HIM 2330 FINAL EXAM PREP 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 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
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
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
In 3-5 sentences, Compare the social insurance model and the private health insurance model. Discuss
similarities and differences. - CORRECT ANSWER✅✅Both the social insurance model and the private
insurance model require employees and employers to contribute funds to a type of insurance company.
In the social insurance model, the "insurance company" is called a sickness fund. They are heavily
regulated by the government, including the determination of how much an individual must pay into the
, sickness fund. In the private health model, the insurance company follows some regulations established
by the federal government, but in this model the insurance company determines the amount the
individual must pay to obtain coverage. In both models, individuals may choose from which sickness
fund or insurance company to obtain insurance coverage.
Another main difference is that the social insurance model calls for universal healthcare coverage for a
set of government-defined benefits. The private health model does not include universal coverage for all
citizens.
In the healthcare sector, what is the term for a group of individual entities, such as individual persons,
employers, or associations, whose healthcare costs are combined for evaluating financial history and
estimating future costs? - CORRECT ANSWER✅✅Risk Pool
What is the term for the set fee that a policyholder or certificate holder must periodically pay a health
insurance plan in return for healthcare coverage? - CORRECT ANSWER✅✅Premium
A worker had group health insurance coverage through her employer. The worker's household included
her spouse, two natural children (ages 28 and 12), an adopted child (age 8), and the worker's mother
(age 58). Who may be included under dependent coverage in the health insurance policy? - CORRECT
ANSWER✅✅Spouse; natural child, age 12; and adopted child, age 8
Jung Hwa was married on July 1, 20XX. She had worked for the organization for the past 8 years and has
been covered under its group health insurance policy during the entire period. When can Jung Hwa add
her new spouse to her insurance plan? - CORRECT ANSWER✅✅Immediately, as marriage is a qualifying
life eventS"
All of the following occurrences are considered "qualifying life events" except: - CORRECT
ANSWER✅✅Car accident
All of the following types of procedures and services typically require prior authorization except: -
CORRECT ANSWER✅✅Emergency services for suspected stroke
Which of the following characteristics is the greatest advantage of group health insurance? - CORRECT
ANSWER✅✅Greater benefits for lower premiums
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 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
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
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
In 3-5 sentences, Compare the social insurance model and the private health insurance model. Discuss
similarities and differences. - CORRECT ANSWER✅✅Both the social insurance model and the private
insurance model require employees and employers to contribute funds to a type of insurance company.
In the social insurance model, the "insurance company" is called a sickness fund. They are heavily
regulated by the government, including the determination of how much an individual must pay into the
, sickness fund. In the private health model, the insurance company follows some regulations established
by the federal government, but in this model the insurance company determines the amount the
individual must pay to obtain coverage. In both models, individuals may choose from which sickness
fund or insurance company to obtain insurance coverage.
Another main difference is that the social insurance model calls for universal healthcare coverage for a
set of government-defined benefits. The private health model does not include universal coverage for all
citizens.
In the healthcare sector, what is the term for a group of individual entities, such as individual persons,
employers, or associations, whose healthcare costs are combined for evaluating financial history and
estimating future costs? - CORRECT ANSWER✅✅Risk Pool
What is the term for the set fee that a policyholder or certificate holder must periodically pay a health
insurance plan in return for healthcare coverage? - CORRECT ANSWER✅✅Premium
A worker had group health insurance coverage through her employer. The worker's household included
her spouse, two natural children (ages 28 and 12), an adopted child (age 8), and the worker's mother
(age 58). Who may be included under dependent coverage in the health insurance policy? - CORRECT
ANSWER✅✅Spouse; natural child, age 12; and adopted child, age 8
Jung Hwa was married on July 1, 20XX. She had worked for the organization for the past 8 years and has
been covered under its group health insurance policy during the entire period. When can Jung Hwa add
her new spouse to her insurance plan? - CORRECT ANSWER✅✅Immediately, as marriage is a qualifying
life eventS"
All of the following occurrences are considered "qualifying life events" except: - CORRECT
ANSWER✅✅Car accident
All of the following types of procedures and services typically require prior authorization except: -
CORRECT ANSWER✅✅Emergency services for suspected stroke
Which of the following characteristics is the greatest advantage of group health insurance? - CORRECT
ANSWER✅✅Greater benefits for lower premiums
