Deck 9: Conquering Medicare’s Challenges

Question 1

A federal insurance program,established in 1966,for people 65 years old and older and certain other qualifying individuals is:

A) Medicaid.
B) Medicare.
C) Medigap.
D) managed care.

Answer 1

Medicare.

Question 2

Individuals pay for Medicare Part B coverage through:

A) wage deductions.
B) monthly premiums.
C) personal checks.
D) electronic funds transfers.

Answer 2

monthly premiums.

Question 3

Part _____ of Medicare helps pay for physician and outpatient charges.

A) A
B) B
C) C
D) D

Answer 3

B

Question 4

Medicare's fee schedule is based on a system whereby each payment value is found within a range of payments known as:

A) OPPS.
B) RBRVS.
C) fee-for-service.
D) usual, customary, and reasonable.

Question 5

Part _____ of Medicare helps pay for prescription drugs.

A) A
B) B
C) C
D) D

Question 6

Medicare Part A helps pay for all of the following,except:

A) office visits.
B) home health care.
C) hospice.
D) blood.

Question 7

When a service or procedure meets Medicare's criteria for coverage,it is said to be:

A) eligible.
B) qualifying.
C) medically necessary.
D) an entitlement.

Question 8

When it is likely that Medicare will not pay for a service or procedure that Medicare ordinarily covers but is likely to be denied on this particular occasion,the patient should be asked to sign a/an:

A) ABN.
B) CMS-1500.
C) release of information.
D) assignment of benefits.

Question 9

A private insurance company that serves as the federal government's agent in the administration of the Medicare program,including the payment of claims.

A) Beneficiary
B) Third party
C) Financial mediator
D) Medicare administrative contractor

Question 10

Beneficiaries can change their Medicare prescription drug coverage:

A) on the last day of each calendar month.
B) at the end of the federal fiscal year.
C) on their birthday.
D) during the annual open enrollment period.

Question 11

The term used when Medicare is not responsible for paying first because of coverage under another insurance policy is:

A) Medigap.
B) Medi-Medi.
C) supplemental payer.
D) Medicare secondary payer (MSP).

Question 12

There are _____ parts to the Medicare program.

A) two
B) three
C) four
D) five

Question 13

The duration of time during which a Medicare beneficiary is eligible for Part A benefits for inpatient hospital or skilled nursing facility charges is called a/an:

A) time period.
B) limiting phase.
C) benefit period.
D) episode of care.

Question 14

Insurance coverage that is typically primary to Medicare includes all of the following,except:

A) Medicaid.
B) group health plans.
C) workers' compensation.
D) automobile liability insurance.

Question 15

Fees that Medicare permits for a particular procedure,service,or supply are called:

A) UCR fees.
B) cap limits.
C) restrictive fees.
D) allowable fees.

Question 16

The act that provides for a federal system of old age,survivors,disability,and hospital insurance is the:

A) Federal Insurance Contribution Act (FICA).
B) Health Insurance Portability and Accountability Act (HIPAA).
C) Emergency Medical Treatment and Active Labor Act (EMTLA).
D) Consolidated Omnibus Budget Reconciliation Act (COBRA).

Question 17

Part _____ of Medicare helps pay for charges incurred during an inpatient hospital stay.

A) A
B) B
C) C
D) D

Question 18

Part _____ of Medicare includes Medicare Advantage options.

A) A
B) B
C) C
D) D

Question 19

An individual who has health insurance coverage through either the Medicare and Medicaid programs is commonly referred to as a:

A) client.
B) customer.
C) beneficiary.
D) member.

Question 20

When a Medicare claim is filed,the beneficiary receives a document explaining the claim adjudication called a/an:

A) SPRA.
B) MSN.
C) ABN.
D) EOB.

Question 21

The act that established quality standards for all laboratory testing to ensure safety,accuracy,reliability,and timeliness is:

A) CLIA.
B) LMRP.
C) EMTLA.
D) COBRA.

Question 22

In January of 1999,the Balanced Budget Act (BBA)of 1997 went into effect,expanding the role of private plans to include ____________________.

Question 23

Medicare claims may be electronically submitted from a provider's office to a:

A) fiscal intermediary (FI).
B) Medicare administrative contractor.
C) DME MAC.
D) all of the above

Question 24

Beneficiaries who are not satisfied with the amount of a claim reimbursement may file a/an:

A) secondary claim.
B) grievance.
C) appeal.
D) ABN.

Question 25

For Medicare Part A,a benefit period begins the day an individual is _______________ to a hospital or SNF and ends when the beneficiary has not received care in a hospital or SNF for _____ days in a row.

Question 26

Medicare Part A is free to those who have _____ or more quarters of Social Security work credits.

A) 10
B) 20
C) 30
D) 40

Question 27

Medicare Part C was previously called ___________;it was renamed by The Medicare Prescription,Improvement,and Modernization Act of 2003 (MMA)and is now called ___________.

Question 28

A physician,practitioner,facility,or supplier with fewer than 10 FTE employees is considered a:

A) PAR provider.
B) non-PAR provider.
C) small provider.
D) qualified provider.

Question 29

The Tax Relief and Health Care Act (TRHCA)of 2006 established a Physician Quality Reporting System referred to as:

A) HIPAA.
B) SHIIP.
C) PQRS.
D) MIPPA.

Question 30

Providers that bill Medicare administrative contractors (or FIs)can also submit claims electronically using:

A) PDF files.
B) direct data entry.
C) wireless Internet.
D) HIPAA.

Question 31

Medicare payments can be automatically deposited into a provider's designated bank account using:

A) money orders.
B) cashier's checks.
C) certified deposits.
D) electronic funds transfers.

Question 32

A claim for which a beneficiary elects to assign his or her benefits under a Medigap policy to a PAR is called a:

A) mandated Medigap transfer.
B) assignment of benefits.
C) coordination of benefits.
D) Medicare claim allocation.

Question 33

The Patient Protection and Affordable Care Act included a provision that limited timely filing of Medicare claims to:

A) 90 days from the date(s) of service.
B) October 1 of the year following the date(s) of service.
C) one year from the date of service(s).
D) December 1 of the year in which services were rendered.

Question 34

Analyses performed to improve the processes and outcomes of patient care are called:

A) appeals.
B) peer reviews.
C) redeterminations.
D) quality review studies.

Question 35

The length of time Medicare uses for hospital and skilled nursing facility (SNF)services is called a/an ____________________.

Question 36

Billing Medicare for a more complicated procedure than was actually done or for a multiple-procedure operation as if several separate procedures were performed are examples of:

A) fraud.
B) abuse.
C) negligence.
D) criminal offense.

Question 37

Unless an individual has health coverage through his or her employer,when he or she becomes eligible for Medicare,late enrollment can result in:

A) rejection into the Medicare program.
B) penalties.
C) limitations in coverage.
D) all of the above

Question 38

One of the cost-sharing requirements of Medicare Part B is an annual deductible which is subject to change annually,after which Medicare pays ____ percent of ______________.

Question 39

There are _____ levels to the Medicare appeals process.

A) three
B) five
C) seven
D) ten

Question 40

The program that provides community-based,long-term care services to eligible recipients is:

A) PACE.
B) Medicare Part A.
C) Medicare Part D.
D) SHIIP.

Question 41

List three advantages of providers becoming PAR.

Question 42

An individual is generally not eligible to elect a Medicare Advantage plan if he or she has been diagnosed with _________.

Question 43

List the five levels of the Medicare appeal request process.

Question 44

The ________________ mandated by the Social Security Act is activated when (1)a PAR Medicare provider includes a specific identifier-a COBA ID number-on the beneficiary's claim and (2)assigns payment benefits to that provider.

Question 45

The intention of Part D is for all Medicare beneficiaries to choose a prescription drug plan to help offset the increasing cost of ______________.

Question 46

All Medicare Advantage plans offer the exact same coverage as original Medicare.

Question 47

List four coverage choices under Medicare Part C.

Question 48

______ was established to set quality standards for all laboratory testing to ensure the safety,accuracy,reliability,and timeliness of patient test results regardless of where the test was performed.

Question 49

An individual cannot qualify for both Medicare and Medicaid.

Question 50

Plans that are not Medicare Advantage plans but are still part of Medicare include which plans?

Question 51

List the information typically included on an MSN.

Question 52

What current Medicare Part D regulation will be phased out by 2020 and how will this be accomplished?

Question 53

Under Medicare Part D,individual prescription drug plans must offer no less than the basic Medicare coverage.

Question 54

The 6-month period during which an individual can sign up for the Medicare program is called the open enrollment period.

Question 55

Define a remittance advice,and describe the information it contains.

Question 56

Explain why the information contained in Chapter 9 (Medicare)is important to the health insurance professional.

Question 57

Coverage with Medicare Part C (Medicare Advantage plans)typically includes both Part A and Part B expenses.

Question 58

There are 20 standard Medigap policies.

Question 59

Unlike original Medicare,Medicare managed care plans often pay for what items?

Question 60

Individual plans,such as group health insurance plans that include prescription coverage,offer varying benefits;however,they must offer no less than the basic Medicare coverage,referred to as ____________________.

Question 61

If individuals do not sign up for Medicare Part B when first becoming eligible and later decide to enroll,the monthly premiums may be higher due to penalties.

Question 62

Workers' compensation would likely be a primary payer to Medicare.

Question 63

Most Medicare Part B beneficiaries pay for Part B coverage in the form of a premium deducted from their monthly Social Security check.

Question 64

Medicare Parts A and B are provided free of charge for all individuals over 65.

Question 65

Neither (original)Medicare Part A nor Part B covers any preventive care services.

Question 66

Medicare non-PARs do not have to submit claims for their Medicare patients.

Question 67

Medicare HICNs are typically in the format of nine numeric characters followed by one alpha character.

Question 68

If a beneficiary has a Medicare Advantage plan,he or she still needs a supplemental policy.

Question 69

Medicare is always the "payer of last resort."

Question 70

A local coverage determination (LCD)consists only of information pertaining to when a procedure is considered medically reasonable and necessary.

Question 71

The private organization that determines payment of Part B covered items and services is called a peer review organization (PRO).

Question 72

When an individual turns 65 and enrolls in Medicare,federal law forbids insurance companies from denying eligibility for Medigap policies for 6 months.

Question 73

An individual must be eligible for Part A or B to enroll in a Medicare Advantage plan.

Question 74

A Medicare beneficiary can sign a special release of information that is good for his or her lifetime.

Question 75

For durable medical equipment (DME)to qualify for Medicare payment,it must be ordered by a physician for use in the home and items must be reusable.

Question 76

An individual who has traditional Medicare Parts A and B is required to have a Medigap policy.

Question 77

Part A Medicare beneficiaries are allowed only one "benefit period" per year.

Question 78

Medicare Part A covers custodial and long-term care.

Question 79

Medicare's definition of medical necessity must meet specific criteria.

Question 80

Medicare HMO member/enrollees must receive care only from the providers in the network except in emergencies.