Unformatted text preview: Unit 4 Seminar Questions
1. A health insurance claim is the documentation submitted to the patient requesting
reimbursement for health care services provided.
2. Health insurance specialists (or reimbursement specialists) review health-related claims to
determine the medical necessity for procedures or services performed before reimbursement is
made to the provider.
3.The mutual exchange of data between the provider and insurance company is called electronic
4. A health care facility (or physician) that employs health insurance specialists is legally
responsible for employees' actions performed within the context of their employment. This is
called respondeat superior.
5. The AAPC, AHIMA, and AMBA offer exams leading to professional credentials.
6. The accurate coding of diagnoses, procedures, and services rendered to the patient allows a
medical practice to communicate diagnostic and treatment data to a patient's insurance plan to
assist the patient in obtaining maximum benefits.
7. Fluency in the language of medicine and the ability to use a medical dictionary as a reference
are not necessary skills for a health insurance specialist.
8.To reduce coding and billing errors, health insurance specialists need to explain complex
insurance concepts and regulations to patients and effectively communicate with providers
regarding documentation of procedures and services.
9. Coding is the process of reporting diagnoses, procedures, and services as numeric and
alphanumeric characters on the explanation of benefits (EOB).
10.Medical necessity involves linking every procedure or service code reported on the claim to
an HCPCS code that justifies the necessity for performing that procedure or service. FALSE
11. Liability insurance is a policy that covers losses to a third party caused by the insured.
12. The primary intent of HIPAA is to provide better access to health insurance, limit fraud and
abuse, and reduce administrative costs.
13. The introduction of prepaid health plans was the forerunner of today's private insurance
14. A copayment is a provision in an insurance policy that requires the policyholder or patient to
pay a specified dollar amount to a health care provider for each visit or medical service received.
15. The intent of managed health care was to replace conventional fee for service plans with
more affordable quality care to health care consumers.
16. In a managed health care plan, enrollees receive care from a primary care provider who is a
physician that serves as a gatekeeper by providing essential health care services at the lowest
17. The utilization management (or utilization review) is a method of controlling health care
providers and quality of care by reviewing the appropriateness and necessity of care provided to
patients prior to administration of care.
18. Case management involves the development of patient care plans for the coordination and
provision of care for complicated cases in a cost-effective manner.
19. When a second physician is asked to evaluate the necessity of surgery and recommend the
most economic, appropriate facility, it is considered coordination of care.
20. A network provider is a physician or health care facility under contract to the managed care
21. In a point of service plan, patients have the freedom to use the HMO panel of providers or to
self-refer to non-HMO providers. TRUE
22. A preferred provider organization (PPO) is a network of physicians and hospitals that have
joined together to contract with insurance companies, employers, or other organizations to
provide health care to subscribers for a substantial fee.
23. A health maintenance organization (HMO) is an alternative to traditional group health
insurance coverage and provides comprehensive health care services to voluntarily-enrolled
members on a pay monthly basis.
24. HMOs do not provide preventative care services to promote "wellness" or good health.
25. The development of an insurance claim is initiated when the patient arrives at the health care
26. To accept assignment means the patient and/or insured authorizes the payer to reimburse the
27. When submitting claims, "SIGNATURE ON FILE" can be substituted for the patient's
signature, as long as the patient's signature is on file in the office.
28. A participating provider (PAR) contracts with a health insurance plan and accepts whatever
the plan pays for procedures or services performed. The patient is billed for the difference
between the insurance payment and the provider's fee.
29. The encounter form is the financial record source document used by health care providers
and other personnel to record treated diagnoses and services rendered to the patient during the
30. HIPAA requires all health plans, health care clearinghouses, and health care providers that
conduct electronic financial or administrative transactions to comply with national patient
31. The National Provider Identifier (NPI) is assigned to health care providers as a 10 digit
numeric identifier, without a check digit in the last position. FALSE
32. Protected health information (PHI) is information that is identifiable to an individual, such as
name, address, telephone number, date of birth, and social security number.
33. To remain up-to-date with the frequent changes of health insurance processing, health
insurance specialists should:
D. make certain they are on mailing lists to receive newsletters from third-party payers
remain current on news released by the CMS
stay current with the DHHS updates
all of the above 34. The process of reporting diagnoses, procedures, and services as numeric and alphanumeric
characters on the insurance claim is called:
D. Data entry
Health information technology
Coding 35. Accurate coding of diagnoses, procedures, and services rendered to the patient allows a
medical practice to:
A. facilitate analysis of the practice's patient base for improvement and efficiency
B. communicate diagnostic and treatment data to insurance plans for maximum recovery of
C. process claims for a limited number of insurance companies
D. both a and b
36. If preauthorization for treatment by specialists and post-treatment reports were not filed, the
claim would be:
C. Billed only to the patient
37. What involves linking every procedure or service code reported on the claim to a condition
code that justifies the necessity of performing that procedure or service?
A. Diagnosis coding
B. Procedure coding
C. Medical necessity
D. Both a and c
38. ICD-9-CM stands for:
International Classification of Diseases -Ninth Revision, Clinical Modification 39. What does CPT stand for?
Current Procedural terminology
40. A successful health insurance specialist should have which of the following characteristics:
A. Attention to detail
B. Strong sense of ethics
C. Ability to work independently
D. All of the above
41. What is the program mandated by federal and state governments that requires employers to
cover medical expenses and loss of wages for workers who are injured on the job?
42. TRICARE includes three plan options. Which of the following is not one of those options?
A. TRICARE standard
B. TRICARE prime
C. TRICARE extra
D. TRICARE select
43.Managed care plan enrollees receive care from:
A. Their primary care provider
B. Physician of their choice
C. Any nonparticipating provider
D. All of the above
44. A method of controlling health care costs and quality of care by reviewing the
appropriateness and necessity of care provided to patients prior to the administration of care is:
A. Case management
B. Surgical management
C. Utilization management
D. Physician management
45. The development of a(an) ____ begins when the patient contacts a health care provider's
office and schedules an appointment.
A. Patient file
B. Insurance claim
C. Super bill
D. Encounter form
46. The CMS-1500 claim form is used to report:
A. professional services
B. inpatient expenses
C. technical services
D. both a and c 47. The check-in procedure for a patient who is ____ to the provider's office is more extensive
than for a ____ patient.
New and returning
48. The ____ is the person responsible for paying the charges
49. copayments are to be paid
Upon receipt of the super bill
50. The patient ledger is also known as the:
Patient account record
51. Disability insurance provides the disabled person with financial assistance, but does not
generally pay for:
A. Unemployed insurance benefits
B. Medical services
C. Both a and b
D. Neither a or b
52. The health care industry is heavily regulated by ____ and ____ legislation.
Federal ; state
53. Medical necessity is the measure of whether a health care procedure or service is appropriate
Diagnosis and/or treatment of condition ...
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- Fall '18
- Monique Johnson