form locators, or fields which are divided into five sections.

ANS: T

DIF: Moderate

REF: 450

OBJ: 1

12. A comorbidity is a diagnosis or condition that arises during the patient’s hospitalization that

increases the patient’s length of stay.

ANS: F

DIF: Moderate

REF: 454

OBJ: 7

Chapter 20: Seeking a Job and Attaining Professional Advancement Smith: Fordney’s Medical Insurance, 15th Edition MULTIPLE CHOICE 1. Career titles that an individual with insurance billing training may be interested in applying

for would include all of the following EXCEPT a. electronic claims processor. b. Medicare billing specialist. c. reimbursement specialist. d. medical office assistant.

ANS: D

DIF: Easy

REF: 461

OBJ: 1

2. As the insurance billing specialist gains experience and additional knowledge, employment

opportunities in more advanced roles would include all of the following EXCEPT a. claims examiner. b. coding specialist. c. clinical documentation improvement specialist. d. auditor.

ANS: A

DIF: Moderate

REF: 461

OBJ: 1

3. An individual who oversees billing teams that manage accounts, communications with

insurance, collections, contract analysis, cash posting, billing transactions with clients and report created is referred to as a. office manager. b. claims manager. c. revenue cycle manager. d. compliance manager.

ANS: C

DIF: Moderate

REF: 462

OBJ: 1

4. The process of earning a credential through a combination of advanced education and

experience and completion of the requirements of an association is referred to as a. credentialing. b. career advancement. c. certification. d. networking.

ANS: C

DIF: Easy

REF: 462

OBJ: 2

5. Sending a resume and cover letter to an employer who you do not know personally and who

has not advertised for a job opening is referred to as a. networking. b. cold calling. c. blind mailing. d. a and b.

ANS: C

DIF: Moderate

REF: 467

OBJ: 3

6. When attending job fairs, it is wise to go prepared and practice a

introduction before

attending. a. 15-second b. 30-second c. 1-minute d. 2-minute ANS: B

DIF: Easy

REF: 468

OBJ: 4

7. When completing a job application form, if a question does not apply or cannot be answered,

you should a. leave the answer blank. b. insert “NA” for not applicable. c. insert “CA” for cannot answer. d. b or c.

ANS: B

DIF: Easy

REF: 468

OBJ: 5

8. When completing a job application form, if there is a question asked about salary amount, it is

best to a. write down an amount higher than what you expect. b. write down an amount lower than what you expect. c. write in “negotiable.” d. write in “whatever is offered.”

ANS: C

DIF: Moderate

REF: 468

OBJ: 5

9. The main goal of a cover lT etE teS r iTs B toANKSELLER.COM a. introduce yourself. b. state a summary of your qualities. c. take notice of your resume. d. provide information on how you can be reached.

ANS: C

DIF: Moderate

REF: 471

OBJ: 6

REF: 471

OBJ: 6

10. Cover letters should be a. customized. b. typed for neatness. c. addressed to a specific person. d. all of the above.

ANS: D

DIF: Moderate

11. A functional résumé a. lists the most recent work experiences first with dates and descriptive data for each

job. b. states the applicant’s qualifications or skills the individual is able to perform. c. lists the applicant’s job skills, education, and employment history. d. introduces the applicant and summarizes all important data.

ANS: B

DIF: Moderate

12. The ideal length for a résumé is

REF: 472

OBJ: 7

a. b. c. d.

one page. two pages. three pages. dependent on the work history of the applicant.

ANS: A

DIF: Moderate

REF: 472

OBJ: 7

13. The preferred type of résumé for an insurance billing specialist to submit is one using a. chronologic format. b. functional format. c. combination format. d. basic format.

ANS: C

DIF: Moderate

REF: 472

OBJ: 7

14. All of the following should be included in a résumé EXCEPT: a. education. b. salary requirements. c. previous place of employment. d. telephone number.

ANS: B

DIF: Moderate

REF: 473

OBJ: 7

15. Accounts receivable bookkeeping experience would be listed on a résumé under the heading a. skills. b. education. c. professional experience. d. references.

ANS: A

DIF: Moderate

REF: 473

OBJ: 7

16. Under the title “References” on a résumé, the applicant should a. list names in order, according to how long he or she has known each person; list

longest relationship first. b. list names in order, according to how influential the person is; list most influential

person first. c. list names in alphabetic order, with last names first. d. type in the phrase “Furnished on request.”

ANS: D

DIF: Moderate

REF: 473

OBJ: 7

17. In an interview, inquiries about all of the following are illegal EXCEPT a. family planning. b. dependents. c. maiden name. d. place of last employment.

ANS: D

DIF: Hard

REF: 474

OBJ: 9

18. According to the IRS, payroll records and summaries should be retained a. for 3 years. b. for 5 years. c. for 7 years.

d. permanently.

ANS: C

DIF: Hard

REF: 478

OBJ: 11

19. When an individual wishes to start his or her own medical billing service, he or she should

have sufficient funds to run the business for a period of a. 2–4 months. b. 3–6 months. c. 1 year or more. d. 1–3 years.

ANS: C

DIF: Moderate

REF: 478

OBJ: 11

20. Under HIPAA, when a health care provider outsources billing, this individual is known as a a. Certified Medical Billing Specialist. b. Registered Medical Coder. c. business associate. d. billing associate.

ANS: C

DIF: Moderate

REF: 479

OBJ: 11

21. A medical insurance billing specialist prices his or her services by a. percentage of reimbursement. b. an annual or hourly fee. c. a set fee per claim. d. all of the above.

ANS: D

DIF: Moderate

REF: 480

OBJ: 11

COMPLETION 1. An employer may evaluate the application itself to determine whether the applicant can follow

.

ANS:

instructions directions DIF: Moderate

REF: 468

OBJ: 5

2. A résumé that provides recent experiences first, with dates and descriptive data for each job, is

.

ANS: chronologic DIF: Moderate

REF: 471

OBJ: 7

3. A résumé that states the skills an individual is able to perform is ANS: functional DIF: Moderate

REF: 472

OBJ: 7

.

4. A résumé that summarizes the applicant’s job skills, as well as educational and employment

history, is of the

.

ANS: combination style DIF: Moderate

REF: 472

OBJ: 7

5. When writing a resume, it is important to name all employers in

order and to

include addresses, telephone numbers and dates of employment.

ANS: reverse chronological DIF: Moderate

REF: 473

OBJ: 7

6. When writing a resume, it is important to type the phrase “references furnished upon requests”

and to contact approximately

individuals to reference.

ANS:

five 5 DIF: Moderate

REF: 473

OBJ: 7

the résumé carefully for spelling, punctuation, grammatical, and

7.

typographic errors.

ANS: Proofread DIF: Moderate

REF: 473

OBJ: 7

8. It has been found that when applicants have similar skills and education, the decision to hire

has been based on

at the interview.

ANS: physical appearance DIF: Moderate

REF: 473

OBJ: 8

9. If an interviewer asks a question about marital status, provision for child care or family

planning, it is illegal, and you may want to refuse to answer the question and contact the nearest office.

ANS: EEOC DIF: Hard

REF: 474

OBJ: 9

10. Letters of recommendation, school diplomas or degrees, certificates, names and addresses of

references, and some neatly typed insurance claim forms are items an applicant may enclose in a/an .

ANS: web-based portfolio

DIF: Moderate

REF: 474

OBJ: 10

11. It is recommended that a job seeker write a follow-up letter or send an e-mail message within

of the interview to thank the person for the interview and restate your interest in the position.

ANS: 24 hours DIF: Moderate

REF: 474

OBJ: 10

12. When working from home, it is important to follow all HIPAA privacy regulations and protect

all

,

, and

information from family members and visitors.

ANS:

oral written electronic oral written electronic written electronic oral written oral electronic electronic oral written electronic written oral oral, written, electronic oral, written, electronic written, electronic, oral written, oral, electronic electronic, oral, written electronic, written, oral DIF: Moderate

REF: 474

OBJ: 11

13. Individuals who intend to start their own business should begin with a smart

to ensure success.

ANS: business plan DIF: Moderate

REF: 477

OBJ: 11

14. Individuals who intend to start their own business should consider purchasing

insurance to protect them and the company from claims if a client holds them responsible for errors or the failure to perform as promised in a service contract.

ANS:

professional liability/error and omissions insurance professional liability error and omissions insurance DIF: Moderate

REF: 478

OBJ: 11

15. An individual who operates their own medical billing company must remember that under

HIPAA, a Business Associate must agree to use appropriate patient’s PHI and to prevent unauthorized use or disclosure of PHI.

to protect

ANS: safeguards DIF: Hard

REF: 479

OBJ: 11

16. An individual who operates their own medical billing company should enter into a

contract with their clients, which is a necessary document that defines the duties and obligations of each party involved in the business relationship.

ANS: service DIF: Hard

REF: 479

OBJ: 11

17. An individual who operates their own medical billing company should seek legal advice when

structuring fee schedules for clients as some states consider

_ billing illegal.

ANS: percentage DIF: Hard

REF: 480

OBJ: 11

18. A

is a service that maintains an environment to grow and nurture small businesses by offering an array of business assistance services, shared resources, and networking.

ANS: business incubator DIF: Moderate

19.

REF: 481

OBJ: 11

is essential for developing any career through the exchange of information or services among individuals, groups, or institutions and making use of professional contacts.

ANS: Networking DIF: Moderate

REF: 481

OBJ: 1

20. An individual who can assist with career development by offering advice, criticism, wisdom,

guidance, and perspective to someone starting a new career path is a business.

in

ANS: mentor DIF: Moderate

REF: 481

OBJ: 1

21. An individual who holds the Certified Professional Coder (CPC) credential has taken an

examination of approximately 5 hours in length that has been prepared by the organization.

ANS:

American Academy of Professional Coders (AAPC) American Academy of Professional Coders AAPC DIF: Moderate

REF: 465

OBJ: 2

SHORT ANSWER 1. List five ways to search for a job.

ANS:

Any 5 of the following 18 answers are correct: network with other professionals; attend meetings; contact school placement personnel; tell classmates, instructors, and friends; contact pharmaceutical representatives; visit public and private employment agencies; inquire at state and federal government offices and their employment agencies; look for part-time employment; check bulletin boards in personnel offices; go to the local medical society; send a blind mailing; visit the city’s Chamber of Commerce; subscribe to an online newspaper; telephone job hotlines of large medical clinics; cold call at job locations; explore the Internet using a smart phone, tablet, or computer; search names of professional offices and hospitals near your location to contact.

DIF: Moderate

REF: 467

OBJ: 3

2. What should a cover letter end with?

ANS:

A request for an interview DIF: Moderate

REF: 471

OBJ: 6

TRUE/FALSE 1. Because coding errors can result in accusations of fraud and abuse, coding specialist is

expected to code with a minimum of 75% accuracy.

ANS: F

DIF: Easy

REF: 461

OBJ: 1

2. Revenue cycle managers are hired only by hospitals.

ANS: F

DIF: Easy

REF: 462

OBJ: 1

3. An insurance billing specialist should join a professional organization of billers because this

helps in keeping up to date with current trends.

ANS: T

DIF: Easy

REF: 462

OBJ: 1

4. Individuals who are certified through professional organizations must earn continuing

education credits to maintain their certification credential.

ANS: T

DIF: Easy

REF: 467

OBJ: 2

5. An insurance billing specialist may be employed by a physician, hospital, or other medical

facility or may choose to be self-employed.

ANS: T

DIF: Easy

REF: 467

OBJ: 1

6. A blind mailing means sending information to potential employers who have not advertised a

job opening.

ANS: T

DIF: Moderate

REF: 467

OBJ: 3

7. It is recommended that cover letters be hand-written, to provide the potential employer with a

sampling of your hand-writing.

ANS: F

DIF: Moderate

REF: 471

OBJ: 6

8. Education and professional experience should be listed on a résumé in chronologic order.

ANS: F

DIF: Moderate

REF: 473

OBJ: 7

9. It is a well-known fact that the first 30 seconds of a job interview makes either a positive or

negative impression.

ANS: T

DIF: Moderate

REF: 473

OBJ: 8

10. It is discriminatory for an employer to ask if an applicant smokes.

ANS: F

DIF:

EF 47R4.COM TMEoSdeTraBteANKSRE L:LE

OBJ: 9

11. If an employer asks an illegal question, it is all right for an applicant to answer the question

and ignore the fact that he or she knows it is illegal.

ANS: F

DIF: Hard

REF: 474

OBJ: 9

12. All employees must have on file with his or her employer an Employment Eligibility

Verification Form.

ANS: T

DIF: Moderate

REF: 474

OBJ: 8

13. Never use a post office box for a home-based business.

ANS: F

DIF: Moderate

REF: 477

OBJ: 11

14. The IRS mandates that bank statements and canceled checks of a business be retained

permanently.

ANS: F

DIF: Moderate

REF: 478

OBJ: 11

15. According to the IRS, tax documents should be maintained permanently.

ANS: F

DIF: Moderate

REF: 478

OBJ: 11

16. It is never acceptable to fax a résumé to a prospective employer.

ANS: F

DIF: Moderate

REF: 481

OBJ: 7