HIM 2330 MIDTERM QUESTIONS AND ANSWERS
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to
calculate the group's premiums? - CORRECT ANSWER✅✅To assure that the pool is large enough to pay
losses of the entire group
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was
cancelled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on
prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents
who have healthcare insurance through the mother's employment at the State Department of Treasury.
Who is the first party in this healthcare reimbursement scenario? - CORRECT ANSWER✅✅Parents
Use the following scenario to answer questions 2-4.
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was
cancelled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on
prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents
who have healthcare insurance through the mother's employment at the State Department of Treasury.
Who is the second party in this healthcare reimbursement scenario? - CORRECT ANSWER✅✅Dr. Gilbert
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was
cancelled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on
prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents
who have healthcare insurance through the mother's employment at the State Department of Treasury.
Who is the third party in this healthcare reimbursement scenario? - CORRECT ANSWER✅✅Insurance
company
The goal of revenue integrity is to produce a claim that is __________. - CORRECT ANSWER✅✅Clean,
complete, and compliant
Which of the following is not a component of the revenue cycle? - CORRECT ANSWER✅✅Revenue
calculation
Use the following contract matrix to answer question 7
, Payer
Inpatient Services
Outpatient Services
A
62% billed charges
56% of billed charges
B
$6,500 obstetric delivery case rate
Fee Schedule
$70 per clinic visit
$85 per initial OT evaluation
$50 per OT visit (non-eval)
C
$2,100 obstetric delivery per diem
$75 per clinic visit
$45 per OT visit
D
$6,350 obstetric delivery case rate
$65 per clinic visit
$55 per initial OT evaluation
$35 per OT visit (non-eval)
Patient 89423 is seen in the outpatient clinic at Happy Hospital for a pneumonia follow-up visit. The
charges for the encounter total $135.00. Which payer will reimburse the hospital the lowest amount? -
CORRECT ANSWER✅✅Payer D
Which of the following is a key factor in establishing highly ethical culture promotes honesty and
openness? - CORRECT ANSWER✅✅Transparency
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to
calculate the group's premiums? - CORRECT ANSWER✅✅To assure that the pool is large enough to pay
losses of the entire group
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was
cancelled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on
prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents
who have healthcare insurance through the mother's employment at the State Department of Treasury.
Who is the first party in this healthcare reimbursement scenario? - CORRECT ANSWER✅✅Parents
Use the following scenario to answer questions 2-4.
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was
cancelled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on
prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents
who have healthcare insurance through the mother's employment at the State Department of Treasury.
Who is the second party in this healthcare reimbursement scenario? - CORRECT ANSWER✅✅Dr. Gilbert
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was
cancelled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on
prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents
who have healthcare insurance through the mother's employment at the State Department of Treasury.
Who is the third party in this healthcare reimbursement scenario? - CORRECT ANSWER✅✅Insurance
company
The goal of revenue integrity is to produce a claim that is __________. - CORRECT ANSWER✅✅Clean,
complete, and compliant
Which of the following is not a component of the revenue cycle? - CORRECT ANSWER✅✅Revenue
calculation
Use the following contract matrix to answer question 7
, Payer
Inpatient Services
Outpatient Services
A
62% billed charges
56% of billed charges
B
$6,500 obstetric delivery case rate
Fee Schedule
$70 per clinic visit
$85 per initial OT evaluation
$50 per OT visit (non-eval)
C
$2,100 obstetric delivery per diem
$75 per clinic visit
$45 per OT visit
D
$6,350 obstetric delivery case rate
$65 per clinic visit
$55 per initial OT evaluation
$35 per OT visit (non-eval)
Patient 89423 is seen in the outpatient clinic at Happy Hospital for a pneumonia follow-up visit. The
charges for the encounter total $135.00. Which payer will reimburse the hospital the lowest amount? -
CORRECT ANSWER✅✅Payer D
Which of the following is a key factor in establishing highly ethical culture promotes honesty and
openness? - CORRECT ANSWER✅✅Transparency
