Question 1

When a provider receives a fixed amount to provide only the care that an individual needs from the provider, this is known as a _____________ payment.

capitation

fixed

premium

sub-capitation

Question 2

The healthcare industry is heavily regulated by ____ and ____ legislation.

city; local

state; city

county; state

federal; state

Question 3

When a patient signs a release of medical information at a physician's office, that release is generally considered to be valid

for six months

for a single visit to the physician

for one year from the date entered on the form

until the patient changes insurance companies

Question 4

When the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to

accept assignment

assignment of benefits

authorize services

coordination of benefits

Question 5

Which document is used to guarantee the patient's financial and medical record?

encounter form

patient insurance form

patient ledger

patient registration form

Question 6

The person responsible for paying the charges for services rendered by the provider is the

beneficiary

guarantor

guardian

subscriber

Question 7

Which federal legislation was enacted in1995 to restrict the referral of patients to organizations in which providers have a financial interest?

Federal Anti-Kickback Law

Hill-Burton Act

HIPAA

Stark II laws

Question 8

The recognized difference between fraud and abuse is the

cost

intent

payer

timing

Question 9

The specified amount of annual out-of-pocket expenses for covered health care services that the insured must pay annually for health care is called the

coinsurance

copayment

deductible

premium

Question 10

Which three components constitute the RBRVS payment system?

fee schedule, practice expense, and malpractice expense

physician work, practice expense, and geographical location

physician work, practice expense, and malpractice insurance espense

practice expense, malpractice insurance expense, and liability insurance expense

Question 11

Mandates are

directives

laws

regulations

standards

Question 12

Which type of HMO offers subscribers health care services by physicians who remain in their individual office setting?

closed panel

independent practice association

network model

staff model

Question 13

HIPAA requires payers to implement rules called electronic __________, which result in a uniform language for electronic data interchange.

data interchanges

health records

medical records

transaction standards

Question 14

The ambulatory payment classification prospective payment system is used to reimburse claims for what services?

inpatient

nursing facility

outpatient

rehabilitation

Question 15

Breach of confidentiality can result from

discussing patient health care information with unauthorized sources

discussing the patient's case in the business office

sending medical information to non-health care entities with the patient's consent

sending patient health care information to the patient's insurance company

Question 16

When a patient elects to receive care from a non-PAR, the patient will accrue _____.

higher copays

higher out-of-pocket expenses

lower premiums

lower copays

Question 17

When a number of people are grouped for insurance purposes, this is known as a(n)

adverse selection

insurance pool

member group

risk pool

Question 18

Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment), some hospitals engaged in a practice called __________, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the purpose of illegally increasing reimbursement.

downcoding

jamming

unbundling

upcoding

Question 19

The problem-oriented record (POR) is a systematic method of documentation that consists of

a database.

progress notes.

an initial plan.

all of the above.

Question 20

Which of the following is an example of fraud?

billing noncovered services as covered services

falsifying certificates of medical necessity plans of treatment

reporting duplicative charges on an insurance claim

submitting claims for services not medically necessary

Question 21

Care rendered to a patient that was not properly approved (e.g., preapproved) by the insurance company is known as

medical necessity

noncovered benefits

unapproved services

unauthorized services

Question 22

A risk contract is defined as an arrangement among health care providers

stating that the HMO can provide services to Medicare beneficiaries only

that allows higher payments to the HMO if they treat Medicare beneficiaries

to make available capitated health care services to Medicare beneficiaries

to offer fee-for-service health care services to Medicare beneficiaries

Question 23

Which of the following is an example of abuse?

billing noncovered services/procedures as covered services/procedures

falsifying health care certificates of medical necessity plans of treatment

misrepresenting ICD-10-CM and CPT/HCPCS codes to justify payment

submitting claims for services and procedures knowingly not provided

Question 24

Preventive services

may result in the early detection of health problems.

are required by most insurance companies.

allow treatment options that are less dramatic and less expensive.

both a and c.

Question 25

Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work related.

Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contacting the provider, who is liable for the __________ because of the provider's failure to disclose that the injury was work-related.

adjudication

mediation

overpayment

unbundling