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.
increased employee premium contributions.
B.
refused to extend health insurance to employees.
C.
decreased the number of health plans available to employees.
D.
hired younger employees.
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.
discounted fees for services and mandatory high deductibles across all health plans.
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.
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.
internal medicine doctor.
B.
dermatologist.
C.
general practitioner.
D.
family practitioner.
Question #5
The duties of a primary care physician (PCP) in a health maintenance organization (HMO) include:
A.
All of these.
B.
referring patients to specialists.
C.
acting as a gatekeeper to services.
D.
coordinating patient care.
Question #6
The subscriber in a health maintenance organization (HMO) can also be called a(n):
A.
member or provider.
B.
patient or carrier.
C.
policyholder or member.
D.
employer or policyholder.
Question #7
Which is true regarding health reimbursement arrangements (HRAs)?
A.
unused reimbursements cannot be accessed.
B.
the funds cannot be used for dental and vision care.
C.
expenses must have incurred during the coverage period.
D.
participation ends upon termination of employment.
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.
enroll more members in the health plan.
C.
maintain their income.
D.
minimize malpractice suits.
Question #9
All of the following are types of health maintenance organizations (HMOs) EXCEPT the:
A.
preferred provider model.
B.
individual practice association.
C.
group model.
D.
open access model.
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 is also known as Obamacare.
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.
The plan is more restrictive than a health maintenance organization (HMO).
B.
Members must obtain referrals to see a specialist.
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.
Physicians run the risk of unfavorable evaluations by enrollees.
C.
Providers strive to improve the quality of their care.
D.
Data is collected and analyzed to measure health outcomes.
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.
payment by capitation.
C.
gatekeepers.
D.
a flexible benefit design.
Question #14
Physician-hospital organizations (PHOs) may include:
A.
surgery centers.
B.
laboratories.
C.
nursing homes.
D.
All of these.
Question #15
Group insurance is issued to an employer to provide coverage for:
A.
employees only.
B.
employees and all their dependents.
C.
employees and spouses only.
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.
long-term care insurance.
C.
special risk insurance.
D.
short-term health 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.
provider and patient.
B.
provider and insurer.
C.
insurer and employer.
D.
patient and insurer.
Question #19
A provider who enters into a contract with an MCO is referred to as a(n):
A.
active provider.
B.
MCO provider.
C.
participating provider.
D.
permanent provider.
Question #20
A managed care contract will include a:
A.
description of how the physician will be paid for services.
B.
list of physicians in the network.
C.
description of what types of employer groups are offered coverage.
D.
list of patients covered by the plan.
Question #21
Under a discounted fee-for-service arrangement, covered services are compensated at a:
A.
discounted per-diem rate.
B.
per-member-per-month rate.
C.
reduced percentage of usual and customary charges.
D.
reduced per-case 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.
make frequent referrals to contracted network specialists.
B.
expand office hours and/or staff to permit more patients to be seen each day.
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.
physicians.
B.
actuaries.
C.
accountants.
D.
managers.
Question #25
A managed care organization (MCO) uses a credentialing process to evaluate a provider's:
A.
All of these.
B.
service fees.
C.
workplace environment.
D.
medical credentials.
Question #26
With respect to National Committee for Quality Assurance (NCQA) accreditation:
A.
some MCOs are accredited, and some are not.
B.
accredited MCOs are always better than nonaccredited MCOs.
C.
MCOs must be accredited to operate.
D.
MCOs have all asked to be accredited, but some do not qualify.
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.
26
B.
19
C.
21
D.
25
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.
True
B.
False
Question #30
Most managed care contracts allow an unlimited time frame for submitting claims.
A.
True
B.
False
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.
False
B.
True
Question #34
HIPAA guidelines apply to which of the following types of healthcare administrative transactions?
A.
health insurance claims
B.
eligibility requests and verifications
C.
All of these
D.
claim status requests and reports
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 payment for services is past due.
C.
the patient is unconscious.
D.
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.
designation for release of medical information form.
B.
designation of beneficiary form.
C.
assignment of benefits form.
D.
acknowledgment of informed consent form.
Question #37
A.
A coroner requests it to assist in identifying a body.
B.
An organ procurement organization requests it to facilitate the donation and transplantation of organs.
C.
All of these
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.
at least 10 free copies.
B.
designate a specific person at an insurance company who may also have access.
C.
request corrections of any inaccuracies in the records.
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.
Consumer Protection Agency.
B.
individuals whose records were affected.
C.
Centers for Medicare and Medicaid Services (CMS).
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.
450
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.
code sets.
B.
descriptors.
C.
claim forms.
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, administrative, and technical.
D.
physical, technical, and procedural.
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 patients.
B.
business associates of covered entities.
C.
corporate owners of covered entities.
D.
friends and family of providers.
Question #45
Healthcare providers who achieve the standards of each HITECH stage by a designated date are eligible for:
A.
free license renewals as long as they remain in practice.
B.
Medicare incentive payments.
C.
Medicare and Medicaid 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.
2 % reduction of Medicare reimbursement.
B.
1% reduction of Medicare reimbursement.
C.
4 % 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.
True
B.
False
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