CCM practice questions: Reimbursement

Question 1

John is diagnosed with congestive heart failure and is prescribed furosemide 20 mg by mouth twice daily. John goes to the local pharmacy and picks up his medicine at no cost. The cost of the medication is an example of what type of insurance payment?

a. co-insurance
b. deductible
c. co-pay
d. extra-contractual benefit

Answer 1

c. Correct. John has a zero-dollar co-pay for tier 1 medication such as furosemide.

a. Incorrect. Co-insurance refers to the percentage amount paid by the insurance company after the deductible is met.
b. Incorrect. The deductible is the money that is insured before the insurance company pays.
d. Incorrect. Extra-contractual benefits are benefits not covered by insurance.

Question 2

Mike recently signed up for a new PPO plan. He has an appointment with his primary care physician (PCP) and receives a call from the office informing him that the physician is not in Mike’s network. Which of the following is true?

a. Mike can negotiate with his PCP to lower his out-of-pocket costs.
b. Mike will pay the same amount to see his PCP even though he is now out of network.
c. Mike can no longer see his PCP.
d. Mike cannot find a new PCP in-network since he already has a PCP.

Answer 2

a. correct. Mike can attempt to negotiate with his PCP to see if he can pay a lower rate. Some doctors are willing to lower their cash rate to maintain continuity of care.

b. Incorrect. Now that his PCP is out is out of network, Mike will have to pay a higher co-pay and will have a higher deductible for services.
c. Incorrect. Mike can continue to see his PCP, but insurance will not cover as much of the cost.
d. Incorrect. Within a PPO, patients may switch PCPs whenever they want.

Question 3

A Client with chronic shoulder pain thinks he needs an MRI to identify the source of the pain. If the client has an EPO plan, who should the case manager suggest he contact to get pre-authorization for the MRI?

a. the insurance company
b. the client’s primary care physician (PCP)
c. an orthopedic specialist
d. a private MRI imaging center

Answer 3

c. Correct. An in-network orthopedic specialist will be able to assess the patient and submit a pre-authorization form that explains the need for the MRI. Because the client has an EPO, he can see the specialist without first seeing his PCP.

a. Incorrect. The insurance company will require a physician to complete the pre-authorization paperwork.
b. Incorrect. Depending on the situation, the PCP may be able to submit a pre-authorization form, but the insurance company will most likely ask for a specialist’s assessment.
d. incorrect. Pre-authorization requires a physician and is not usually done by private diagnostic centers such as labs and imaging centers.

Question 4

Capitation is a payment method in which

A. physicians are paid directly by the HMO
B. services are bundled into a single payment
C. out-of-network services are denied
D. providers are paid a flat rate for each HMO member

Answer 4

D. Correct. In a capitation arrangement, the HMO compensates providers with a flat fee for each member who uses their services.

A. Incorrect. The process of capitation does not specify who is paid. For example. In a group model HMO, the HMO pays the group, which in turn pays the physicians.
B. Incorrect. Bundled payments are a separate type of payment arrangement from capitation.
C. Incorrect. Capitation is not specific to in- or out-of-network payments.

Question 5

Allison has a rare inflammatory disease and has had her care successfully managed. By her PCP for many years. However, she would like to see an out-of-network rheumatologist who her PCP thinks may be able to help with her pain. What type of insurance plan would best suit her needs?

A. HMO
B. PPO
C. EPO
D. POS

Answer 5

D. Correct. With a POS plan, Allison can keep her PCP. And pay lower premiums while still receiving some coverage to see a specialist.

A. Incorrect. With an HMO, her insurer would not cover any of the costs to see the specialist.
B. Incorrect. Allison would Like to keep her PCP to coordinate her care, so a PPO would not be the best choice for her.
C. Incorrect. As With an HMO, her insurer will likely not cover the cost of the specialist under as EPO plan.

Question 6

Which of the following statements from a client suggests that he may benefit from a secondary indemnity policy?

A. I live in a rural region with a very small number of medical providers.
B. I cannot afford high premiums or out-of-pocket expenses.
C. I would like to keep my current PCP.
D. I’m not sure how insurance works and am not very good at filling out paperwork.

Answer 6

A. Correct. Access to a very limited number of providers may be a reason to have an indemnity policy because the client can see any doctor available.

B. Incorrect. Indemnity policies typically have higher premiums and may require substantial out-of-pocket expenses.
C. Incorrect. The client will likely be able to keep his PCP with a PPO or POS plan, he does not need a secondary indemnity plan.
D. Incorrect. Indemnity plans often require members to closely manage their health care expenses and reimbursements, so they would not be recommended for this client.

Question 7

An employee at a large company was recently laid off. Which of the following would be a good reason for her to enroll in COBRA coverage instead of an individual plan?

A. Shopping for new health insurance is time consuming.
B. She has already met her deductible for the year.
C. She would save money.
D. She needs to include dependents on her health insurance.

Answer 7

B. Correct. If the deductible has already been met, the employee may save money by staying on the same insurance plan.

A. Incorrect. Although this statement is true, it is generally not a good reason to enroll in COBRA without exploring other options.
C. Incorrect. The employee will likely be able to find a marketplace plan that cosets less than COBRA coverage.
D. Incorrect. The employee with likely be able to find plans for all family members through the marketplace, likely a cheaper rate.

Question 8

A self-employed individual purchases a PPO plan through the health exchange. Which of the following services would the plan have to cover?

A. Chiropractic appointments for muscle pain
B. Hearing aids for congenital hearing loss
C. Dental exams and X-rays
D. Annual physicals

Answer 8

D. Correct. Preventative care, including annual physicals, is included as an essential health benefit in plans purchased through a health exchange.

A. Incorrect. Chiropractors are not essential health benefits and may not be covered.
B. Incorrect. Coverage for medical equipment and accommodations will vary by state and plan, so hearing aids may not be covered.
C. Incorrect. Adult dental coverage must be purchased separately through the health exchange.

Question 9

Mrs. Turner is about to turn sixty-five and is looking at Medicare plans. Twice a week she receives dialysis at the only clinic available in her small town. Which plan should she purchase to cover these treatments?

A. Medicare Part A
B. Medicare Part B
C. Medicare Part C
D. Medicare Part D

Answer 9

B. Correct. Medicare Part B covers outpatient services such as dialysis. Because Part B plans are optional and must be purchased, Mrs. Turner should plan to enroll in a Part B plan as soon as she is eligible.

A. Incorrect. Medicare Part A covers inpatient services.
C. Incorrect. Most Medicare Part C plans are HMOs, which may not cover the only clinic she has access to.
D. Incorrect. Medicare Part D plans cover prescriptions drugs.

Question 10

Which of the following people is most likely to have dual eligibility for Medicare and Medicaid?

A. A twenty-five-year-old woman who has recently given birth to a child with a congenital heart disorder.
B. A twenty-one-year-old woman with end-stage renal disease who cannot purchase health insurance.
C. A sixteen-year-old boy who is addicted to opioids.
D. A retired sixty-five-year-old man who frequently travels out of the country.

Answer 10

B. Correct. People with end-stage renal disease qualify for Medicare. She may also qualify for Medicaid because her income is low.

A. Incorrect. The woman is not old enough to receive Medicare.
C. Incorrect. The teen may qualify for Medicaid due to his age but will not qualify for Medicare.
D. Incorrect. The man is old enough to qualify for Medicare. However, if he travels frequently, he likely does not meet the income requirements for Medicaid.

Question 11

Which of the following people is most likely to be receiving SSDI benefits?

A. a single mother raising a child with disabilities.
B. a construction worker recently diagnoses with a serious mental impairment
C. an injured factory worker who is expected to return to an alternate job within nine months.
D. an administrative assistant with disabilities that affect her mobility.

Answer 11

B. Correct. The teen is old enough to receive SSDI and may receive benefits if his mental impairment prevents him from working.

A. Incorrect. The mother is not disabled and cannot receive SSDI.
C. Incorrect. Workers who will return to work in less than a year are not eligible for SSDI.
D. Incorrect. People who are able to work are not eligible for SSDI.

Question 12

A CCM has a client with disabilities. She should advise her client to apply for SSI if the client needs
A. supplemental health insurance to cover physical therapy.
B. additional income to supplement her earnings from a full-time job.
C. additional income because her disability prevents her from working full time.
D. supplemental health insurance to cover prescription medications.

Answer 12

C. Correct. She has a limited income and may be eligible for SSI based on her disability.

A. Incorrect. SSI is a cash benefit, not health insurance.
B. Incorrect. She has a full-time job and may not be eligible for SSI.
D. Incorrect. SSI is a cash benefit, not health insurance.

Question 13

Which of the following people would NOT be eligible for TRICARE?

A. the widow of a uniformed service member who has remarried
B. the child of a uniformed service member who just turned twenty-one
C. a member of the National Guard
D. the six-year-old child of an Army serviceman

Answer 13

A. Correct. Widows and surviving spouses who remarry are no longer eligible for TRICARE.

B. Incorrect. Children of uniformed service members may be eligible for TRICARE for Young Adults until age twenty-six.
C. Incorrect. Members of the National Guard are eligible for TRICARE.
D. Incorrect. Children of uniformed service members are eligible for TRICARE.

Question 14

Which of the following people is MOST likely to be eligible for VA benefits?

A. a person currently serving in the armed forces
B. a veteran given a dishonorable discharge for desertion
C. an army serviceman who has been discharged from active duty following an injury.
D. a retired mental health provider.

Answer 14

C. Correct. Service members who have been honorably discharged are eligible for VA benefits.

A. Incorrect. Active-duty personnel are not eligible for VA benefits.
B. Incorrect. Veterans who separated with a dishonorable discharge are not eligible for VA benefits.
D. Incorrect. VA benefits are only available to those who served on active duty in the US military.

Question 15

A veteran is 100 percent disabled due to a war event. Which type of health care coverage is he most likely to receive?

A. TRICARE
B. CAMPVA
C. Veterans Health Administration
D. SSI

Answer 15

A. Correct. This is a military health plan.

B. Incorrect. This is military coverage for spouses and dependents of a disabled veteran.
C. Incorrect. This is an integrated health care system.
D. Incorrect. This is a cash benefit

Question 16

Which of the following prescriptions likely cost the customer the least amount of money out of pocket?

A. a thirty-day supply of a brand name
B. a thirty-day supply of a tier 3 medication delivered by mail
C. A ninety-day supply of a tier 2 medication picked up at the local pharmacy
D. a ninety-day supply of a tier 1 medication delivered by mail

Answer 16

D. Correct. Tier 1 medications cost the least, and the customer likely saved money by having it delivered by mail.

A. Incorrect. Brand-name medications are more expensive than generics, and the patient did not save money by buy having the medication delivered by mail.
B. Incorrect. Tier 3 medications are the most expensive.
C. Incorrect. Tier 2 medications cost more than tier 1 medications and are usually more expensive when picked up at the pharmacy.

Question 17

Sarah has suffered an occupational injury and wishes to utilize her workman’s compensation benefit. She is unable to speak due to her injury and needs family support. Who is most likely to file the First Report of Injury on Sarah’s behalf?

A. her family
B. her employer
C. her insurance carrier
D. state regulators

Answer 17

B. Correct. The employer is responsible.

A. Incorrect. It is not the responsibility of her family.
C. Incorrect. The employer notifies the insurance carrier.
D. Incorrect. It is not the responsibility of the state regulators.

Question 18

Alsn is a sixty-five-year-old retiree whose granddaughter has multiple sclerosis. He would like to contribute to the cost of her medical care but does not want to prevent her from receiving SSI benefits. Which financial resource should Alan use?

A. special needs account
B. viatical settlement
C. accelerated death benefit
D. reverse mortgage

Answer 18

A. Correct. A special needs trust would allow Alan to set aside money for his grandaughter’s medical care that would not prevent her from receiving SSI benefits.

B. Incorrect. Giving his granddaughter the profits from selling his life insurance policy would prevent her from accessing SSI benefits.
C. Incorrect. Alan does not have a terminal diagnosis, so he is not eligible for accelerated death benefits.
D. Incorrect. Alan is eligible for a reverse mortgage, but gifting money to his granddaughter would prevent her from accessing SSI benefits.

Question 19

Which reimbursement method results in an itemized bill that lists the cost of each individual service provided during a medical procedure?

A. prospective payment system
B. episode of care
C. fee for service
D. case rate

Answer 19

C. Correct. Fee for service is a payment system that pays for each aspect pf care separately.

A. Incorrect. A prospective payment system provides a predetermined reimbursement amount based on the average cost of the care the patient ultimately needed.
B. Incorrect. An episode of care is a medical treatment event that includes all medical services needed for a specific medical condition.
D. Incorrect. Case rate is a type of bundled payment based on the type of patient and the typical care needed for a specific condition, such as myocardial infarction.

Question 20

A patient has been admitted to the cardiac care unit (CCU) following a myocardial infarction. Which of the following medical providers would NOT play a role in the hospital’s utilization management review of the patient?

A. the attending physician in the CCU
B. the patient’s insurance provider
C. the pharmacist who dispenses medications for the CCU
D. The CCU’s discharge planner

Answer 20

C. Correct. Physicians, insurance companies, and discharge planners will all play a role in utilization management. The pharmacist will not.

Question 21

The primary factor that improves patient outcomes in a patient-centered medical home (PCMH) is

A. coordination of care between providers.
B. increased compensation for providers.
C. access to new medications and procedures.
D. providing patients with access to community resources.

Answer 21

A. Correct. PCMHs coordinate care to improve patients’ health outcomes.

B. Incorrect. Increased compensation based on health outcomes is not generally a part of a PCMH.
C. Incorrect. PCMHs focus on care coordination, not access to new medical services
D. Incorrect. While some PCMHs may help patients with community resources, this is not the primary factor that improves patient outcomes.

Question 22

All of the following are important reasons for accurate coding using the ICD system EXCEPT

A. tracking disease trends within and across communities.
B. preventing the patient for being billed for the wrong diagnosis.
C. ensuring the patient will receive care from the correct physician.
D. improving hospital quality control.

Answer 22

C. Correct. ICD codes are not used to verify whether a patient receives treatment from the correct physician.

A. Incorrect. The ICD system allows medical researchers to track trends in diseases and injuries.
B. Incorrect. In the US, medical billing relies on the ICD codes.
D. Incorrect. ICD codes are used by the hospital quality control personnel to track patient diagnoses.

Question 23

Which of the following does not have a CPT code?

A. venipuncture
B. MRI
C. myocardial infarction
D. CABG

Answer 23

C. Correct. Myocardial infarction is a diagnosis and does not have a CPT code; it has an ICD code.

A. Incorrect. Venipuncture (for a blood draw) is a diagnostic procedure with the CPT code 36415.
B. Incorrect. An MRI is a diagnostic test; it has different CPt codes depending on the type of MRI.
D. Incorrect. CABG (coronary artery bypass grafting) is a surgical procedure with carious CPT codes for the type of CABG performed.

Question 24

What characteristic would be considered when placing patients into a diagnosis-related group (DRG)?

A. their income
B. their living environment
C. the reason they were admitted to the hospital
D. the number of children they have

Answer 24

C. Correct. The patient’s diagnosis or scheduled procedure is a consideration for DRG placement.

A. Incorrect. A patient’s income is a social determinant of health but is not considered in DRG placement.
B. Incorrect. A patient’s living environment does impact illness but is not a consideration for DRG placement.
D. Incorrect. The number of children a patient has does not factor into a DRG.

Question 25

Which of the following diagnoses can be found in the DSM-5?

A. reactive attachment disorder
B. myocardial infarction
C. irritable bowel syndrome
D. racing thoughts

Answer 25

A. Correct. Reactive attachment disorder is a trauma-related mental disorder.

B. Incorrect. Myocardial infarction is a medical diagnosis.
C. Incorrect. Irritable bowel syndrome is a medical diagnosis.
D. Incorrect. Racing thoughts are a symptom, not a diagnosis.

Question 26

Alice was awarded a tier reduction for the price of a high-cost medication. She would like to be reimbursed for her out-of-pocket cost for the medication that she has paid for the entire year. The CCM can best help her by

A. calling the pharmacy and negotiating a lower cost of the medication.
B. calling the insurance company to determine what Alice needs to do to receive reimbursement.
C. calling the provider to report the complication and request medication samples.
D. contacting the medication’s manufacturer to find available subsidies or coupons.

Answer 26

B. Correct. The CCM can use her expertise to communicate her client’s needs to the insurance company and complete the necessary paperwork.

A. Incorrect. Alice has already received a cost reduction for the mediation; trying to lower it further will not help Alice get reimbursed for previous prescriptions.
C. Incorrect. The provider will likely not be able to help Alice get reimbursement from her insurance company.
D. Incorrect. While this may lower the out-of-pocket cost of medications, it will not help Alice get reimbursed.