HINM 230 com final Exam Solution Manual 100% Guaranteed Success
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to
calculate the group's premiums? - Answers To assure that the pool is large enough to pay losses of the
entire group
Where and when did health insurance become established in the United States? - Answers Texas, 1929
There are 3 parties in healthcare reimbursement. Who is the first party? - Answers Patient or guarantor
There are 3 parties in healthcare reimbursement. Who is the second party? - Answers Provider of care
or services
There are 3 parties in healthcare reimbursement. Who is the third party? - Answers Payer
In the healthcare insurance sector, what does UCR stand for? - Answers Usual Customary and
Reasonable
In the healthcare insurance environment, what phrase means "per head"? - Answers Per Capita
What payment methods are global payments? - Answers All of the above
The federal government funds significant portions of which groups' healthcare? - Answers All of the
above
In the United States, what is healthcare insurance? - Answers Reduction of a person's or a group's
exposure to risk for unknown healthcare costs by the assumption of that risk by an entity
In the healthcare industry, what is the term for receiving compensation for healthcare services that
were previously provided? - Answers Reimbursement
In which type of reimbursement methodology do healthcare insurance companies determine payment
to providers before the services have been delivered? - Answers Prospective payment
In which type of reimbursement methodology does the health insurance company have the greatest
degree of risk? - Answers Retrospective
Which type of reimbursement methodology is associated with the abbreviation "PMPM"? - Answers
Capitated payment
In the healthcare industry, what is another term for "fee"? - Answers Charge
In the accounting system of the physician office, the account is categorized as "self-pay." How should
the insurance analyst interpret this category? - Answers The guarantor will pay the entire bill
The bill that the pathologist's office submitted for a laboratory test was $54.00. In its payment notice
(remittance advice), the healthcare plan lists its payment for the laboratory test as $28.00. What does
the amount of $54.00 represent? - Answers Charge
, Which discounted fee-for-service healthcare payment method does Medicare use to reimburse
physicians? - Answers RBRVS
What is the per diem payment method? - Answers Fixed rate for each day a covered member is
hospitalized
Which national model for the delivery of healthcare services is financed by general revenue funds from
taxes? - Answers National health service (Beveridge) model
What is the coding system that is used primarily for reporting diagnoses for hospital inpatients? -
Answers ICD-10-CM
What coding system was created for reporting procedures and services performed by physicians in
outpatient clinical practice? - Answers CPT
What is the definition of fraud? - Answers Billing for a service not furnished as represented on the claim
What policies and procedures should be included in a Coding Compliance Plan? - Answers Performing
job functions according to the
laws, regulations, and guidance set fourth by Medicare and other third-payer payers.
How are Recovery Audit Contractors different from other improper payment review contractors? -
Answers RACs are reimbursed on a contingency-based system
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? - Answers Risk pool
What healthcare organization is one of the most influential in the healthcare sector because it insures
nearly one in three Americans? - Answers BCBSA
Which type of healthcare insurance policy offers the widest ranging coverage but requires the insured to
pay coinsurance until the maximum out-of-pocket costs are met? - Answers Comprehensive
Which type of healthcare insurance policy provides benefits to a resident requiring nursing home care
and services? - Answers Long-term or extended care insurance
Which type of healthcare insurance policy provides benefits to an insured who is blinded as the result of
an accident? - Answers Accidental death and disbursement insurance
Which type of healthcare insurance policy provides benefits to a homeowner who requires an 8-month
recuperation after a fall down her basement stairs? - Answers Disability income protection insurance
Which type of healthcare insurance policy provides benefits to pay for Medicare deductibles and
coinsurance? - Answers Medigap
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to
calculate the group's premiums? - Answers To assure that the pool is large enough to pay losses of the
entire group
Where and when did health insurance become established in the United States? - Answers Texas, 1929
There are 3 parties in healthcare reimbursement. Who is the first party? - Answers Patient or guarantor
There are 3 parties in healthcare reimbursement. Who is the second party? - Answers Provider of care
or services
There are 3 parties in healthcare reimbursement. Who is the third party? - Answers Payer
In the healthcare insurance sector, what does UCR stand for? - Answers Usual Customary and
Reasonable
In the healthcare insurance environment, what phrase means "per head"? - Answers Per Capita
What payment methods are global payments? - Answers All of the above
The federal government funds significant portions of which groups' healthcare? - Answers All of the
above
In the United States, what is healthcare insurance? - Answers Reduction of a person's or a group's
exposure to risk for unknown healthcare costs by the assumption of that risk by an entity
In the healthcare industry, what is the term for receiving compensation for healthcare services that
were previously provided? - Answers Reimbursement
In which type of reimbursement methodology do healthcare insurance companies determine payment
to providers before the services have been delivered? - Answers Prospective payment
In which type of reimbursement methodology does the health insurance company have the greatest
degree of risk? - Answers Retrospective
Which type of reimbursement methodology is associated with the abbreviation "PMPM"? - Answers
Capitated payment
In the healthcare industry, what is another term for "fee"? - Answers Charge
In the accounting system of the physician office, the account is categorized as "self-pay." How should
the insurance analyst interpret this category? - Answers The guarantor will pay the entire bill
The bill that the pathologist's office submitted for a laboratory test was $54.00. In its payment notice
(remittance advice), the healthcare plan lists its payment for the laboratory test as $28.00. What does
the amount of $54.00 represent? - Answers Charge
, Which discounted fee-for-service healthcare payment method does Medicare use to reimburse
physicians? - Answers RBRVS
What is the per diem payment method? - Answers Fixed rate for each day a covered member is
hospitalized
Which national model for the delivery of healthcare services is financed by general revenue funds from
taxes? - Answers National health service (Beveridge) model
What is the coding system that is used primarily for reporting diagnoses for hospital inpatients? -
Answers ICD-10-CM
What coding system was created for reporting procedures and services performed by physicians in
outpatient clinical practice? - Answers CPT
What is the definition of fraud? - Answers Billing for a service not furnished as represented on the claim
What policies and procedures should be included in a Coding Compliance Plan? - Answers Performing
job functions according to the
laws, regulations, and guidance set fourth by Medicare and other third-payer payers.
How are Recovery Audit Contractors different from other improper payment review contractors? -
Answers RACs are reimbursed on a contingency-based system
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? - Answers Risk pool
What healthcare organization is one of the most influential in the healthcare sector because it insures
nearly one in three Americans? - Answers BCBSA
Which type of healthcare insurance policy offers the widest ranging coverage but requires the insured to
pay coinsurance until the maximum out-of-pocket costs are met? - Answers Comprehensive
Which type of healthcare insurance policy provides benefits to a resident requiring nursing home care
and services? - Answers Long-term or extended care insurance
Which type of healthcare insurance policy provides benefits to an insured who is blinded as the result of
an accident? - Answers Accidental death and disbursement insurance
Which type of healthcare insurance policy provides benefits to a homeowner who requires an 8-month
recuperation after a fall down her basement stairs? - Answers Disability income protection insurance
Which type of healthcare insurance policy provides benefits to pay for Medicare deductibles and
coinsurance? - Answers Medigap
