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136 Cards in this Set
- Front
- Back
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Billing for services not provided is an example of
A. incentives B. pre-planning C. fraud D. abuse |
C fraud
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claims for services deemed not medically necessary by insurance plans or programs are examples of
A. abuse B. hardship waivers C. improper delegation D. fraud |
A abuse
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for the physician involved, Medicare program-related crimes result in
A. insurance cancellation B. embezzlement charges C. higher malpractice insurance premiums D. exclusion from program participation |
exclusion from program participation
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misconduct that occurs within a physician's field of expertise and results in injury or loss to the recipient
of service is called A. liability B. slander C. negligence |
negligence
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before performing surgery, what must the physician obtain from the patient
A. informed consent B. diagnosis and prognosis C. admission of fault D. second opinion |
informed consent
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if a patient does not follow instructions, does not take recommended medications, and fails to return for an appointment, the physician may
A. prescribe medication for mental issues B. waive an arbitration agreement C. terminate further care of the patient D. recommend further test |
terminate further care of the patient
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a form sent to the insurance company to find out the maximum dollar amount that will be paid for a procedure is called an insurance
A. certification form B. preauthorization form C. precertification form D. predetermination form |
predetermination
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a government program that provides medical services for dependents of active military personnel
is know as A. Medicare B. Medicaid C. Tricare D. Champva |
Tricare
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an organization that provides a wide range of services group at a fixed periodic payment is called a
A. PMO B. HMO C. PPO D. PPS |
HMO
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in California, the Medicaid program is called
A. Calimed B. HMO C. Medicare D. Medi-Cal |
Medi -Cal
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a program that insures a person against on-the-job injury or illness is called
A. state disability B. worker' compensation C. workmen's insurance D. prepaid health |
worker' compensation
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one of the first steps in processing an insurance claim is to
A. obtain a release of information statement B. evaluate the laboratory results C. post payment to the day sheet D. take a comprehensive history |
obtain a release of information statement
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a convenient arrangement for following up on the progress of paper insurance claims is to use a
A. calendar B. rolodex C. tickler file D. ledger |
tickler file
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third party payers require all the following information except
A. triplicate copies of invoices B. diagnoses using ICD-9 -CM codes C. DOS D. POS |
triplicate copies of invoices
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careful and thorough recording of information at the time of the initial office visit
A. takes too long B. is always done by the insurance specialist C. enables one to handle insurance claims promptly D. is done only when the patient is scheduled for surgery |
is always done by the insurance specialist
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obtaining all the names of insurance companies form patients is important for
A. notifying the next of kin B. purging the alpha file C. making future appointments D. coordinating benefits |
coordinating benifits
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another name for the release of information from is the
A. assignment of benefits B. requisition form C. consent form D. spreadsheet |
consent form
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the number of views, part of the body, and type of view are necessary pieces of information for itemizing
A. level of E/M service B. x-rays C. location of a tumor D. laboratory work |
level of E/M service
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if a claim is filed after the submission time limit for the carrier, payment is usually
A. processed B. guaranteed C. denied D. suspended |
denied
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incorrect payments from an insurance company should be
A. appealed B. accepted C. forwarded to the patient D. deposited |
appealed
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assignment means which of the following
A. contracting with an insurance company B. accepting what the insurance company pays for a claim C. requesting that the patient's health benefit payment be sent to the doctor D. having a specialist assigned to the patient |
accepting what the insurance company pays for a claim
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the amount that a physician normally or usually charges the majority of his or her patients is the
A. Usual and customary provider fee B. RUV C. RBRVS D. UCR |
usual and customary provider fee
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when coding some procedures and services it is sometimes necessary to add a 2 digit modifier to
A. indicate usual charges B. provide more information for the insurance company C. give a more accurate description D. all choices are correct |
all choices are correct
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random audits of medical records by insurance carriers are used to
A. catch errors by insurance companies B. monitor coding accuracy C. assess physician dictation timelines D. revise CPT codes |
monitor coding accuracy
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a patient was seen in February. He has not met his annual deductible. what should the billing specialist do
A. delay claim submission until the deductible has been met B. don't submit the claim; office will collect the full charges, including deductible C. submit the claim in December because the deductible will be met by then D. submit the claim within applicable timely filing limits |
submit the claim within applicable timely filing limits
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a correctly completed claim submitted within the policy time limit is termed a
A. paper claim B. paid claim C. legal claim D. clean claim |
clean claim
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an EOB document may include all of the following except
A. deductible B. patient name C. allowed amounts D. coding updates |
coding updates
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claims paid with no errors are considered
A. closed claim B. pending C. filed D. suspended |
closed claim
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a group of electronic claims submitted from one facility is termed a
A. bunch B. batch C. cluster D. bundle |
bunch
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from beginning to end, an electronic claim versus a paper claim requires
A. fewer steps B. more steps C. signature stamps D. documents be sent |
fewer steps
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a third party entity that receives, separates, and transmits claims to the appropriate payer is called a(n)
A. carrier B. insurance specialist C. clearinghouse D. national network |
clearinghouse
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Medicaid policy allows for coverage and payment of all services that are
A. billed by a physician B. medically necessary C. viewed as appropriate by the physician D. less than $100 |
medically necessary
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a plastic card containing information regarding a patient's insurance, history and eligibility is called a
A. disk B. record C. debit card D. smart card |
smart card
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when may a physician modify, change, or add an addendum to a medical record
A. only after a claim is submitted B. only before a claim is submitted C. never D. when an omission or error comes to his or her attention |
when an omission or error comes to his or her attention
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Large medical practices generally submit electronic claims
A. daily B. hourly C. weekly D. monthly |
daily
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a digital fax claim is a claim that arrives at the insurance carrier via fax machine but is
A. printed on paper B. never printed on paper C. duplicated and verified D. monitored by phone |
never printed on paper
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in order to receive the carrier's fax back verification, the physician's office
A. runs a test phase B. follows a schedule C. fax must be turned on D. staff use be present |
fax must be turned on
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which of the following is not recommended on fax claims
A. dark, distinct print B. font size of 10-14 points C. handwritten information D. CMS - 1500 forms |
handwritten information
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submissions to the insurance commissioner should be handled
A. electronically B. by telephone C. in writing D. by the patient |
in writing
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if an insurance carrier sends payment directly to the patient even though the physician has been assigned the benefits, the
A. carrier must pay the physician within 2 to 3 weeks B. payment is not recoverable C. patient will pay the physician D. physician will revoke the assignment of benefits form |
carrier must pay the physician within 2 to 3 weeks
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the following are the types of problem claims except
A. partial payment B. clean claims C. delinquent claims D. suspended claims |
clean claims
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the following are common reasons for denial of claims except
A. deleted codes B. when gender does not match service C. correct dates of service D. transposed numbers |
correct dates of service
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if a claim is denied for lack of medical necessity and the physician feels the service was medically necessary, the physician should
A. contact the commissioner B. write a letter of appeal C. resubmit the claim D. write off the amount of the claim |
write a letter of appeal
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an inquiry made to locate the status of an insurance claim is called a
A. follow-up B. tracer C. review D. tracker |
tracer
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if an appeal for a legitimate claim is unsuccessful, the physician may request a
A. different tracer B. refund C. new carrier arrangement D. peer review |
peer review
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it is important for Tricare patients to always
A. present a military ID B. submit the claim on- line C. register with social services D. enroll with deers |
present a military ID
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if a nonmember physician treats an HMO patient, the services are termed
A. provisional B. approved C. out of plan D. improper |
out of plan
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which of the following practices would NOT be noted utilization review
A. churning B. turfing C. excessive overtime D. buffing |
excessive overtime
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capitation refers to a
A. type of payment agreement where the physician is paid per person whether seen or not B. type of posting done manually in the physician' office C. fee for service agreement where a dollar amount is set for each service or procedure D. tax paid by the physician to the internal revenue service |
fee for service agreement where a dollar amount is set for each service or procedure
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an indemnity benefit contract
A. offers physician participation B. makes no promise to cover a full fee C. is a service contract D. is offered through Medicare |
makes no promise to cover a full fee
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second opinion programs
A. refer data to clearinghouse B. are billed electronically C. benefit referring physician D. reduce the incidence of surgery |
reduce the incidence of surgery
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which of the following is an ERISA benefit plan
A. an HMO through Blue Cross provided by Wal-Mart to an employee of Wal-Mart B. an HMO through Aetna provided by the Catholic Church to a priest C. A PPO through United Healthcare provided by the city Dallas to a city employee D. A POS provided through a Medicare Part C plan |
An HMO through Blue Cross provided by Wal-Mart
to an employee of Wal-Mart |
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each state designs its own Medicaid program within
A. local guidelines B. federal guidelines C. international guidelines D. AMA guidelines |
international guidelines
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all but which of the following may be covered by Medicaid
A. 65 year old business executives B. patients who cannot see C. patients with disabilities D. 65 year old patients |
65 year old business executives
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in the Medicaid program, which one of the following groups is NOT usually considered categorically needy
A. QMBs B. AFDC- related groups C. SSI cash recipients D. Military dependents |
Military dependents
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which of the following is NOT covered by Medicaid
A. birth control B. cosmetic surgery C. X-Rays D. Immunizations |
cosmetic surgery
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prior approval for certain services in the Medicaid program is necessary EXCEPT for
A. transportation B. a true emergency C. hearing aids D. prosthetic devices |
a true emergency
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all but which of the following might be covered by Medicaid
A. inpatient care for a digestive disorder B. hemodialysis for a kidney patient C. surgery ( hysterectomy) for dysfunctional uterine bleeding D. contact lens to change the color of the eyes |
contact lens to change the color of the eyes
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if a patient require care while out of state, most states offer Medicaid
A. training B. education C. reciprocity D. refunds |
reciprocity
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if a Medicaid bill is submitted after the time limit it will most likely be
A. rejected B. reviewed C. paid D. ignored |
rejected
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Medicaid eligibility for participants should be verified every
A. month B. three months C. six months D. year |
month
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if a person eligible for Medicaid has other insurance coverage, Medicaid is always
A. firs insurance billed B. responsible third party liability carrier C. primary carrier D. secondary carrier |
secondary carrier
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Medicare is a federal health insurance program for the following categories of people EXCEPT
A. people 65 years or older B. preschool children with no permanent disabilities C. blind individuals D. disabled widows |
preschool children with no permanent disabilities
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for Medicare inpatient services, a benefit period begins the
A. day a patient enters the hospital B. first day the physician sees the patient in the office for the illness or injury C. 3rd day of a hospital stay D. first day home from the hospital |
day a patient enters the hospital
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a patient might submit his own Medicare claim when
A. the hospital is in a rural location B. the time limit has passed C. purchasing medical equipment D. the physician is too busy |
purchasing medical equipment
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when an illiterate patient cannot sign a Medicare form,
A. s/he should be referred to a literacy program B. a supervisor should be notified C. a witness should sign the form D. care is denied |
a witness should sign the form
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to be eligible for Medicare, an alien resident must have lived in the U.S. for
A. 5 consecutive years B. 3 consecutive years C. 1 year D. 10 years |
5 years
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if Medicare beneficiaries have memory impairment, they have a legal right to
A. hearing aids B. appoint a representative C. private hospital rooms D. audit their claims |
appoint a representative
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a physician may be penalized by Medicare for
A. billing for laboratory services B. submitting a late claim C. billing for services not provided D. billing inpatient services |
billing for services not provided
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when a patient is scheduled to receive a service that is not covered by Medicare, it is recommended to
A. advise the patient prior and obtain an ABN when needed B. confer with the physician prior to providing the service C. submit a clean claim D. appoint a representative |
advise the patient prior and obtain an ABN when needed
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mandated by HIPAA and implemented in May 2005, the standard unique identifier that all health care providers will be required to use when filing and processing health care claims is the
A. UPIN B. NPI C. PIN D. SUI |
NPI
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when a patient is placed in custodial care in a nursing home, Medicare will
A. pay 8% B. pay 50% C. pay 25% D. pay nothing |
pay nothing
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Medigap policies
A. supplement the traditional Medicare policy B. supplement the Medicaid program C. supplement private insurance D. are regulated and offered by individual states |
supplement the traditional Medicare policy
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it is important for the insurance billing specialist to determine whether a patient's Medicare coverage
is primary or A. tertiary B. supplemental C. MSP D. indemnity |
MSP
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some HMO's provide Medicare patients with
A. eyeglasses B. cosmetic surgery C. therapeutic massage D. personal trainers |
eyeglasses
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if medical services are covered under auto insurance policy the
A. auto insurance is secondary B. auto insurance is primary C. patient files the claim D. auto insurance is billed after the primary insurance pays |
auto insurance is primary
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in a case of auto insurance coverage, claim for Medicare benefits may be submitted
A. only after denial by the primary insurer B. only after the patient has recovered C. with 2 years of the auto accident D. any time |
only after denial by the primary insurer
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receiving Medicare payment for a patient who has died is
A. rare B. impossible C. possible D. unusual |
possible
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Medicare mandated prepayment screens are intended to
A. assist physicians B. facilitate the filing of claims C. prevent unnecessary services D. monitor patient activity |
prevent unnecessary services
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an overpayment check from Medicare should be
A. returned to Medicare B. filed in the physician's office C. held until action is specified by Medicare D. deposited and reported to Medicare |
Deposited and reported to Medicare
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TRICARE Standard is similar to a
A. HMO plan B. PPO plan C. fee-for-service plan D. senior Medicare plan |
fee-for-service
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all of the following may receive benefits under CHAMPVA EXCEPT
A. spouses of disabled veterans B. active duty military dependents C. children of disabled veterans D. surviving spouse of a veteran |
active duty military dependents
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for participating physician services, what portion of the patient's expenses does Medicare pay
A. 20% of the Medicare allowed amount B. 20% of the physician's billed amount C. 80% of the physician's billed amount D. 80% of the Medicare allowed amount |
80% of the Medicare allowed amount
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if an army or navy hospital cannot provide a TRICARE patient with a needed service
A. the patient must forego that service B. a congressman is notified C. the ombudsman may be contacted D. the patient may go to a civilian hospital |
the patient may go to a civilian hospital
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the following healthcare provider may treat a TRICARE patient EXCEPT which one
A. M.D. B. Doctor of homeopathy C. audiologist D. physical therapist |
Doctor of homeopathy
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DEERS is
A. data base for military personnel and family B. conservation program for physicians C. type of claims processing procedure D. payment notification system |
data base for military personnel and family
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TRICARE prime co-payment are collected
A. monthly B. at the time service are rendered C. at the time the patient registers D. at the time of claim submission |
at the time services are rendered
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some very large employers have fought high medical costs of employee accidents by
A. lobbying for legislation B. self-insuring employees C. promoting workers' compensation reform D. using mediators instead of lawyers |
self-insuring employees
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the minimum number of employees required for a company in order for state workers' compensation to be effective is
A. 1 to 5 B. 2 to 6 C. 3 to 7 D. 5 to 10 |
5 to 10
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types of compensation benefits for injuries on the job include the following EXCEPT
A. medical treatment B. temporary disability payments C. legal fees D. survivors' benefits |
legal fees
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a minor injury on the job in which the patient is seen by a doctor but is able to continue working is a
A. non-disability claim B. temporary disability claim C. permanent disability claim D. retroactive claim |
non-disability claim
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Medicaid is always the
A. primary insurance B. secondary insurance C. payer of last resort D. only claim submitted |
secondary insurance
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vocational rehabilitation may include the following EXCEPT
A. severance benefits B. physical therapy C. job placement D. retraining |
severance benefits
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if an employee's injury prevents the return to a previous occupation, s/he may
A. receive SSI B. receive unemployment C. be trained for another career D. receive permanent total disability |
be trained for another career
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a permanent disability rating depends on the following EXCEPT
A. level of income B. occupation at the time of injury C. age of the injury D. severity of the injury |
level of income
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in a permanent disability claim, an agreement between the injured party and the insurance company is called a
A. P&S agreement B. permanent disclosure C. disability petition D. compromise and release |
compromise and release
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final determination of issues concerning settlement of an industrial accident are called
A. adjudication B. closure C. petition and appeal D. case completion |
adjudication
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surveillance videotape obtained to disqualify a person from receiving permanent disability are termed
A. silence films B. sub rosa films C. clandestine films D. detective films |
sub rosa films
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which of the following is NOT a sign of fraudulent workers' compensation claims
A. missing the first physician appointment B. vague and dramatic complaints C. complaining of pain D. Changing physicians frequently |
complaining of pain
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a person who makes a fraudulent claim for works' compensation is guilty of
A. willful injury B. a misdemeanor C. misrepresentation D. a felony |
a felony
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an employer could be guilty of workers' compensation fraud if he or she does any of the following EXCEPT
A. misrepresents the annual payroll B. gives a false address C. reports an accurate numbers of workers D. falsely classifies the job duties of workers |
reports an accurate numbers of workers
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the office whose purpose is to protect employees against on the job health and safety hazards is
A. OSHA B. AMA C. CLIA D. EDTA |
OSHA
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which of the following are not covered by occupational safety laws
A. nonprofit institutions B. farmers' immediate family members C. Religious hospitals D. light industry workers |
farmers' immediate family members
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workers who come in contact with HIV virus have a right for the workplace to supply them with
A. a leave of absence B. a different job C. information regarding precautions D. vaccinations |
information regarding precautions
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An OSHA inspector may visit a medical office
A. every year B. by invitation C. unannounced D. accompanied by law enforcement officials |
unannounced
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a proceeding in which an attorney asks a witness questions but not in open court is termed
A. deposition B. testimony C. inquisition D. interrogation |
deposition
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if a physician assigns a delinquent account to a collection agency, the physician may
A. collect full payment directly from the patient B. lose a percentage of the charge C. lose the entire fee D. violate collection laws |
lose a percentage of the charge
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copies of a lien in a workers' compensation case should be sent to the following EXCEPT
A. patient's employer B. insurance carrier C. state insurance commissioner D. appeals court |
state insurance commissioner
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the subsequent injury fund was established to meet problems which arise when a
A. previously injured person is injured again at work B. rehabilitated person returns to work C. military person is injured in the job D. claim is filed later than the time limit |
previously injured person is injured again at work
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medical records for industrial injuries should be set up separately from private medical records because
A. paperwork is reduced B. there are separate disclosure laws for each C. colored files are easier to view D. it will save space |
there a separate disclosure laws for each
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physician narrative letters, which support claims regarding accidents, should include the following EXCEPT
A. complete medical findings B. patient's present complaints C. history of the accident D. a police report |
a police report
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if another condition not related to the industrial accident or injury is discovered during the course of treatment for a workers' compensation case,
A. if is included in the workers' compensation case B. the patient is financially responsible C. a second claim is filed with workers' compensation D. the employer is responsible |
the patient is financially responsible
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the time frame between the beginning of the disability to receiving the first payment of disability
A. waiting period B. eligibility period C. benefit period D. exclusion |
waiting period
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benefits paid to the insured wile disabled are called
A. Premiums B. deductible C. indemnity D. provisional |
indemnity
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if the insured has a work-related impairment that is expected to continue for his or her lifetime, he or she is considered
A. temporarily disabled B. totally disabled C. rehabilitated D. permanently disabled |
permanently disabled
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benefits from disability insurance are not taxable if the premiums are paid by the
A. individual B. state C. federal government D. professional association |
individual
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in some policies, a provision for death resulting from an unexpected and unforeseeable accident is called
A. waiver of premium B. dismemberment C. double indemnity D. total indemnity |
double indemnity
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which of the following is NOT an example of a typical exclusion in an insurance policy
A. attempted suicide B. injury due to acts of war C. condition arising while legally intoxicated D. congestive heart failure |
congestive heart failure
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group disability income insurance commonly covers
A. payments for short term conditions B. medical expenses due to HIV C. self-inflicted injury D. retirement benefits |
payments for short term conditions
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which of the following would probably NOT be covered by group disability insurance plans
A. loss of income payments B. long term disabilities C. short term disabilities D. medical expenses |
medical expenses
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Disability payments provided to needy people with limited income and few resources are provided by
A. Medicare B. workers' compensation C. SSI D. Medicaid |
Medicaid
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special rules allowing disabled people to work while receiving government benefits are called
A. internship B. work incentives C. scholarships D. shadowing |
work incentives
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which of the following would probably not be covered by VA benefits
A. non-prescription drugs B. travel expenses to a VA hospital C. agent orange exposure D. alcohol outpatient care |
non-prescription drugs
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reasons for denial of a non-work related disability claim could include
A. inadequate medical information B. subjective symptoms C. dates of disability D. inclusion of photocopies of lab tests |
inadequate medical information
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all of the following are options for careers in the billing and coding field EXCEPT
A. CT technician B. claims assistance professional C. electronic claims processor D. insurance billing specialist |
CT technician
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patients who leave the hospital without notifying medical personnel or against the advice of medical staff are given the discharge status of
A. AWOL B. AMA C. DOA D. ambulatory patient |
AMA
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an organization, which provides pain relief and symptom management to the terminally ill is called
A. a domiciliary B. hospice C. a caravansary D. home support agency |
hospice
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not doing something that a reasonable person would do under ordinary circumstances or doing something that a reasonable person would not do is called
A. negligence B. willfulness C. irresponsibility D. mental illness |
negligence
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diagnostic test done 1 to 3 days before a patient is admitted to a hospital are called
A. post-admission testing B. admission preliminaries C. pre-admission testing D. outpatient work |
pre-admission testing
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physician liability in certain cases for wrongful acts of assistants and employees is called
A. restrictive liability B. respondent superior C. master privilege D. status quo |
respondent suerior
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services provided by specialists as neurosurgeons and intensive care units are often viewed as
A. tertiary care B. binary care C. skilled care D. primary care |
tertiary care
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a process by which an insurance company attempts to recover losses from a third party who caused a loss is called
A. review of damage B. third party adjudication C. third party subrogation D. medical service order |
third party subrogation
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a primary care physician who controls patient access to specialists is called
A. gatekeeper B. ancillary physician C. primary staff D. risk incentive promoter |
gatekeeper
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kidney donor coverage includes
A. preoperative testing B. surgery C. postoperative services D. all answers are correct |
all answers are correct
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all payments for medical expenses incurred by a kidney donor are made directly to the
A. health care providers B. kidney donor C. kidney recipient D. physician in charge |
health care providers
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an_______ must be obtained for all services that are not medical necessary according to Local Coverage Determinations and/or National Coverage Determinations, with just a few exceptions
A. Advanced Directive B. Advanced Beneficiary Notice C. Ancillary Services Permit D. Ancillary Benefit Directive |
Advanced Beneficiary Notice
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