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.
refused to extend health insurance to employees.
B.
hired younger employees.
C.
decreased the number of health plans available to 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.
provider networks and discounted fees for services.
C.
prohibiting the use of out-of-network providers.
D.
discounted fees for services and mandatory high deductibles across all health plans.
Question #3
To determine the amount due from a patient, it is necessary to know the:
A.
allowed amount.
B.
diagnostic code.
C.
billed amount.
D.
adjusted amount.
Question #4
In a managed care organization (MCO), a primary care physician (PCP) is any of the following EXCEPT:
A.
general practitioner.
B.
dermatologist.
C.
internal medicine doctor.
D.
family practitioner.
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.
patient or carrier.
B.
policyholder or member.
C.
member or provider.
D.
employer or policyholder.
Question #7
Which is true regarding health reimbursement arrangements (HRAs)?
A.
unused reimbursements cannot be accessed.
B.
participation ends upon termination of employment.
C.
expenses must have incurred during the coverage period.
D.
the funds cannot be used for dental and vision care.
Question #8
By accepting lower payments from MCOs, physicians are forced to see more patients each day in order to:
A.
enroll more members in the health plan.
B.
minimize malpractice suits.
C.
maintain their income.
D.
deliver MCO-required preventive care.
Question #9
All of the following are types of health maintenance organizations (HMOs) EXCEPT the:
A.
open access model.
B.
preferred provider model.
C.
group model.
D.
individual practice association.
Question #10
All the following are true regarding the Affordable Care Act EXCEPT:
A.
It requires people to prove citizenship before receiving services.
B.
It cannot deny coverage due to a pre-existing condition.
C.
It offers five different types of government plans.
D.
It is also known as Obamacare.
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.
The plan is more restrictive than a health maintenance organization (HMO).
C.
Members select a primary care physician (PCP) as a gatekeeper.
D.
It includes a contracted network of providers.
Question #12
Advantages of managed care include all of the following EXCEPT:
A.
Hospitals and physicians provide services more efficiently.
B.
Data is collected and analyzed to measure health outcomes.
C.
Providers strive to improve the quality of their care.
D.
Physicians run the risk of unfavorable evaluations by enrollees.
Question #13
An exclusive provider organization (EPO) is similar to a preferred provider organization (PPO) because they both have:
A.
a limited provider network.
B.
gatekeepers.
C.
payment by capitation.
D.
a flexible benefit design.
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 spouses only.
B.
employees only.
C.
employees and all their dependents.
D.
employees and children only.
Question #16
The type of policy that would provide coverage for custodial care in a nursing home is:
A.
major medical insurance.
B.
short-term health insurance.
C.
long-term care insurance.
D.
special risk insurance.
Question #17
Contracts between the physician and managed care organization (MCO) are generally negotiated by the:
A.
account manager or business manager.
B.
physician or upper management.
C.
attorney.
D.
medical office specialist.
Question #18
A managed care contract is considered a legal document between the:
A.
patient and insurer.
B.
insurer and employer.
C.
provider and insurer.
D.
provider and patient.
Question #19
A provider who enters into a contract with an MCO is referred to as a(n):
A.
MCO provider.
B.
active provider.
C.
permanent provider.
D.
participating provider.
Question #20
A managed care contract will include a:
A.
description of how the physician will be paid for services.
B.
list of patients covered by the plan.
C.
description of what types of employer groups are offered coverage.
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.
take legal action against the MCO.
C.
charge the usual and customary fee instead of the discounted fee.
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.
see as many patients each day as possible, even if this means less time with each patient.
B.
treat the patient as much as possible without a specialist referral unless absolutely necessary.
C.
expand office hours and/or staff to permit more patients to be seen each day.
D.
make frequent referrals to contracted network specialists.
Question #24
In MCOs, the business aspects of healthcare are not being controlled by:
A.
managers.
B.
actuaries.
C.
physicians.
D.
accountants.
Question #25
A managed care organization (MCO) uses a credentialing process to evaluate a provider's:
A.
workplace environment.
B.
All of these.
C.
medical credentials.
D.
service fees.
Question #26
With respect to National Committee for Quality Assurance (NCQA) accreditation:
A.
MCOs have all asked to be accredited, but some do not qualify.
B.
accredited MCOs are always better than nonaccredited MCOs.
C.
MCOs must be accredited to operate.
D.
some MCOs are accredited, and some are not.
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.
21
C.
19
D.
26
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.
False
B.
True
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.
True
B.
False
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.
claim status requests and reports
B.
health insurance claims
C.
eligibility requests and verifications
D.
All of these
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.
both the patient is unconscious and the patient has given verbal consent.
B.
the patient is unconscious.
C.
the patient has given verbal consent.
D.
the payment for services is past due.
Question #36
The document used to authorize permission for the release of protected health information (PHI) is the:
A.
designation of beneficiary form.
B.
designation for release of medical information form.
C.
acknowledgment of informed consent form.
D.
assignment of benefits form.
Question #37
A.
A coroner requests it to assist in identifying a body.
B.
All of these
C.
An organ procurement organization requests it to facilitate the donation and transplantation of organs.
D.
The U.S. Food and Drug Administration requests it in relation to a product recall.
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.
at least 10 free copies.
C.
designate a specific person at an insurance company who may also have access.
D.
file a complaint about how long it takes to get a claim paid.
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.
450
B.
350
C.
500
D.
400
Question #41
HIPAA requires that diagnoses and services be reported in a standard, consistent manner; this is accomplished by using uniform:
A.
modifiers.
B.
claim forms.
C.
descriptors.
D.
code sets.
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.
physical, administrative, and technical.
C.
physical, technical, and procedural.
D.
administrative, physical, and electronic.
Question #43
Criminal penalties for HIPAA violations can include prison time and financial penalties up to what maximum amount?
A.
$100,000
B.
$250,000
C.
$400,000
D.
$150,000
Question #44
The HITECH Act expands the privacy provisions of HIPAA to include:
A.
corporate owners of covered entities.
B.
business associates of covered entities.
C.
friends and family of providers.
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.
Medicaid incentive payments.
B.
Medicare and Medicaid incentive payments.
C.
Medicare incentive payments.
D.
free license renewals as long as they remain in practice.
Question #46
A.
4 % reduction of Medicare reimbursement.
B.
2 % reduction of Medicare reimbursement.
C.
1% reduction of Medicare reimbursement.
D.
3 % 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.
False
B.
True
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