FINAL EXAM HEALTH & REIMB EXAM
ACTUAL UPDATED QUESTIONS AND VERIFIED ANSWERS
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
ACTUAL UPDATED QUESTIONS AND VERIFIED ANSWERS
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
