MED 131 exam final review - Flashcards

question

The CHAMPUS Reform Initiative (CRI) of 1988 resulted in a new program called TRICARE, which includes three options. Which of the following is not one of the original three options?

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TRICARE Select

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the most common form of Medicare ____ is billing for services not furnished.

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fraud

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The CPT manual is published by the

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American Medical Association.

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Which act mandates regulations that govern privacy, security, and electronic transactions standards for healthcare information?

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Health Insurance Portability and Accountability Act of 1996

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health insurance claim is the documentation submitted to a ___ ___ ___ or government program.

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third-party payer

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What is the program mandated by federal and state governments that requires employers to cover medical expenses and loss of wages for workers who are injured on the job?

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workers' compensation

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The ___________ authorized the federal government to monitor the purity of foods and the safety of medicines, which is now a responsibility of the Food and Drug Administration.

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Food and Drug Act

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the first health insurance policy was introduced by the ____ _____ ____Company of Massachusetts.

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Franklin Health Assurance

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The ___________ is responsible for establishing the first Medicare prospective payment system, which was implemented in 1983.

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Tax Equity and Fiscal Responsibility Act

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Which type of insurance provides coverage for catastrophic or prolonged illness and injuries?

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major medical insurance

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The ____ mandates the retention of patient records and health insurance claims for a minimum of six years, unless state law specifies a longer period.

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HIPAA

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an insurance company does guarantee_____ to the insured for an unforeseen event.

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payment

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The patient receives a ____ ____, which is a report that details the results of processing a claim.

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explanation of benefits (EOB

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RBRVS is an abbreviation for ______-Based Relative Value Scale.

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Resource

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The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim is called

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coding

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medical necessity involves linking every procedure or service code to a ____ code.

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condition

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What does CPT stand for?

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Current Procedural Terminology

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Which of the following involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity of performing that procedure or service?

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medical necessity

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To accurately process health insurance claims, especially for government programs like Medicare and Medicaid, a health insurance specialist should become familiar with the

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Code of Federal Regulations.

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In 1996, Congress passed the ____ because of concerns about fraud and abuse.

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Health Insurance Portability and Accountability Act

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A healthcare facility (or physician) that employs health insurance specialists is legally responsible for employees' actions performed within the context of their employment. This is called ?

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respondeat superior

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Which of the following is not a professional association for health insurance specialists?

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American Medical Association

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____ is the process of reporting diagnoses, procedures, and services on the insurance claim.

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coding

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_____ ____ _____ is information that is identifiable to an individual, such as name, address, telephone number, date of birth, and social security number.

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Protected health information (PHI)

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This CMS program was created to review billing trends and patterns, focusing on providers whose billing for Medicare services are higher than the majority of providers in the community

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ZPIC

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Which act focuses on private health insurance reform to provide better coverage for individuals with pre-existing conditions, improve prescription drug coverage under Medicare, and extend the life of the Medicare Trust Fund by at least 12 years?

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PPACA

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If the insurance plan has a hold harmless clause, it means

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the patient is not responsible for paying what the insurance plan denies.

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The __________ regulated fraud associated with military contractors selling supplies and equipment to the Union Army

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false claims act

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A ___ _____ ____ can help physicians avoid generating erroneous and fraudulent claims by ensuring that submitted claims are true and accurate.

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A voluntary compliance program

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The primary intent of _____ is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs.

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HIPAA

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ICD-9-CM stands for

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International Classification of Diseases, 9th Revision, Clinical Modification.

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_____ was designed to protect all employees.

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OSHA

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HIPAA mandates that health insurance claims be retained for a minimum of ____ years after a patient's death.

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two

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The _____ ____ ____ ___ was developed to reduce Medicare program expenditures by detecting inappropriate codes submitted on claims and denying payment.

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National Correct Coding Initiative

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____ _____ ____ administer healthcare plans and process claims, thus serving as a system of checks and balances for labor and management.

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Third-party administrators (TPAs)

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The ______ authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, and anti-fraud activities.

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MIP

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Healthcare coverage available through employers and other organizations in which employers usually pay part or all of the premium costs is

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group health insurance.

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A claims examiner employed by a third-party payer reviews health-related claims to determine whether the charges are reasonable, in addition to determining

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medical necessity.

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many health insurance plans require _____ for treatment provided by specialists.

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preauthorization

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____ refers to the storage of documentation for an established period of time, which is usually mandated by federal and/or state law.

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Record retention

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the _____ ____ ___ program is mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

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Recovery Audit Contractor (RAC)

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This act amended the Public Health Service Act to establish an Office of National Coordinator for Health Information Technology with HHS to improve healthcare quality, safety, and efficiency.

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HITECH

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____ ____ ___is assigned to healthcare providers as a 10-digit numeric identifier, with a check digit in the last position.

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NPI or national provider identifier

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A(n) ____________ is created when a number of people are grouped for insurance purposes and the cost of healthcare coverage is determined by employees' health status, age, sex, and occupation

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risk pool

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The person who takes out the insurance policy is referred to as the _____________.

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insured

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A _______________________ is a certain amount of allowable or covered medical expense the insured must incur before the insurance carrier will begin paying benefits.

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deductible

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____ ____ ___ provides health care for a discounted fee

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preferred provider organization (PPO)

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What is the payment system Medicare uses for establishing payment for hospital stays?

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Diagnosis related grouping

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________________ is the percentage of each covered claim that the insured must pay, according to the terms of the insurance policy.

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coinsurance

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COB stands for ______________________.

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coordination of benefits

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What type of insurance provides reimbursement for income lost because of the insured person's inability to work as a result of an illness or injury, which may or may not be work-related?

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Disability

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Which of the following terms means an insurance policy pays a percentage of the balance after application of the deductible?

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Co-insurance

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What rule is used as a guideline for determining which of two parents with medical coverage has the primary insurance for a child?

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Birthday rule

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The statement mailed to the patient summarizing how the insurance carrier determined the reimbursement is known as what?

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explanation of benefits EOB

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Medicare Part ____, also known as hospital insurance, covers hospital, nursing facility, home health, hospice, and inpatient care.

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A

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____ is a voluntary process that a healthcare facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.

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accreditation

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____ ____ ___ is a government health insurance program that covers the expenses of the families of veterans with total, permanent, service-connected disabilities.

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Civilian Health and Medical Program of the Veterans Administration

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According to contract law, when a physician agrees to treat a patient who is seeking medical services, there is a(n) ____________ contract between the two.

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Unwritten

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_____ is a voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law

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Accreditation

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____ provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis.

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HMO

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Which of the following terms is applied when more than one policy covers an individual?

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coordinaton of benefits

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Which of the following applies to persons who are eligible for Medicare?

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Receive disability income

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When the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium, this indicates what type of consumer-directed health plan?

answer

customized subcapitation plan (CSCP)

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Under his insurance plan, Scott is required to have prior approval for his upcoming knee replacement. Before the surgery, the surgeon must have which approval document from the insurance carrier for the surgery?

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Preauthorization/precertification approval

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________ payment is made by the insurance carrier after the patient has received medical services.

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fee-for-service

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_____ ____ was designed To help individuals and families compensate for high medical costs

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health insurance

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A plan offered either by a single insurance policy or as a joint venture by two or more insurance carriers and which provides subscribers or employees with a choice of HMO, PPO, or traditional health plan is a a. triple option plan. b. cafeteria plan. c. flexible benefit plan.

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all of the above

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A method of controlling healthcare costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care is

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utilization management

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The amount of money that the insured must incur for medical services before the policy begins to pay is known as what?

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deductible

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________________ is a federal health plan that provides insurance to citizens and permanent residents aged 65 and older; people with disabilities, including kidney failure; and spouses of entitled individuals.

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medicare

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_________________________ is the practice of billing the patient for the unclaimed amount.

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balance billing

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What organization is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system?

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managed care organization

question

which of the following is a type of insurance coverage for persons injured on the job?

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Workers' Compensation

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The healthcare plan that reimburses providers for individual healthcare services provided is a

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fee-for-service plan.

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Before certain procedures or visits can be made, some insurance policies require which of the following?

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preauthorization

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A(n) __________________ is a stated amount an insured must pay for an insurance policy.

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premium

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a network of providers and hospitals who have a contract with insurance companies to provide discounted health care?

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Preferred provider organization

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Which of the following is not an example of a managed care plan?

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consumer-directed health plan

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What type of managed care plan is more popular than an HMO?

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PPO

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What organization is owned by hospital(s) and physician groups that obtain managed care plan contracts?

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physician-hospital organization

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The amount of charges the provider would have to write off if insurance did not cover it, is known as what?

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adjustment

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Which of the following applies to medical insurance for dependents of active duty or retired military personnel and their dependents?

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tricare

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Which of the following best describes insurance policies that provide coverage on a fee-for-service basis?

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traditional

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Which of the following best describes the managed care organization model having the freedom of obtaining medical services from an HMO provider or by self-referral to a non-HMO provider?

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point-of-service plan

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________ is the organization that administers Medicare and Medicaid.

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CMS (Centers for Medicare and Medicaid

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Which of the following is medical insurance for the spouse and unmarried dependent children of a veteran with permanent total disability resulting from a service-related injury?

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CHAMPVA

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If the patient has a policy with an insurance company in which the insurance company agrees to carry the risk of paying for those services, the insurance company is referred to as the "third party" and is therefore called a _________________________________.

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Third-party payer

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A network of physicians and hospitals that have joined together to contract with insurance companies to provide health care to subscribers for a discounted fee is a

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preferred provider organization.

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Consumer-directed health plans provide incentives for controlling healthcare expenses and give individuals a(n) ____ regarding traditional health insurance and managed care coverage.

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alternative

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HMOs help control access to services by requiring the patient to select a ______________.

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Primary care provider

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A physician who accepts an assignment of benefits agrees to receive payment directly from the __________.

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Patient's insurance carrier

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Which of the following traditional types of insurance coverage covers specific dollar amounts for provider's fees, hospital care, and surgery?

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basic

question

The Medicare Catastrophic Coverage Act of 1988 mandated the reporting of ICD-9-CM diagnosis codes on what types of claims?

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all Medicare claims

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Removal of a cast applied by another physician, personal history of breast cancer, and exposure to tuberculosis are all examples of what types of codes?

answer

v codes

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___ codes are located in the Tabular List of Diseases and are assigned for patient encounters when a circumstance other than a disease or injury is present.

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v

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____ codes are located in the Tabular List of Diseases and describe external causes of injury, poisoning, or other adverse reactions affecting a patient's health

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E

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____ identify codes to be assigned when information needed to assign a more specific code cannot be located in the ICD-9-CM coding manual.

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NECs

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The list of three-digit categories is found in which appendix of the ICD-9-CM?

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appendix E

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Which of the following is completed using data from the patient's electronic health record in most offices today?

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CMS 1500

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What volume of the ICD-9-CM contains the Index to Diseases?

answer

Volume 2

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These codes are reported for environmental events, industrial accidents, or injuries inflicted by criminal activity.

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e codes

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A ____ is a procedure performed for definitive treatment rather than diagnostic purposes.

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principal procedure

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a person admitted to a hospital for treatment with the expectation that he or she will remain in the hospital for a period of 24 hours or more.

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inpatient

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Which of the following is NOT included in the insurance carrier's role?

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Collect a co-payment from the physician.

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Which of the following are codes applied to an injury or poisoning?

answer

e codes

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Which of the following is the volume of the ICD-9-CM known as the tabular list?

answer

volume 1

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What type of code describes external causes of injury, poisoning, or other adverse reactions affecting a person's health?

answer

e codes

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Which of the following is a convention used when there is not enough information to find a more specific code?

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NEC

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Which of the following organizations developed ICD-9-CM?

answer

World Health Organization

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___ ____ ___ is signed by the patient as an acknowledgement that Medicare may deny the claim, and the patient is therefore responsible for payment.

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advance beneficiary notic

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Which of the following is NOT affected by coding accuracy?

answer

Resubmissions

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Which of the following volumes is the alphabetic index of ICD-9-CM?

answer

volume II

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Supplementary words located in parentheses after a main term in the ICD Index to Diseases are ____ ____ that do not have to be included in the diagnostic statement for the code number listed (after parentheses) to apply.

answer

nonessential modifiers

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Which of the following ICD-9-CM volumes is recommended as the first reference when coding diagnoses?

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volumeII

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The health insurance specialist employed in a physician's office assigns ICD-9-CM codes to

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diagnoses, signs, and symptoms documented by the provider.

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Codes used for the diagnosis of external causes in ICD-10-CM begin with which letter or letter range?

answer

V-Y

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Assign the appropriate _______ code when a drug was correctly prescribed and properly administered.

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adverse affect

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Why is it important for the medical assistant to understand medical insurance coding?

answer

Serves as basis for the information on the claim form

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The character ____ is used as a placeholder in ICD-10-CM.

answer

x

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Which of the following wil become a legacy coding system or legacy classification system?

answer

ICD-9-CM

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The letters "CM" in ICD-10-CM stand for ________________.

answer

clinical modification

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Volume 2 of the ICD-10-CM manual is the _____________________________.

answer

Alphabetic Index

question

The ________________________ is made up of three characters in ICD-10-CM coding.

answer

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