Deck 14: Basics of Health Insurance

Question 1

Which type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own offices?

A) Staff model
B) Independent practice association
C) Group model
D) None of the above

Answer 1

Independent practice association

Question 2

A review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called a(n)

A) credentialing committee review.
B) peer review committee evaluation.
C) utilization review.
D) audit committee review.

Answer 2

utilization review.

Question 3

A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called

A) an individual policy.
B) workers' compensation.
C) unemployment insurance.
D) disability insurance.

Answer 3

workers' compensation.

Question 4

Which of the following expenses would be paid by Medicare Part B?

A) Inpatient hospital charges
B) Hospice services
C) Physician's office visits
D) Home healthcare charges

Question 5

Entities that make payment on an obligation or debt but are not parties of the contract that created the debt are called

A) riders.
B) service benefit plans.
C) third-party payers.
D) capitation.

Question 6

Which part of Medicare covers prescription drug services?

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

Question 7

The federal- and state-sponsored health insurance program for the medically indigent is called

A) Medicare.
B) Medicaid.
C) Medigap.
D) MediCal.

Question 8

Organizations that fund their own insurance programs offer their employees

A) group coverage.
B) individual coverage.
C) government plans.
D) self-funded plans.

Question 9

The maximum amount of money third-party payers will pay for a specific procedure or service is called the

A) benefit.
B) allowable amount.
C) allowed service.
D) incurred amount.

Question 10

Which of the following individuals would not normally be eligible for Medicare?

A) A 66-year-old retired woman
B) A blind teenager
C) A 23-year-old recipient of AFDC
D) A person on dialysis

Question 11

The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage is called the

A) benefits.
B) deductible.
C) premium.
D) co-pay.

Question 12

Which of the following is not a disadvantage of managed care?

A) Authorized services usually are covered.
B) Physicians' choices in the treatment of patients can be limited.
C) More paperwork may be necessary.
D) Reimbursement is historically less than with traditional health insurance.

Question 13

The amount of money the policyholder pays per claim or per accident toward the total amount of an insured loss before the company will pay on the claim is known as the

A) exclusion.
B) premium.
C) deductible.
D) remittance.

Question 14

Health insurance benefits are determined by

A) indemnity schedules.
B) service benefit plans.
C) relative value studies.
D) All of the above

Question 15

Which of the following is not an advantage of managed care?

A) Healthcare costs are usually contained.
B) Access to specialized care and referrals is limited.
C) Most preventive medical treatment is covered.
D) Out-of-pocket expenses tend to be less than traditional insurance.

Question 16

The amount of money paid to keep an insurance policy in force is the

A) premium.
B) deductible.
C) co-pay.
D) co-insurance.

Question 17

Health insurance designed for military dependents and retired military personnel is called

A) CHAMPVA.
B) TRICARE.
C) Medicare.
D) Medicaid.

Question 18

A policy that covers a number of people under a single master contract issued to the employer or to an association with which they are affiliated and that is not self-funded is usually called

A) group policy.
B) individual policy.
C) a government plan.
D) a self-insured plan.

Question 19

Veterans of the U.S. armed forces may be covered by

A) CHAMPVA.
B) TRICARE.
C) workers' compensation.
D) Blue Cross/Blue Shield.

Question 20

The physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ______ provider.

A) participating
B) paying
C) physician
D) None of the above

Question 21

Which of the following pays the hospital surgical room fee?

A) Disability
B) Basic medical
C) Surgical
D) Hospital
E) Both C and D

Question 22

Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?

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

Question 23

A physician can choose whether to accept Medicaid patients.

Question 24

Which of the following managed care plans require preauthorization for medical services such as surgery?

A) HMOs
B) PPOs
C) EPOs
D) Both A and B
E) All of the above

Question 25

Which of the following are not reviewed by a utilization review committee?

A) Physician referrals
B) Cases of emergency department visits and urgent care
C) Individual cases to ensure medical care services are medically necessary
D) Fees for services provided

Question 26

Most of today's health insurance policies cover which of the following?

A) Preventive care
B) Procedures deemed medically necessary
C) Elective procedures
D) All of the above
E) Both A and B

Question 27

If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay and then pays 80% of the charges, how much will his policy pay on his bill of $4,359?

A) $3027.20
B) $3047.20
C) $3047.00
D) $3067.50

Question 28

The TRICARE option that is similar to a preferred provider network is TRICARE

A) Prime.
B) Extra.
C) Standard.
D) Basic.

Question 29

Medigap polices cover which of the following?

A) Difference between major medical reimbursement and patient financial responsibilities
B) Difference between Medicare reimbursement and patient financial responsibilities
C) Any services not covered under Medicare
D) Any services not covered under Major medical

Question 30

Dependents of military personnel are covered by which of the following government-sponsored health insurance plans?

A) Medicaid
B) Medicare
C) TRICARE
D) CHAMPVA
E) Workers' compensation

Question 31

A payment method in which providers are paid for each individual enrolled in a plan, regardless of whether the person sees the provider that month, is called a ______ plan.

A) capitation
B) self-insured
C) managed care
D) fee-for-service

Question 32

Which of the following MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility?

A) Medicare/Medicaid
B) PPOs
C) HMOs
D) BC/BS
E) IPA

Question 33

Employee-sponsored group policies usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected. However, these employee-sponsored group health insurance plans offer limited benefits, and healthcare access is limited to healthcare providers that are contracted with them.

A) Both statements are true.
B) Both statements are false.
C) The first statement is true; the second is false.
D) The first statement is false; the second is true.

Question 34

The medical assistant should always verify which of the following prior to the patient's appointment?

A) Eligibility
B) Benefits and exclusions
C) Effective date of insurance
D) All of the above

Question 35

Which type of referral is usually processed immediately?

A) Regular
B) Urgent
C) STAT
D) All of the above

Question 36

Which of the following HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network?

A) IPA
B) Staff model
C) Group model
D) PPO

Question 37

TRICARE is a form of government insurance for veterans of the U.S. armed forces.

Question 38

If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay, how much will his insurance pay on his bill of $4,359?

A) $3,809
B) $2,809
C) $3,980
D) $3,900

Question 39

Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department?

A) Regular referral
B) Urgent referral
C) STAT referral
D) All of the above

Question 40

Which of the following plans require healthcare providers to become participating providers?

A) All government-sponsored health plans
B) Most privately sponsored health plans
C) Indemnity health insurance plans
D) Both A and B
E) All of the above

Question 41

Nearly all of the physician's income is derived from the insurance payments received for services rendered.

Question 42

Health insurance typically covers services and procedures considered medically necessary. Most insurance policies also cover "elective" procedures, such as certain cosmetic surgeries, that are not considered medically necessary.

Question 43

The "cafeteria-style" plan allows employers to choose the benefits they want for their respective employees.