Chapter 2 Test Flashcards
Physician-Hospital Organizations (PHO), Management Service Organization (MSO), and Integrated Provider Organiztion (IPO) are examples of what type of healthcare models?
(A) Integrated Delivery Systems.
(B) Affiliated Healthcare Systems.
(C) Preferred Provider Organizations.
(D) Alliance for Healthcare Systems.
(A) Integrated Delivery Systems.
Integrated Delivery Systems are a network of providers and facilities that work together to offer joint healthcare services to its members.
Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct?
(A) CMS reviews all state plans to make sure they offer federal regulations.
(B) Individual states establish their own rates based on the multiple criteria.
(C) All Medicaid plans offer HMO options.
(D) States have the option to charge co-pays and deductibles.
(C) All Medicaid plans offer HMO options.
Although Medicaid plans are overseen by CMS, the individual states have the option to decide rates, co-pays for certain populations, and if co-pays and deductibles will be required. Not all states offer HMO plans.
A Medicare patient presents after slipping and falling in a neighbor’s walkway. The cement had a large crack, which caused the pavement to raise and be unsteady. The neighbor has contacted his homeowner’s insurance and they are accepting liability and have initiated a claim. How should the visit be billed?
(A) Bill the Homeowner’s insurance only. Medicare will not pay anything.
(B) Bill Medicare, then the Homeowner’s insurance as secondary.
(C) File to both at the same time and see which pays more.
(D) Bill the Homeowner’s first, then Medicare secondary if it is not paid within 120 days.
(D) Bill the Homeowner’s first, then Medicare secondary if it is not paid within 120 days.
No-fault insurance or liability insurance would be the primary insurance in an accident with injury cases instead of a patient’s own medical insurance. If the provider/practice/facility knows the patient has a no-fault or liability insurance claim, the claim should be filed to the no-fault or liability insurer first.
Which of the following services is NOT covered under Medicare Part B?
(A) Cardiovascular disease screening.
(B) Diabetes self-management.
(C) Nutrition therapy services.
(D) Home health services.
(D) Home health services.
Home health services are covered under Part A.
What does the acronym CHIP stand for?
(A) Combined Health Information Plan.
(B) Children’s Health Information Plan.
(C) Combined Health Insurance Program.
(D) Children’s Health Insurance Program.
(D) Children’s Health Insurance Program.
The Children’s Health Insurance Program (CHIP), is designed to offer free or low-cost health insurance coverage to those whose incomes are too high to qualify for Medicaid, but cannot afford private coverage.
Which of the following is NOT evaluated in the credentialing process?
(A) Physician’s education.
(B) Physician’s residency.
(C) Physician’s request for privileges.
(D) Physician’s license(s).
(C) Physician’s request for privileges.
The credentialing process evaluates the licenses, residency, medical school education, and any adverse clinical information. Request for privileges is part of the privileging process for the hospital.
NPI is an abbreviation for a unique number that is required by HIPAA. What does NPI stand for?
(A) National Physician Identifier.
(B) National Provider Insurance.
(C) National Provider Identifier.
(D) National Participating Identifier.
(C) National Provider Identifier.
A National Provider Identifier (NPI), is a unique 10-digit identification number required by HIPAA.
What is the benefit of using NPI numbers for payers?
I. It is a single identifier for all payers.
II. It contains the providers’ birthdates to allow certain identification.
III. Each payer can make their own number.
IV. It has no personal identifying information in the number.
(A) I, II.
(B) III, IV.
(C) I, I, IV.
(D) I, IV.
(D) I, IV.
A National Provider Identifier (NPI), is a unique 10-digit identification number required by HIPAA. In the past, providers’ had different identification numbers for each payer, but the introduction of the NPI is a single identifier for all payers to improve efficiency of the healthcare system. It will also help reduce fraud and abuse. It is an “intelligence-free” number, meaning that there is no personal identifying information (birthdate or social security number) other than a name and business address.
Medicare coverage provides hospital coverage and voluntary medical insurance to:
(A) Certain individuals of low-income.
(B) Persons age 65 or older.
(C) Certain disabled individuals under age 65.
(D) Both B and C are correct.
(D) Both B and C are correct.
Medicare is offered to those that are age 65 or older, and to certain individuals under 65 that have disabilities.
A Medicare beneficiary needing to fill a prescription would utilize what Part of their Medicare benefits?
(A) Part A.
(B) Part B.
(C) Part C.
(D) Part D.
(D) Part D.
Medicare Part D reimburses for prescription drugs.
NPI numbers have two types of entities-identify the two types:
(A) Employee and Group.
(B) Sole Proprietor and Group.
(C) Location and Group.
(D) Sole Proprietor and Individual.
(B) Sole Proprietor and Group.
There are two types of NPI entities: Entity 1 and Entity 2. Entity type 1: sole proprietor/sole proprietorship, which is an individual. The individual must apply using their own Social Security Number. They will need only one number, regardless of how many locations they provide services to as they are not allowed to have subparts as a type 1 entity. Entity type 2: group healthcare providers. These are entities with EIN numbers, whether they have one employee (the physician him/herself) or thousands. These may include hospitals, home health agencies, clinics, and nursing homes.
Medicaid coverage is provided for low-income individuals and families. Individual states decide the coverage benefits for their plans, however some benefits are mandated by the Federal government. Which of these is not a federal mandate?
(A) Vaccines for children.
(B) Optometry services.
(C) Family planning.
(D) Nurse mid-wife services.
(B) Optometry services.
Optometry services are listed as one of the 34 optional services that individual states can choose to provide and receive matching funds.
A patient presenting for care does not have an insurance card and is billed CPT 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed?
(A) Nothing has to be done.
(B) File a claim to Medicaid and refund the $100 to the patient.
(C) File a claim with Medicaid, a refund will be completed when the EOB is received showing the patients responsibility.
(D) None of the above.
(C) File a claim with Medicaid, a refund will be completed when the EOB is received showing the patients responsibility.
If the patient has coverage at the time of service the contracted provider is obligated to file a claim. The patient will be refunded the difference of $100 paid at the time of the visit and her liability.
The 2020 Medicare deductible and co-insurance amount for outpatient services on Part B is:
(A) $198 per calendar year and 20% of approved amount.
(B) $198 per calendar year and 20% of the billed amount.
(C) $198 per hospitalization and 20% of approved amount.
(D) $198 per calendar year.
(A) $198 per calendar year and 20% of approved amount.
The Medicare deductible is $198 per calendar year with co-insurance 20% of the approved amount.
An employee signed up for a program through her employer. It allows her to put pre-tax money away from her paycheck in order to pay for out-of-pocket healthcare expenses. She may contribute up to $2,750 (2020) per year. If she does not use all of the money during the current year, she forfeits it. What is this?
(A) Health Savings Account.
(B) Flexible Spending Account.
(C) Health Savings Security Account.
(D) Healthcare Reimbursement Account.
(B) Flexible Spending Account.
An FSA is an account where an individual puts money into that is used to pay for certain out-of-pocket healthcare costs. It is a tax-advantaged healthcare account available for most employees as no taxes are paid on the money in the account. Up to $2,750 (2020) may be put into an FSA each year, but if the money is not used during the plan year, it is forfeited. A Health Savings Account may be funded by employers and is portable. In order to participate in a Health Savings Account, a person must be enrolled in a high-deductible health plan. In a Healthcare Reimbursement Account, employers have full power over structuring. There is no limit an employer can contribute and the balances may roll over from year to year.
