Chapter 03: Basics of Health Insurance

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chapter test

Insurance is considered a federally regulater industry.

False

An insurance billing specialist can escape liability by pleading ignorance.

False

If the physician no longer wishes to treat an HMO or a PPO patient, termination is handled according the same method that is used when discharging patients who are insured under private insurance.

True

Basic health insurance coverage includes benefits for skilled nursing facilities.

False

A subscriber of insurance policy may also be known as a policyholder.

True

The insured may not necessarily be the patient seen for medical service

True

Basic health insurance offsets large medical expenses caused by serious illnesses.

False

The insured in health insurance policy may also be the patient.

True

An insurance claims representative also known as the claims adjudicator.

True

A coordination of benefits statement in an insurance policy refers to the waiting period

False

Insurance claims may not be legally denied for payment even if submitted after the insurance company's time limit.

False

Personal insurance is usually less expensive than other health insurance

False

Medicare is a program jointly sponsored by federal and state governments for those eligible for public assistance.

False

A two- or three-part form that incorporates a combination bill, insurance form, and routing document used in both computer- and paper-based systems is called an encounter form.

True

Hospital patients' insurance claims should be submitted on a monthly basis regardless of their discharge status.

False

The efficient medical insurance specialist usually groups together all outstanding charges of patients who have the same type of insurance and processes these insurance claims at the same time

True

State laws may bar the use of signature stamps

True

Workers' compensation insurance covers off-the-job injuries.

False

Information such as the deductible, copayment, preapproval provisions, and insurance company address and telephone number usually can be found on the insurance card.

True

If a patient has an individual insurance policy, a release of information does have to be signed before the physician's office submits a claim to the insurance company.

True

Private insurance companies with whom the provider does not have a contractual agreement will send the check to the patient regardless of whether the patient has signed an assignment of benefits

False

For Medicaid cases there is no assignment of benefits unless the patient has other unsurance in addition Medicaid

True

Which statement is correct regarding the insurance industry?
a. In the past decade medical care costs have escalated, forcing the insurance industry to increase their forms of coverage
b. The insurance industry is among the world's largest businesses
c. The insurance industry has provided health insurance since the mid-1900s.
d. The insurance industry is a dying industry.

b. The insurance industry is among the world's largest businesses

Most legal issues of private health insurance claims fall under
a. Federal law
b. Civil law
c. Regional law
d. Government laws

b. Civil law

When does the physician/patient contract begin?
a. After the physician has examined the patient for the first time.
b. When the patient steps into the examination room to be treated.
c. When the physician accepts the patient and agrees to treat the patient.
d. When the patient verbally agrees to accept the advice of the physician

c. When the physician accepts the patient and agrees to treat the patient.

Most physicians/patient contracts are
a. Implied
b. Expressed
c. Written
d. Verbal

a. Implied

When a patient carries private medical insurance, the contract for treatment exists between.
a. The patient and the insurance company.
b. the physician and the patient
c. the physician and the insurance company
d. the policy holder and the insurance company

b. the physician and the patient

An emancipated minor is
a. A person younger than the age of 18 who lives independently
b. A person older then the age of 21
c. A person younger than the age of 16 who lives with his or her parents.
d. A person younger than the age of 18 who does not live with his or her parents.

a. A person younger than the age of 18 who lives independently

Who does the contract exist between in a worker's compensation case?
a. The patient and the insurance company
b. The physician and the patient
c. The physician and the insurance company
d. The policyholder and the insurance company

c. The physician and the insurance company

In health insurance, the insured is also known as
a. The subscriber
b. the member
c. The policyholder.
d. all of the above

d. all of the above

The insured is always
a. The patient
b. the person at risk
c. The individual enrollee or organization protected
d. The employer

c. The individual enrollee or organization protected

The reason for a coordination of benefits statement in a health insurance policy is
a. To prevent duplication or overlapping of payments for the same medical expense.
b. To ensure adequate payment to the insured who holds more than on policy
c. To ensure payment to the physician
d. To make the insurance companies responsible for full payment of claims

a. To prevent duplication or overlapping of payments for the same medical expense.

Mr. Talil has two medical insurance policies. To prevent duplication of payment for the same medical expense, the policies include a
a. coordination of benefits statement
b. basic health insurance statement
c. guaranteed benefits statement
d. conditional benefit statement

a. coordination of benefits statement

When a medical facility is sent correct reimbursement from an insurance company for professional services, the site receives
a. The indemnity
b. The payment
c. The check
d. All of the above

d. All of the above

If a child has health insurance coverage from two parents, according to the birthday law
a. The father's insurance is always primary
b. The mother's insurance is always primary
c. The health plan of the person whose birthday (month and day) falls earlier in the calendar year will pay first.
d. It is only in effect if the parents are divorced.

c. The health plan of the person whose birthday (month and day) falls earlier in the calendar year will pay first.

According to the birthday law, if both the mother and the father have the same birthday
a. The hour of birth determines who pays first
b. The plan of the person who has coverage longer is the primary payer
c. The plan that offers the best coverage is primary payer
d. The father's policy is the primary payer

b. The plan of the person who has coverage longer is the primary payer

Conditions that existed and were treated before the health insurance policy was issued are called
a. Accidents
b. Illnesses
c. Preexisting
d. Unforeseen occurrences

c. Preexisting

An attachment to insurance policy that excludes certain illnesses or disabilities that would otherwise be covered is referred to as a/an
a. Waiver
b. Exclusion
c. Grace period
d. Deductible

a. Waiver

What is the correct term used to determine if a procedure is covered and medically necessary?
a. Preauthorization
b. Predetermination
c. Precertification
d. Verification

a. Preauthorization

Mrs. Thompsett leaves her place of employment. She is eligible to transfer her medical insurance coverage from a group to individual contract. That is known as
a. contract privilege
b. conversion privilege
c. coordination privilege
d. exclusion privilege

b. conversion privilege

Why would conversion from a group policy to an individual policy be advantageous?
a. Premiums would be reduced
b. Benefits would be increase
c. No physician examination is required
d. No precertification is necessary

c. No physician examination is required

Mr. Ott was laid off from his job. He is protected by COBRA, which requires his employer to
a. Pay him partial salary for 6 months
b. Extend group health insurance coverage for 18 months
c. Extend individual health insurance policies for 18 months.
d. Pay him full salary for 6 months.

b. Extend group health insurance coverage for 18 months

What is the minimum number of employees a company must have to meet criteria of the Consolidated Omnibus Budget Reconciliation Act (COBRA) for continued medical benefits if an employee is laid off from a company?
a. 15
b. 20
c. 25
d. 50

b. 20

The act created to protect workers and their families so that they can get and maintain health insurance if they change or lose their jobs is called the
a. Consolidated Omnibus Budget Reconciliation Act (COBRA)
b. Health Care Finance Administration Act (HCFAA)
c. Bush Fair Health Act (BFHA)
d. Health Insurance Portability and Accountability Act (HIPPA)

d. Health Insurance Portability and Accountability Act (HIPPA)

An organization of physicians, sponsored by a state or local medical association, concerned with the development and delivery of medical services and the cost of health care is known as
a. Competitive medical plan (CMP)
b. Exclusive provider organization(EPO)
c. Foundation for medical care
d. Independent practice association (IPA)

c. Foundation for medical care

A type of managed care organization created by the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA) that allows for enrollment of Medicare beneficiaries in to managed care plan is a/an
a. Preferred provider organization (PP)
b. Competitive medical plan (CMP)
c. independent practice association (IPA)
d. point-of-service plan (POS)

b. Competitive medical plan (CMP)

A state and federal program for children who are younger then 21 years of age and have special health care needs is
a. Medicaid
b. Children's Protective Services
c. Medi-Med-
d. Maternal and Child Health Programs (MCHP)

d. Maternal and Child Health Programs (MCHP)

A patient intake sheet is also called a
A. Patient form
B. Patient report
C. Patient registration form
D. Medical record

C. Patient registration form

The first document obtained in the initial patient visit is a/an
a. Encounter form
b. Patient chart
c. Patient information form
d. Patient ledger

c. Patient information form

Assignment of benefits is
a. Used only by nonparticipating physicians
b. Never used by participation physicians
c. The transfer of physician's right to collect an amount payable to the patient
d. The transfer of one's legal right to collect an amount payable under an insurance contract.

d. The transfer of one's legal right to collect an amount payable under an insurance contract.

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