MOA 183 - Intro to Health Insurance » Fall 2022 » Midterm Exam Chapter 2 to 9 & 16
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Question #1
Managed care systems ensure the delivery of high-quality care while managing costs through:
A.
provider networks and discounted fees for services.
B.
discounted fees for services and mandatory high deductibles across all health plans.
C.
provider networks and regular premium increases.
D.
prohibiting the use of out-of-network providers.
Question #2
To determine the amount due from a patient, it is necessary to know the:
A.
allowed amount.
B.
adjusted amount.
C.
billed amount.
D.
diagnostic code.
Question #3
In a managed care organization (MCO), a primary care physician (PCP) is any of the following EXCEPT:
A.
general practitioner.
B.
family practitioner.
C.
dermatologist.
D.
internal medicine doctor.
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.
maintain their income.
C.
deliver MCO-required preventive care.
D.
enroll more members in the health plan.
Question #5
All of the following are types of health maintenance organizations (HMOs) EXCEPT the:
A.
preferred provider model.
B.
group model.
C.
open access model.
D.
individual practice association.
Question #6
A managed care contract should clearly state all of the following EXCEPT:
A.
the time limit for submitting claims to the MCO.
B.
when payment should be received from the MCO.
C.
how much the physician will be paid for services.
D.
the list of employers with MCO contracts.
Question #7
A medical office specialist must do all the following EXCEPT:
A.
promote the provider network.
B.
be familiar with managed care terms.
C.
explain the ACO to the patient.
D.
know the Patient Bill of Rights.
Question #8
The schedule of benefits section of a managed care contract lists the:
A.
medical services covered under the managed care plan.
B.
providers in the contracted network.
C.
deductible and coinsurance amounts that patients must pay.
D.
benefits of participating in 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.
treat the patient as much as possible without a specialist referral unless absolutely necessary.
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.
make frequent referrals to contracted network specialists.
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.
disciplinary actions.
B.
criminal activity.
C.
salary history.
D.
malpractice history.
Question #11
Under the HIPAA Privacy Rule, a patient's medical record and payment history are considered:
A.
protected health information.
B.
electronically transmitted data.
C.
managed care plan information.
D.
secure medical data.
Question #12
A person who has a privacy complaint can file it with the:
A.
American Medical Association (AMA).
B.
Office for Civil Rights (OCR).
C.
Centers for Medicare and Medicaid Services (CMS).
Question #13
The process of scrambling and encoding electronic data to prevent it from being read by unauthorized users is known as:
A.
transcription.
B.
encryption.
C.
translation.
D.
coding.
Question #14
ICD-10-CM codes submitted on insurance claim forms are used to:
A.
report patient demographic information.
B.
report specific procedures and services.
C.
record a patient's office visits or inpatient days.
D.
determine medical necessity for covered procedures and services.
Question #15
The ICD-10-PCS is used to report:
A.
outpatient procedure coding.
B.
proper diagnosis coding.
C.
proper mortality coding.
D.
inpatient procedure coding.
Question #16
To locate the correct code for the first encounter, the medical specialist must first look for the term in the:
A.
Alphabetic Index.
B.
Tabular List of Diseases and Injuries.
C.
External Causes Index.
D.
Neoplasm Table.
Question #17
Subterms in an ICD-10-CM entry may show:
A.
a better description of the disease.
B.
treatments of the disease.
C.
another name for the disease.
D.
the cause or origin of the disease.
Question #18
The code next to the main term is called the:
A.
primary code.
B.
specified code.
C.
default code.
D.
combination 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.
represent the practice in any lawsuits that arise over privacy issues.
B.
respond to insurance carriers' questions and handle patient billing complaints.
C.
file monthly reports with the office of the state insurance commissioner.
D.
respond to requests for medical records and handle privacy-related complaints.
Question #20
Providers are legally obligated to disclose protected health information (PHI) to public health authorities when a:
A.
particularly severe flu epidemic has occurred.
B.
patient has returned from a trip to a country with poor sanitation.
C.
person may have been exposed to certain communicable diseases.
D.
patient or staff member has a prison record.
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.
1992
B.
1977
C.
1986
D.
2006
Question #22
The temporary codes used for emerging technology, services, or procedures are:
A.
ICD-10-CM codes.
B.
Category I CPT codes.
C.
Category III CPT codes.
D.
Category II CPT codes.
Question #23
The most-often reported evaluation and management (E/M) services are:
A.
consultations.
B.
emergency room services.
C.
hospital (inpatient) services.
D.
office and other outpatient 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.
5 years.
C.
2 years.
D.
1 year.
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.
past history.
C.
family 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.
at the discretion of the physician.
B.
monitored to control costs.
C.
provided only by in-network physicians.
D.
based on the patient's ability to pay.
Question #28
A practice with 10 or more physicians would generally be categorized as a:
A.
private practice.
B.
small-group practice.
C.
large-group practice.
D.
solo 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.
payment poster.
D.
medical office assistant.
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.
insurance verification representative.
B.
admitting clerk.
C.
privacy compliance officer.
D.
medical collector.
Question #31
The duties and responsibilities of a medical biller may include all of the following EXCEPT:
A.
submitting insurance claims.
B.
explaining HIPAA regulations.
C.
analyzing patient charge information.
D.
contacting insurance carriers on incorrectly paid claims.
Question #32
The duties and responsibilities of a privacy compliance officer may include all of the following EXCEPT:
A.
posting payments or making adjustments to patient accounts.
B.
explaining DNR orders to patients and their family members.
C.
data entry of patient demographics.
D.
answering questions about privacy regulations.
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.
orthotic procedures.
B.
temporary hospital outpatient.
C.
diagnostic radiology services.
D.
private payer codes.
Question #36
The code for durable medical equipment (DME) would be found in the:
A.
This is not considered a HCPCS code.
B.
Level III HCPCS code book.
C.
Level II HCPCS code book.
D.
Level I HCPCS code book.
Question #37
HCPCS Level II national codes are used in claims submitted to:
A.
public insurers only.
B.
self-funded plans only.
C.
private insurers only.
D.
public and private insurers.
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.
accurate.
B.
clean.
C.
complete.
D.
authorized.
Question #39
Billing the parts of a bundled procedure as separate procedures is referred to as:
A.
bundling.
B.
downcoding.
C.
upcoding.
D.
unbundling.
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.
date of service.
B.
patient insurance eligibility.
C.
patient insurance identification number.
D.
sign-in sheets and appointment scheduling practices.
Question #42
An internal audit would determine:
A.
All of these.
B.
the coder's skill and knowledge.
C.
if additional training is needed for office staff.
D.
whether procedures were coded correctly.
Question #43
An independent audit should be performed a minimum of:
A.
once a month.
B.
twice a year.
C.
once a quarter.
D.
once a year.
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.
respiratory system.
C.
neurological system.
D.
cardiovascular 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.
risk of significant complications, morbidity, and/or mortality.
B.
number of diagnoses or management options.
C.
amount and/or complexity of data to be reviewed.
D.
All of these.
Question #46
An examination and verification of claims and supporting documentation submitted by a physician is known as a(n):
A.
review.
B.
audit.
C.
reconsideration.
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.
wait until the effective date of the coverage, then bill the insurance carrier.
B.
bill the patient.
C.
write off the entire amount.
D.
change the date of service and resubmit the claim.
Question #48
Reasons for follow-up include:
A.
an incorrect payment is received.
B.
unclear denial of payment is received.
C.
reimbursement is received for an unknown patient.
D.
All of these.
Question #49
If a physician requests a peer review that results in confirmation that services were NOT medically necessary:
A.
there is no charge for the review.
B.
the physician must pay 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.
noncovered emergency services
B.
both noncovered emergency services and not related to diagnoses
C.
claim processing error
D.
not related to diagnoses
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