HIM 2330 Healthcare Reimbursement
Exam-Graded A
Why do health insurers pool premium payments for all the insureds in a group and use
actuarial data to calculate the group's premiums? - 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? - ANSWER-The
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? - 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? - ANSWER-Insurance
company
The goal of revenue integrity is to produce a claim that is __________. - ANSWER-
Clean, complete, and compliant
Which of the following is not a component of the revenue cycle? - ANSWER-Revenue
calculation
Which of the following is a key factor in establishing highly ethical culture promotes
honesty and openness? - ANSWER-Transparency
,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? - ANSWER-Payer D
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? - 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? - 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? - 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? -
ANSWER-Immediately, as marriage is a qualifying life events
All of the following occurrences are considered "qualifying life events" except: -
ANSWER-Car accident
All of the following types of procedures and services typically require prior authorization
except: - ANSWER-Emergency services for suspected stroke
Which of the following characteristics is the greatest advantage of group health
insurance? - ANSWER-Greater benefits for lower premiums
Which of the following types of care represent healthcare services not delivered by
MCOs? - ANSWER-Experimental devices
Why do health insurers pool premium payments for all the insureds in a group and use
actuarial data to calculate the group's premiums? - 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? - ANSWER-The
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? - 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? - ANSWER-Insurance
company
The goal of revenue integrity is to produce a claim that is __________. - ANSWER-
Clean, complete, and compliant
Which of the following is not a component of the revenue cycle? - ANSWER-Revenue
calculation
Which of the following is a key factor in establishing highly ethical culture promotes
honesty and openness? - ANSWER-Transparency
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? - ANSWER-Payer D
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? - 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? - 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? - 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
Exam-Graded A
Why do health insurers pool premium payments for all the insureds in a group and use
actuarial data to calculate the group's premiums? - 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? - ANSWER-The
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? - 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? - ANSWER-Insurance
company
The goal of revenue integrity is to produce a claim that is __________. - ANSWER-
Clean, complete, and compliant
Which of the following is not a component of the revenue cycle? - ANSWER-Revenue
calculation
Which of the following is a key factor in establishing highly ethical culture promotes
honesty and openness? - ANSWER-Transparency
,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? - ANSWER-Payer D
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? - 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? - 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? - 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? -
ANSWER-Immediately, as marriage is a qualifying life events
All of the following occurrences are considered "qualifying life events" except: -
ANSWER-Car accident
All of the following types of procedures and services typically require prior authorization
except: - ANSWER-Emergency services for suspected stroke
Which of the following characteristics is the greatest advantage of group health
insurance? - ANSWER-Greater benefits for lower premiums
Which of the following types of care represent healthcare services not delivered by
MCOs? - ANSWER-Experimental devices
Why do health insurers pool premium payments for all the insureds in a group and use
actuarial data to calculate the group's premiums? - 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? - ANSWER-The
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? - 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? - ANSWER-Insurance
company
The goal of revenue integrity is to produce a claim that is __________. - ANSWER-
Clean, complete, and compliant
Which of the following is not a component of the revenue cycle? - ANSWER-Revenue
calculation
Which of the following is a key factor in establishing highly ethical culture promotes
honesty and openness? - ANSWER-Transparency
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? - ANSWER-Payer D
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? - 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? - 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? - 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
