MOA 183 - Intro to Health Insurance » Fall 2022 » Midterm Exam Chapter 2 to 9 & 16
Need help with your exam preparation?
Get Answers to this exam for $6 USD.
Get Answers to all exams in [ MOA 183 - Intro to Health Insurance ] course for $25 USD.
Existing Quiz Clients Login here
Question #1
Managed care systems ensure the delivery of high-quality care while managing costs through:
A.
prohibiting the use of out-of-network providers.
B.
discounted fees for services and mandatory high deductibles across all health plans.
C.
provider networks and regular premium increases.
D.
provider networks and discounted fees for services.
Question #2
To determine the amount due from a patient, it is necessary to know the:
A.
billed amount.
B.
adjusted amount.
C.
diagnostic code.
D.
allowed amount.
Question #3
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 #4
By accepting lower payments from MCOs, physicians are forced to see more patients each day in order to:
A.
minimize malpractice suits.
B.
enroll more members in the health plan.
C.
maintain their income.
D.
deliver MCO-required preventive care.
Question #5
All of the following are types of health maintenance organizations (HMOs) EXCEPT the:
A.
individual practice association.
B.
preferred provider model.
C.
open access model.
D.
group model.
Question #6
A managed care contract should clearly state all of the following EXCEPT:
A.
when payment should be received from the MCO.
B.
the list of employers with MCO contracts.
C.
how much the physician will be paid for services.
D.
the time limit for submitting claims to the MCO.
Question #7
A medical office specialist must do all the following EXCEPT:
A.
explain the ACO to the patient.
B.
be familiar with managed care terms.
C.
know the Patient Bill of Rights.
D.
promote the provider network.
Question #8
The schedule of benefits section of a managed care contract lists the:
A.
benefits of participating in the managed care plan.
B.
providers in the contracted network.
C.
deductible and coinsurance amounts that patients must pay.
D.
medical services covered under the managed care plan.
Question #9
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 #10
The credentialing process of a managed care organization (MCO) will examine each physician's background for evidence of all of the following EXCEPT:
A.
salary history.
B.
malpractice history.
C.
disciplinary actions.
D.
criminal activity.
Question #11
Under the HIPAA Privacy Rule, a patient's medical record and payment history are considered:
A.
electronically transmitted data.
B.
managed care plan information.
C.
secure medical data.
D.
protected health information.
Question #12
A person who has a privacy complaint can file it with the:
A.
Office for Civil Rights (OCR).
B.
Centers for Medicare and Medicaid Services (CMS).
C.
American Medical Association (AMA).
Question #13
The process of scrambling and encoding electronic data to prevent it from being read by unauthorized users is known as:
A.
coding.
B.
encryption.
C.
translation.
D.
transcription.
Question #14
ICD-10-CM codes submitted on insurance claim forms are used to:
A.
report specific procedures and services.
B.
determine medical necessity for covered procedures and services.
C.
report patient demographic information.
D.
record a patient's office visits or inpatient days.
Question #15
The ICD-10-PCS is used to report:
A.
proper mortality coding.
B.
inpatient procedure coding.
C.
outpatient procedure coding.
D.
proper diagnosis coding.
Question #16
To locate the correct code for the first encounter, the medical specialist must first look for the term in the:
A.
Tabular List of Diseases and Injuries.
B.
Alphabetic Index.
C.
External Causes Index.
D.
Neoplasm Table.
Question #17
Subterms in an ICD-10-CM entry may show:
A.
another name for the disease.
B.
treatments of the disease.
C.
the cause or origin of the disease.
D.
a better description of the disease.
Question #18
The code next to the main term is called the:
A.
default code.
B.
specified code.
C.
combination code.
D.
primary code.
Question #19
Each medical practice must appoint a person to serve as its Privacy Compliance Officer, who must be familiar with federal and state privacy regulations in order to:
A.
respond to requests for medical records and handle privacy-related complaints.
B.
respond to insurance carriers' questions and handle patient billing complaints.
C.
represent the practice in any lawsuits that arise over privacy issues.
D.
file monthly reports with the office of the state insurance commissioner.
Question #20
Providers are legally obligated to disclose protected health information (PHI) to public health authorities when a:
A.
person may have been exposed to certain communicable diseases.
B.
patient or staff member has a prison record.
C.
patient has returned from a trip to a country with poor sanitation.
D.
particularly severe flu epidemic has occurred.
Question #21
In what year did CMS require state Medicaid agencies to use CPT codes for reporting outpatient hospital procedures as part of the Omnibus Budget Reconciliation Act?
A.
1977
B.
2006
C.
1992
D.
1986
Question #22
The temporary codes used for emerging technology, services, or procedures are:
A.
Category III CPT codes.
B.
Category I CPT codes.
C.
Category II CPT codes.
D.
ICD-10-CM codes.
Question #23
The most-often reported evaluation and management (E/M) services are:
A.
hospital (inpatient) services.
B.
consultations.
C.
office and other outpatient services.
D.
emergency room services.
Question #24
A new patient is considered one who has NOT received professional services from the physician or another physician of the same specialty in the same group within the past:
A.
3 years.
B.
2 years.
C.
1 year.
D.
5 years.
Question #25
Details about a patient's current employment or school history would be part of a:
A.
family history.
B.
history of present illness.
C.
past history.
D.
social history.
Question #26
Details about the health status or cause of death of parents, siblings, and children would be part of a:
A.
history of present illness.
B.
family history.
C.
past history.
D.
social history.
Question #27
Managed care is a system in which physicians contract to participate in a health insurance network and healthcare delivery is:
A.
based on the patient's ability to pay.
B.
at the discretion of the physician.
C.
monitored to control costs.
D.
provided only by in-network physicians.
Question #28
A practice with 10 or more physicians would generally be categorized as a:
A.
private practice.
B.
small-group practice.
C.
solo practice.
D.
large-group practice.
Question #29
The healthcare professional who researches data in medical records in order to accurately document diagnoses and procedures and obtain maximum reimbursement for physicians is the:
A.
medical collector.
B.
medical coder.
C.
medical office assistant.
D.
payment poster.
Question #30
The healthcare professional who is responsible for answering questions and explaining topics such as HIPAA privacy regulations, living wills, and do-not-resuscitate orders (DNRs) to patients and their family members is the:
A.
medical collector.
B.
insurance verification representative.
C.
privacy compliance officer.
D.
admitting clerk.
Question #31
The duties and responsibilities of a medical biller may include all of the following EXCEPT:
A.
submitting insurance claims.
B.
contacting insurance carriers on incorrectly paid claims.
C.
analyzing patient charge information.
D.
explaining HIPAA regulations.
Question #32
The duties and responsibilities of a privacy compliance officer may include all of the following EXCEPT:
A.
data entry of patient demographics.
B.
explaining DNR orders to patients and their family members.
C.
answering questions about privacy regulations.
D.
posting payments or making adjustments to patient accounts.
Question #33
The Certified Professional Coder (CPC) certification is awarded through the:
A.
National Healthcareer Association.
B.
American Health Information Management Association.
C.
American Academy of Professional Coders.
D.
National Center for Competency Testing.
Question #34
A large-group practice will frequently contract out its billing and accounts receivable.
A.
True
B.
False
Question #35
HCPCS Level II codes in the range C1300—C9899 would be used for:
A.
private payer codes.
B.
diagnostic radiology services.
C.
orthotic procedures.
D.
temporary hospital outpatient.
Question #36
The code for durable medical equipment (DME) would be found in the:
A.
Level III HCPCS code book.
B.
Level II HCPCS code book.
C.
This is not considered a HCPCS code.
D.
Level I HCPCS code book.
Question #37
HCPCS Level II national codes are used in claims submitted to:
A.
private insurers only.
B.
self-funded plans only.
C.
public and private insurers.
D.
public insurers only.
Question #38
When each reported service is connected to a diagnosis that supports the procedure as medically necessary, the claim is referred to as:
A.
complete.
B.
authorized.
C.
accurate.
D.
clean.
Question #39
Billing the parts of a bundled procedure as separate procedures is referred to as:
A.
upcoding.
B.
unbundling.
C.
bundling.
D.
downcoding.
Question #40
The best way to be sure that an intended action will NOT be subject to investigation as fraud is to:
A.
get the advice of an attorney.
B.
obtain an advisory opinion from the Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS).
C.
submit the claim, and request an explanation if denied.
D.
base the decision on past practices.
Question #41
A postpayment audit would verify:
A.
patient insurance eligibility.
B.
sign-in sheets and appointment scheduling practices.
C.
patient insurance identification number.
D.
date of service.
Question #42
An internal audit would determine:
A.
whether procedures were coded correctly.
B.
the coder's skill and knowledge.
C.
All of these.
D.
if additional training is needed for office staff.
Question #43
An independent audit should be performed a minimum of:
A.
twice a year.
B.
once a year.
C.
once a month.
D.
once a quarter.
Question #44
If a physician documents that an exam included the measurement of a patient's blood pressure, the system examined would be the:
A.
musculoskeletal system.
B.
neurological system.
C.
cardiovascular system.
D.
respiratory system.
Question #45
If a physician who ordered a test personally reviews the results to supplement information from the physician who prepared the test report, the work would add to the level of the:
A.
number of diagnoses or management options.
B.
risk of significant complications, morbidity, and/or mortality.
C.
All of these.
D.
amount and/or complexity of data to be reviewed.
Question #46
An examination and verification of claims and supporting documentation submitted by a physician is known as a(n):
A.
review.
B.
reconsideration.
C.
audit.
D.
appeal.
Question #47
If a claim is denied because services were provided before insurance coverage was in effect, the medical office specialist should:
A.
write off the entire amount.
B.
wait until the effective date of the coverage, then bill the insurance carrier.
C.
bill the patient.
D.
change the date of service and resubmit the claim.
Question #48
Reasons for follow-up include:
A.
All of these.
B.
unclear denial of payment is received.
C.
reimbursement is received for an unknown patient.
D.
an incorrect payment is received.
Question #49
If a physician requests a peer review that results in confirmation that services were NOT medically necessary:
A.
the physician must pay for the review.
B.
there is no charge for the review.
C.
the patient should be billed for the review.
D.
the insurance carrier will pay for the review.
Question #50
Which of the following are reason codes that require a formal appeal?
A.
both noncovered emergency services and not related to diagnoses
B.
not related to diagnoses
C.
claim processing error
D.
noncovered emergency services
Need help with your exam preparation?
Get Answers to this exam for $6 USD.
Get Answers to all exams in [ MOA 183 - Intro to Health Insurance ] course for $25 USD.
Existing Quiz Clients Login here