MOA 183 - Intro to Health Insurance » Fall 2022 » Exam 1 Chapters 1 - 4
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Question #1
To avoid the higher costs of healthcare, employers:
A.
decreased the number of health plans available to employees.
B.
refused to extend health insurance to employees.
C.
hired younger employees.
D.
increased employee premium contributions.
Question #2
Managed care systems ensure the delivery of high-quality care while managing costs through:
A.
provider networks and regular premium increases.
B.
discounted fees for services and mandatory high deductibles across all health plans.
C.
provider networks and discounted fees for services.
D.
prohibiting the use of out-of-network providers.
Question #3
To determine the amount due from a patient, it is necessary to know the:
A.
adjusted amount.
B.
diagnostic code.
C.
billed amount.
D.
allowed amount.
Question #4
In a managed care organization (MCO), a primary care physician (PCP) is any of the following EXCEPT:
A.
family practitioner.
B.
dermatologist.
C.
general practitioner.
D.
internal medicine doctor.
Question #5
The duties of a primary care physician (PCP) in a health maintenance organization (HMO) include:
A.
coordinating patient care.
B.
acting as a gatekeeper to services.
C.
All of these.
D.
referring patients to specialists.
Question #6
The subscriber in a health maintenance organization (HMO) can also be called a(n):
A.
member or provider.
B.
policyholder or member.
C.
patient or carrier.
D.
employer or policyholder.
Question #7
Which is true regarding health reimbursement arrangements (HRAs)?
A.
participation ends upon termination of employment.
B.
the funds cannot be used for dental and vision care.
C.
unused reimbursements cannot be accessed.
D.
expenses must have incurred during the coverage period.
Question #8
By accepting lower payments from MCOs, physicians are forced to see more patients each day in order to:
A.
deliver MCO-required preventive care.
B.
minimize malpractice suits.
C.
enroll more members in the health plan.
D.
maintain their income.
Question #9
All of the following are types of health maintenance organizations (HMOs) EXCEPT the:
A.
open access model.
B.
preferred provider model.
C.
individual practice association.
D.
group model.
Question #10
All the following are true regarding the Affordable Care Act EXCEPT:
A.
It is also known as Obamacare.
B.
It requires people to prove citizenship before receiving services.
C.
It cannot deny coverage due to a pre-existing condition.
D.
It offers five different types of government plans.
Question #11
Which of the following is a characteristic of a preferred provider organization (PPO)?
A.
Members must obtain referrals to see a specialist.
B.
It includes a contracted network of providers.
C.
The plan is more restrictive than a health maintenance organization (HMO).
D.
Members select a primary care physician (PCP) as a gatekeeper.
Question #12
Advantages of managed care include all of the following EXCEPT:
A.
Physicians run the risk of unfavorable evaluations by enrollees.
B.
Data is collected and analyzed to measure health outcomes.
C.
Hospitals and physicians provide services more efficiently.
D.
Providers strive to improve the quality of their care.
Question #13
An exclusive provider organization (EPO) is similar to a preferred provider organization (PPO) because they both have:
A.
a flexible benefit design.
B.
gatekeepers.
C.
payment by capitation.
D.
a limited provider network.
Question #14
Physician-hospital organizations (PHOs) may include:
A.
surgery centers.
B.
nursing homes.
C.
laboratories.
D.
All of these.
Question #15
Group insurance is issued to an employer to provide coverage for:
A.
employees and children only.
B.
employees only.
C.
employees and all their dependents.
D.
employees and spouses only.
Question #16
The type of policy that would provide coverage for custodial care in a nursing home is:
A.
special risk insurance.
B.
long-term care insurance.
C.
short-term health insurance.
D.
major medical insurance.
Question #17
Contracts between the physician and managed care organization (MCO) are generally negotiated by the:
A.
physician or upper management.
B.
medical office specialist.
C.
attorney.
D.
account manager or business manager.
Question #18
A managed care contract is considered a legal document between the:
A.
insurer and employer.
B.
patient and insurer.
C.
provider and patient.
D.
provider and insurer.
Question #19
A provider who enters into a contract with an MCO is referred to as a(n):
A.
permanent provider.
B.
active provider.
C.
participating provider.
D.
MCO provider.
Question #20
A managed care contract will include a:
A.
list of patients covered by the plan.
B.
description of what types of employer groups are offered coverage.
C.
description of how the physician will be paid for services.
D.
list of physicians in the network.
Question #21
Under a discounted fee-for-service arrangement, covered services are compensated at a:
A.
reduced per-case rate.
B.
per-member-per-month rate.
C.
reduced percentage of usual and customary charges.
D.
discounted per-diem rate.
Question #22
According to some contract terms, if an MCO does not pay a claim within the time limit specified in the contract, the provider may be able to:
A.
terminate the MCO contract after filing a written notice of intention.
B.
charge the usual and customary fee instead of the discounted fee.
C.
take legal action against the MCO.
D.
bill the patient directly.
Question #23
In plans that require the primary care physician (PCP) to play a gatekeeper role, the PCP is given incentives to:
A.
expand office hours and/or staff to permit more patients to be seen each day.
B.
make frequent referrals to contracted network specialists.
C.
see as many patients each day as possible, even if this means less time with each patient.
D.
treat the patient as much as possible without a specialist referral unless absolutely necessary.
Question #24
In MCOs, the business aspects of healthcare are not being controlled by:
A.
accountants.
B.
managers.
C.
actuaries.
D.
physicians.
Question #25
A managed care organization (MCO) uses a credentialing process to evaluate a provider's:
A.
workplace environment.
B.
service fees.
C.
medical credentials.
D.
All of these.
Question #26
With respect to National Committee for Quality Assurance (NCQA) accreditation:
A.
some MCOs are accredited, and some are not.
B.
MCOs must be accredited to operate.
C.
MCOs have all asked to be accredited, but some do not qualify.
D.
accredited MCOs are always better than nonaccredited MCOs.
Question #27
In the Patient's Bill of Rights under the Affordable Health Care Act, young adults who are not offered coverage at work are covered by their parents' plan until they reach:
A.
25
B.
26
C.
21
D.
19
Question #28
Types of payment arrangements in managed care contracts include discounted fee-for-service, per diem, per case, percentage of premiums, and capitation.
A.
True
B.
False
Question #29
ACOs are a group of insurance providers.
A.
False
B.
True
Question #30
Most managed care contracts allow an unlimited time frame for submitting claims.
A.
False
B.
True
Question #31
In order to receive National Committee for Quality Assurance (NCQA) accreditation, a managed care organization (MCO) must demonstrate that it has a thorough credentialing process.
A.
False
B.
True
Question #32
Patients are typically very familiar with their health plan benefits when discussing claims issues with the medical office specialist.
A.
False
B.
True
Question #33
A managed care organization will contract with physicians, laboratories, pharmacies, hospitals, clinics, and other healthcare facilities in building a provider network.
A.
True
B.
False
Question #34
HIPAA guidelines apply to which of the following types of healthcare administrative transactions?
A.
All of these
B.
claim status requests and reports
C.
eligibility requests and verifications
D.
health insurance claims
Question #35
Under the HIPAA Privacy Rule, a physician can discuss a patient's medical condition or treatment with a family member or friend without written consent when:
A.
the patient is unconscious.
B.
the payment for services is past due.
C.
the patient has given verbal consent.
D.
both the patient is unconscious and the patient has given verbal consent.
Question #36
The document used to authorize permission for the release of protected health information (PHI) is the:
A.
acknowledgment of informed consent form.
B.
designation of beneficiary form.
C.
designation for release of medical information form.
D.
assignment of benefits form.
Question #37
Protected health information (PHI) can be disclosed in which of the following circumstances?
A.
All of these
B.
An organ procurement organization requests it to facilitate the donation and transplantation of organs.
C.
The U.S. Food and Drug Administration requests it in relation to a product recall.
D.
A coroner requests it to assist in identifying a body.
Question #38
HIPAA guidelines grant patients the right to access their own medical records and the right to:
A.
request corrections of any inaccuracies in the records.
B.
file a complaint about how long it takes to get a claim paid.
C.
at least 10 free copies.
D.
designate a specific person at an insurance company who may also have access.
Question #39
In the event of a security breach in regard to protected health information (PHI), providers and other covered entities must notify both the Office for Civil Rights (OCR) and the:
A.
individuals whose records were affected.
B.
Centers for Medicare and Medicaid Services (CMS).
C.
Consumer Protection Agency.
D.
insurance carriers whose claims were affected.
Question #40
Approximately how many different formats are currently being used for electronic health claims?
A.
350
B.
400
C.
450
D.
500
Question #41
HIPAA requires that diagnoses and services be reported in a standard, consistent manner; this is accomplished by using uniform:
A.
code sets.
B.
claim forms.
C.
descriptors.
D.
modifiers.
Question #42
The three types of safeguards that must be in place to be in compliance with the HIPAA Security Rule are:
A.
technical, training, and administrative.
B.
administrative, physical, and electronic.
C.
physical, technical, and procedural.
D.
physical, administrative, and technical.
Question #43
Criminal penalties for HIPAA violations can include prison time and financial penalties up to what maximum amount?
A.
$150,000
B.
$400,000
C.
$100,000
D.
$250,000
Question #44
The HITECH Act expands the privacy provisions of HIPAA to include:
A.
friends and family of providers.
B.
corporate owners of covered entities.
C.
business associates of covered entities.
D.
friends and family of patients.
Question #45
Healthcare providers who achieve the standards of each HITECH stage by a designated date are eligible for:
A.
Medicare and Medicaid incentive payments.
B.
free license renewals as long as they remain in practice.
C.
Medicare incentive payments.
D.
Medicaid incentive payments.
Question #46
Providers who do NOT achieve the HITECH meaningful use standards in 2017 will face penalties that consist of a:
A.
3 % reduction of Medicare reimbursement.
B.
2 % reduction of Medicare reimbursement.
C.
4 % reduction of Medicare reimbursement.
D.
1% reduction of Medicare reimbursement.
Question #47
A healthcare provider is not allowed to discuss a patient's medical condition or payment with a person over the phone.
A.
True
B.
False
Question #48
When patients ask a family member to remain with them in a treatment room, this implies that they have given permission for the doctor and/or staff to discuss their condition in front of the family member.
A.
True
B.
False
Question #49
Patients have the right to access and copy their medical records, but they cannot dispute anything in the record.
A.
False
B.
True
Question #50
The Omnibus Rule requires standards for the disclosure and use of protected health information (PHI), including established standards of enforcement for penalties and breach notification.
A.
True
B.
False
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