Unit 4 Seminar Questions.docx

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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. TRUE 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. TRUE 3.The mutual exchange of data between the provider and insurance company is called electronic claims processing. FALSE 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. TRUE 5. The AAPC, AHIMA, and AMBA offer exams leading to professional credentials. TRUE 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. TRUE 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. FALSE 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. TRUE 9. Coding is the process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the explanation of benefits (EOB). FALSE 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. TRUE 12. The primary intent of HIPAA is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs. TRUE 13. The introduction of prepaid health plans was the forerunner of today's private insurance plans. FALSE 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. TRUE 15. The intent of managed health care was to replace conventional fee for service plans with more affordable quality care to health care consumers. TRUE 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 possible cost. TRUE 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. FALSE 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. TRUE 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. FALSE 20. A network provider is a physician or health care facility under contract to the managed care plan. TRUE 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. FALSE 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. FALSE 24. HMOs do not provide preventative care services to promote "wellness" or good health. FALSE 25. The development of an insurance claim is initiated when the patient arrives at the health care provider's office. FALSE 26. To accept assignment means the patient and/or insured authorizes the payer to reimburse the provider directly. FALSE 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. TRUE 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. FALSE 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 current encounter. TRUE 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 privacy standards. TRUE 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. TRUE 33. To remain up-to-date with the frequent changes of health insurance processing, health insurance specialists should: A. B. C. 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: A. B. C. D. Data entry Work 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 benefits 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: A. Paid B. Denied C. Billed only to the patient D. Resubmiited 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? Workers compensation 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 Guarantor 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 for: Diagnosis and/or treatment of condition ...
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  • Fall '18
  • Monique Johnson

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