Chapter 2 Quiz Flashcards
A Medicaid patient presents for services on the rst day of the month. He has a $50
spenddown and has had no services this month. The visit for today was $100.00. If
the patient wants to be covered as long as possible from today’s visit, what can he do?
(A) Turn the receipt in to his caseworker and be eligible for two months of
coverage
(B) Turn the receipt in to his caseworker and be eligible for the month with
$50 to assessed by Medicaid for the visit that is above his spenddown
(C) Coverage is automatic and the patient will be reimbursed the $100 from
Medicaid
(D) Turn in the receipt to his caseworker and be eligible for coverage for the
current month, plus two additional months
(A) Turn the receipt in to his caseworker and be eligible for two months of
coverage
Feedback: A bill that is larger than the spenddown may be used to meet multiple
month’s spenddown. If a patient wants the most coverage possible,
$100 would meet two month’s coverage spenddown.
This type of insurance is paid for by employers for employees and takes advantage of
purchasing power of having large member numbers.
(A) Individual health plan
(B) Group health plan
(C) Medicare
(D) Medicaid
(B) Group health plan
Response Feedback:
Rationale: Group health plans are those purchased by employers for employees. Employers are able to take advantage of purchasing power of the group to allow the insurance company to reduce the rate it charges to provide insurance for each individual member of the group
Why must a provider obtain an NPI number?
I. To submit claims
II. To prove that he is licensed
III. To be HIPAA compliant
IV. To guarantee payment by a health plan
(A) I, II, III
(B) II, III, IV
(C) I, II, III, IV
(D) I, III
(D) I, III
A National Provider Identifier, or NPI, is a unique 10-digit identification number required by HIPAA. All healthcare providers that are covered entities must obtain an NPI. . An NPI doesn’t: 1) ensure a provider is
licensed or credentialed; 2) guarantee payment by a health plan; 3) enroll a provider in a health plan; 4) make a provider a covered provider; 5) require a provider to conduct HIPAA transactions; or 6) change or replace the Medicare enrollment or certification process.
What are the options for a provider with regards to participation with Medicare?
(A) It is mandatory for every provider to participate in Medicare
(B) Providers may participate, may choose not to participate, or may optout of Medicare
(C) Providers are automatically opted-out
(D) Only participating providers must file claims
(B) Providers may participate, may choose not to participate, or may optout of Medicare
In regards to Medicare, a provider may choose to be a participating provider, a non-participating provider, or choose a third option of opting-out of the Medicare program.
Under the Patient Protection and Affordable Care Act (ACA), what is banned?
(A) Coverage for children under the age of 26
(B) Patient appeal rights
(C) Expanded preventative health services
(D) Lifetime limits
(D) Lifetime limits
Under the ACA, lifetime limits are banned on any health plans issued or
renewed on or after September 23, 2010. The law also bans annual
dollar limits on most covered benefits as of January 1, 2014.
A family practitioner sees a Medicare patient and bills a 99213. This provider has opted-out of Medicare. His fee for the service is $125.00. Medicare’s approved
amount is $73.08, and the patient has met $0 of his deductible. What can the provider bill the patient?
(A) $125.00
(B) $73.08
(C) $14.62
(D) $58.46
(A) $125.00
Providers that opt-out of Medicare are not limited to any specific charge limit on their patients. The patient is responsible for payment in full for services as Medicare will not pay any amount to either the patient or
provider in this situation.
A patient has receipts for her dental cleaning, vision exam, and contact lenses. Her employer has set up special accounts for each employee, there is no limit to the amount the employer can contribute and the balances roll over from year to year. What type of account is this?
(A) Flexible Spending Account (FSA)
(B) Health Savings Account (HSA)
(C) Health Insurance Account (HIA)
(D) Traditional Healthcare Reimbursement Arrangement (HRA)
(D) Traditional Healthcare Reimbursement Arrangement (HRA)
With an HRA, the employer has full power over structuring the employee’s use of HRA funds. Unlike an HSA or FSA, there is no limit to the amount an employer can contribute to an employee’s healthcare reimbursement account. The account balances may also roll over from year to year.
An internist sees a 20-year-old patient for an oce visit. The patient needs to see an endocrinologist for a consultation regarding her diabetes. The internist is a
participating provider in her plan. She can choose any provider she wishes for her consultations, but she will save money if she sees a specialist that is in her network. She does not require a referral for her consultation. What type of insurance does the
patient have?
(A) HMO
(B) Indemnity insurance
(C) Medicare Advantage
(D) PPO
(D) PPO
A PPO is a type of insurance plan that allows members to choose the doctors and hospitals they want to visit from providers within the network (preferred providers). Unlike HMOs, patients are not required
to obtain prior approval or go through a “gatekeeper” if they wish to see a specialist. They also are not required to choose a primary care provider. If they choose not to see a preferred provider, the services are still covered, but the patient will pay more out-of-pocket costs as the services provided by non-participating providers are reimbursed at a
lower rate.
Which insurance is a healthcare benefit program for military personnel in all seven uniformed branches?
(A) Medicare
(B) Medicaid
(C) TRICARE
(D) BCBS
(C) TRICARE
TRICARE is a healthcare benefitt program for military personnel in all seven uniformed branches—the Army, the U.S. Navy, the Air Force, the Marine Corps, the Coast Guard, the Commissioned Corps of the U. S.
Public Health Service, and the Commissioned Corps of the National Oceanic and Atmospheric Administration. It was formerly known as the Civilian Health and Medical Program of the Uniformed Services, or
CHAMPUS. TRICARE is managed in three separate stateside regions, North, South, and West, by separate carriers.
A patient presents to be seen in the once. He does not pay at the time the services are rendered as the provider is his primary care provider, or gatekeeper. The large group practice has 800 covered members under this plan as is paid on a monthly basis with a set amount that is based on the number of members covered and their ages. What type of plan is this?
(A) PPO
(B) Capitation
(C) Fee-for-service
(D) Indemnity
(B) Capitation
Capitation payments are used by managed care organizations (MCOs) to control healthcare costs by putting the physicians at financial risk for services provided to patients. Payments are based on a per-person rate, rather than a fee-for-service rate.
