AAPC CPB - Practice Exam B Questions with Correct Answers Graded A

What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? A. Copayment B. Deductible C. Secondary Payment D. Coinsurance - B. Deductible Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? A. Business liability B. Bonding C. Medical malpractice D. Workers' compensation - C. Medical malpractice Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. Employee can make changes to the policy. VI. The employee's spouse and children are not eligible for coverage. A. III, IV, and V B. II, III, and VI C. II, IV, and V D. I, IV, V, and VI - D. I, IV, V, and VI Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan. He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the health plan. C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees. D. Dr. Wallace is required to put the $2,000 in a mutual fund. - A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. What is the deadline for filing a Medicare claim? A. One year from the date of service B. 30 days from the date of service C. 90 days from the date of service D. Two years from the date of service - A. One year from the date of service A provider sees a patient who has TRICARE Select. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for? A. $0.00 B. $20.00 C. $60.00 D. $160.00 - C. $60.00 What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures? A. Utilization Review Organization B. External Quality Review Organization C. Quality Assurance Organization D. Managed Care Organization - A. Utilization Review Organization Medicaid providers are forbidden by law to: A. Refer patients to specialists B. Bill patients for non-covered services C. Balance bill patients D. Accept co-payments - C. Balance bill patients