Commercial

Question 1

Understanding the differences among health plans can be useful and extremely important for case managers in the context of the revenue cycle.
True or False

Answer 1

True

Question 2

Health insurance coinsurance and co-payment are the same thing.
True or False

Answer 2

False

Question 3

Deductibles have remained the same since the implementation of the accountable care act (ACA)
True or False

Answer 3

False

Question 4

It is not critical for CMs involved in the revenue cycle process, to have an understanding of the contract requirements to ensure compliance with program specifications and optimize reimbursement.
True or False

Answer 4

False

Question 5

Up to 61% of provider-submitted claims have demographic and/or technical errors, which means upstream someone collected or entered incomplete or incorrect data.
True or False

Answer 5

True

Question 6

States may require managed care organizations (MCOs) to maintain accreditation from such agencies as URAC or the National Committee for Quality Assurance (NCQA) in order to be granted the required state licensure.
True or False

Answer 6

True

Question 7

The two broad types of health insurance plans in the US are?
A. Commercial and Indemnity
B. Fee for service and Point of service
C. Public insurance and Private Insurance
D. Medicare insurance and Medicaid insurance

Answer 7

C. Public insurance and Private Insurance

Question 8

Which type of managed care plan is usually the lowest cost?
A.  HMO
B.  PPO
C.  POS
D.  HAS

Answer 8

A. HMO

Question 9

Why are PPOs an attractive type of health care plan?
A. PPOs are attractive because they’re so affordable
B. PPOs are attractive because the insured can select any doctor they want
C. PPOs are attractive because they reimburse the insured for out of pocket expenses
D. PPOs are attractive because they have high deductibles so the premiums are super low

Answer 9

B. PPOs are attractive because the insured can select any doctor they want

Question 10

The health plan payment option that is portable and follows the person, not the job or the high deductible insurance plan and can be invested if not used for medical expenses is called?
A. The Flexible Spending Account (FSA)
B. A Medical Savings Account (MSA)
C. A Consumer-Directed Health Plan (CDHP)
D. A Health Savings Account (HSA)

Answer 10

D. A Health Savings Account (HSA)

Question 11

Studies show that the effect of high deductible healthcare insurance is?
A. Causing more people to get their wellcare checkups
B. Causing more people to get immunized
C. Causing more people to forego healthcare altogether
D. Causing more people to change insurance policies

Answer 11

C. Causing more people to forego healthcare altogether

Question 12

Because of the effects of high deductible plans on people needing healthcare, organizations are facing all of the following financial challenges on revenue cycle EXCEPT?
A. Increase in profitability
B. Fewer people seeking care or treatment
C. Increase in uncompensated care
D. Inability to maintain adequate cash flow

Answer 12

A. Increase in profitability

Question 13

What is a participating provider agreement (PPA)?
A. An agreement between the patient and the provider about charges for each encounter
B. A contract between provider and insurer regarding reimbursement for medically necessary healthcare
C. A government regulation covering who is approved to provide healthcare services
D. A list of approved providers for each state

Answer 13

B. A contract between provider and insurer regarding reimbursement for medically necessary healthcare

Question 14

Which of the following is a TRUE statement about claims and reimbursement?
A. The hospital is contractually obligated to collect co-pays from patients
B. The hospital is allowed to bill the patient for claims that are denied due to medical necessity
C. The federal government regulates all PPA definitions and standards regarding insurance claims and hospital reimbursements
D. CMs involved in revenue cycle management have to ensure compliance of insurers with reimbursement regulations.

Answer 14

A. The hospital is contractually obligated to collect co-pays from patients

Question 15

Preventing claims denials is a key strategy to improved reimbursements and revenue flow. 61% of claims denials are caused by?
A. Many denials are traced back to demographic information inaccuracies
B. Many denials are due to technical errors on claims forms
C. Many denials are due to lack of using proper ink color
D. Both A and B are correct

Answer 15

D. Both A and B are correct

(Many denials are traced back to demographic information inaccuracies and Many denials are due to technical errors on claims forms)

Question 16

All of the following are strategies for collecting copays for High-deductible health plans EXCEPT?
A. Offering patients low or no interest payment plans
B. Negotiating discount rates with the insurance carrier
C. Offering patients a healthcare bank loan
D. Providing a discount on the remaining balance in exchange for an upfront cash payment

Answer 16

C. Offering patients a healthcare bank loan

Question 17

A key element to maximizing reimbursement in today’s Value-based Purchasing (VBP) environment is?
A. Preventing hospitalizations at any cost
B. Managing care across the continuum of care
C. Rapid-fire care plans that move the patient quickly through the system
D. Maximizing home care

Answer 17

B. Managing care across the continuum of care

Question 18

Insurance metrics demonstrate that the largest percentage of the healthcare dollar goes toward prescription drugs. However, the growth rate of commercial insurance companies has slowed, largely due to what?
A. Failed medical management
B. High cost duplication of services
C. Increased use of Predictive Healthcare futures
D. Increased use of lower cost generic drugs

Answer 18

D. Increased use of lower cost generic drugs

Question 19

Which of the following is unique to the MCO CM practice?
A. Determine if the patient is an MCO member
B. Perform concurrent review
C. Plan for transitions of care
D. Facilitate access to care

Answer 19

A. Determine if the patient is an MCO member

Question 20

Formulating a Single Case Agreement (SCA) when an out of network provider delivers emergency care is the responsibility of?
A.  The MCO CM
B.  The Payer CM
C.  The Provider CM
D.  The MCO CM and the provider CM team

Answer 20

D. The MCO CM and the provider CM team

Question 21

The Payer CM and the Provider CM have the same goals.  Which of the following is NOT one of their goals?
A.  Increase quality of care
B.  Increase use of hospital admissions
C.  Reduce cost of care
D.  Increase patient satisfaction

Answer 21

B. Increase use of hospital admissions