Final exam Health & Reimb Questions
and Answers 100% Correct
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 health
insurance through the mother's employment at the State Department of
Treasury.Who is the first party in this healthcare reimbursement scenario? -
ANSWER-Parents
An employee paying for 40 percent of the insurance premium through payroll
processing is an example of a transaction between ________ and ________. -
ANSWER-Patient; employer
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
A physician office submitting an invoice (claim) for payment when the patient has
health insurance is an example of a transaction between _____ and ____. -
ANSWER-Provider; third-party payer
All of the following activities are steps in medical necessity and utilization review
except: - ANSWER-Administrative review
All of the following functions are ways that MCOs work toward their goal of
controlling cost except: - ANSWER-Use of evidence based clinical practice
guidelines
All of the following occurrences are considered "qualifying life events" except: -
ANSWER-Car accident
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 event
Compare the social insurance model and the private health insurance model.
Discuss similarities and differences. - ANSWER-Both the social and private
insurance models 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. Still, in this model, the insurance company determines
the individual's amount 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.
Describe the concept of revenue integrity. - ANSWER-Revenue integrity is
performing revenue cycle duties to obtain operational efficiency, compliance
adherence, and legitimate reimbursement. The foundation of revenue integrity is
transparency and honesty. This translates to the every day saying, "doing the right
thing." The goal of revenue integrity is to produce a claim for reimbursement that is
clean, complete, and compliant.
Describe why cost-sharing is a limitation in a health insurance policy. - ANSWER-
Cost-sharing is a limitation because it limits the extent of the benefit. The benefit is
limited because the beneficiary is required to bear some of the costs of the
healthcare that they consume. The concept is designed to decrease the effect of
moral hazard. For example, if a beneficiary has a $250 copayment associated with
emergency department visits, the beneficiary may think twice about using the
emergency department instead of urgent care for minor illnesses and injuries such
as respiratory infections, sprained ankles, etc.
One managed care concept that has carried over to most insurance plans is
utilization management. A key component of utilization management is utilization
review. Describe utilization review. Provide an example of when utilization review
would be used. - ANSWER-Utilization review is a process that determines the
medical necessity of a service and the appropriateness of the setting for the
healthcare service in the continuum of care. An example would be a patient that
needs to have a coronary artery stent placed. First, the insurance company will
determine if the stent placement is medically necessary—for example, for coronary
artery disease. Second, the insurance company will determine if the patient is
healthy enough to have the stent placed in the same-day surgery unit or if the patient
should be admitted as an inpatient because of comorbid conditions or the patient's
overall health status.
Which part of the Medicare program does not include a premium? - ANSWER-Part A
In states where there is not a mandated fund for workers' compensation, which of the
following is an option for employers? - ANSWER-Purchase workers' compensation
insurance from a private carrier
All of the following are true of state Medicaid programs except: - ANSWER-Services
offered to beneficiaries are the same in each state.
Clyde is enrolled in Medicare Parts A and B. He had a knee arthroscopy in January.
This is Clyde's first health encounter for the year so he has not met his deductible.
The approved amount for his surgeon is $550. How much does Clyde owe in cost
sharing for the surgeon's services. Use the following excerpt from table 3.2, Part B
Services 2020. - ANSWER-$308
, Which of the following is(are) true of CHIP? - ANSWER-It is a federal and state
program
Which government-sponsored program provides coverage for active-duty service
members of the armed forces (ADSM)? - ANSWER-TRICARE
Sal is enrolled in Medicare Parts A and B. He goes to the hospital seniors clinic for
congestive heart failure. He had a regular visit in November when Dr. Nauman
examined him, checked his medications, and suggested a high fiber diet. The
approved amount for her visit is $275. Sal met his outpatient deductible in February.
What is his cost sharing amount for the visit to Dr. Nauman? Use the following
excerpt from table 3.2, Part B Services 2020, for questions 5 and 6. - ANSWER-55
Which of the following is a service that is excluded from Medicare Part A and Part B,
but may be provided under Part C? - ANSWER-Eye exams including contacts and
eyeglasses
The coverage gap, which is a period of expanded cost-sharing, is applicable to which
part of Medicare? - ANSWER-Medicare Part D
Wes is enrolled in Medicare Part A. He had his first hospital encounter this March.
He was admitted for congestive heart failure and stayed three days? Which of the
following will Wes need to pay? - ANSWER-Deductible and copayment amount
Discuss how Medicaid is a federal and state program. - ANSWER-Medicaid is a joint
program. The federal government has established categories of individuals that must
be eligible for Medicaid that apply to every state. Additionally, the federal
government establishes a standard set of services that must be provided as benefits
by all states. When a state meets the required conditions, it receives federal funds to
help administer Medicaid. Each state has the ability to customize its Medicaid
program. They may provide benefits beyond the standard set. States may establish
cost-sharing or encourage managed care plans. States may also expand their
eligibility to more categories of individuals, such as low-income children or adults
with dependent children. States supplement the federal Medicaid program funds with
state-generated funds.
There are three government-sponsored healthcare programs related to military
service: TRICARE, VHA, and CHAMPVA. Who uses which program? - ANSWER-
TRICARE- Military Personal
VHA- Veterans
CHAMPVA- Spouse or Widow
The MS-DRG payment includes reimbursement for all of the following inpatient
services except: - ANSWER-Physician hospital visit
What is the basis of the "labor-related share?" - ANSWER-Facilities' costs related to
payrolls, benefits, and professional fees
and Answers 100% Correct
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 health
insurance through the mother's employment at the State Department of
Treasury.Who is the first party in this healthcare reimbursement scenario? -
ANSWER-Parents
An employee paying for 40 percent of the insurance premium through payroll
processing is an example of a transaction between ________ and ________. -
ANSWER-Patient; employer
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
A physician office submitting an invoice (claim) for payment when the patient has
health insurance is an example of a transaction between _____ and ____. -
ANSWER-Provider; third-party payer
All of the following activities are steps in medical necessity and utilization review
except: - ANSWER-Administrative review
All of the following functions are ways that MCOs work toward their goal of
controlling cost except: - ANSWER-Use of evidence based clinical practice
guidelines
All of the following occurrences are considered "qualifying life events" except: -
ANSWER-Car accident
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 event
Compare the social insurance model and the private health insurance model.
Discuss similarities and differences. - ANSWER-Both the social and private
insurance models 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. Still, in this model, the insurance company determines
the individual's amount 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.
Describe the concept of revenue integrity. - ANSWER-Revenue integrity is
performing revenue cycle duties to obtain operational efficiency, compliance
adherence, and legitimate reimbursement. The foundation of revenue integrity is
transparency and honesty. This translates to the every day saying, "doing the right
thing." The goal of revenue integrity is to produce a claim for reimbursement that is
clean, complete, and compliant.
Describe why cost-sharing is a limitation in a health insurance policy. - ANSWER-
Cost-sharing is a limitation because it limits the extent of the benefit. The benefit is
limited because the beneficiary is required to bear some of the costs of the
healthcare that they consume. The concept is designed to decrease the effect of
moral hazard. For example, if a beneficiary has a $250 copayment associated with
emergency department visits, the beneficiary may think twice about using the
emergency department instead of urgent care for minor illnesses and injuries such
as respiratory infections, sprained ankles, etc.
One managed care concept that has carried over to most insurance plans is
utilization management. A key component of utilization management is utilization
review. Describe utilization review. Provide an example of when utilization review
would be used. - ANSWER-Utilization review is a process that determines the
medical necessity of a service and the appropriateness of the setting for the
healthcare service in the continuum of care. An example would be a patient that
needs to have a coronary artery stent placed. First, the insurance company will
determine if the stent placement is medically necessary—for example, for coronary
artery disease. Second, the insurance company will determine if the patient is
healthy enough to have the stent placed in the same-day surgery unit or if the patient
should be admitted as an inpatient because of comorbid conditions or the patient's
overall health status.
Which part of the Medicare program does not include a premium? - ANSWER-Part A
In states where there is not a mandated fund for workers' compensation, which of the
following is an option for employers? - ANSWER-Purchase workers' compensation
insurance from a private carrier
All of the following are true of state Medicaid programs except: - ANSWER-Services
offered to beneficiaries are the same in each state.
Clyde is enrolled in Medicare Parts A and B. He had a knee arthroscopy in January.
This is Clyde's first health encounter for the year so he has not met his deductible.
The approved amount for his surgeon is $550. How much does Clyde owe in cost
sharing for the surgeon's services. Use the following excerpt from table 3.2, Part B
Services 2020. - ANSWER-$308
, Which of the following is(are) true of CHIP? - ANSWER-It is a federal and state
program
Which government-sponsored program provides coverage for active-duty service
members of the armed forces (ADSM)? - ANSWER-TRICARE
Sal is enrolled in Medicare Parts A and B. He goes to the hospital seniors clinic for
congestive heart failure. He had a regular visit in November when Dr. Nauman
examined him, checked his medications, and suggested a high fiber diet. The
approved amount for her visit is $275. Sal met his outpatient deductible in February.
What is his cost sharing amount for the visit to Dr. Nauman? Use the following
excerpt from table 3.2, Part B Services 2020, for questions 5 and 6. - ANSWER-55
Which of the following is a service that is excluded from Medicare Part A and Part B,
but may be provided under Part C? - ANSWER-Eye exams including contacts and
eyeglasses
The coverage gap, which is a period of expanded cost-sharing, is applicable to which
part of Medicare? - ANSWER-Medicare Part D
Wes is enrolled in Medicare Part A. He had his first hospital encounter this March.
He was admitted for congestive heart failure and stayed three days? Which of the
following will Wes need to pay? - ANSWER-Deductible and copayment amount
Discuss how Medicaid is a federal and state program. - ANSWER-Medicaid is a joint
program. The federal government has established categories of individuals that must
be eligible for Medicaid that apply to every state. Additionally, the federal
government establishes a standard set of services that must be provided as benefits
by all states. When a state meets the required conditions, it receives federal funds to
help administer Medicaid. Each state has the ability to customize its Medicaid
program. They may provide benefits beyond the standard set. States may establish
cost-sharing or encourage managed care plans. States may also expand their
eligibility to more categories of individuals, such as low-income children or adults
with dependent children. States supplement the federal Medicaid program funds with
state-generated funds.
There are three government-sponsored healthcare programs related to military
service: TRICARE, VHA, and CHAMPVA. Who uses which program? - ANSWER-
TRICARE- Military Personal
VHA- Veterans
CHAMPVA- Spouse or Widow
The MS-DRG payment includes reimbursement for all of the following inpatient
services except: - ANSWER-Physician hospital visit
What is the basis of the "labor-related share?" - ANSWER-Facilities' costs related to
payrolls, benefits, and professional fees
