question

Numerical values are assigned to medical services, based on nationwide research, in a (n) ?

answer

Relative value scale ( RVS)

question

The centers for Medicare and Medicaid Services (CMS) Resources-based Relative Value Scale (RBRVS) builds on the RVS method by adding factors for ?

answer

provider expenses

question

The comparison of the usual fee and individual physician charges for a services, the customary fee charged by most physicians in the community, and the reasonable fee for service is known as what approach ?

answer

usual, customary, and reasonable (UCR)

question

Fees that physicians charge to most of their patients most of the time under typical conditions are ?

answer

usual fees

question

If a patient makes a payment at the time of services, a medical billing program is used to print a (n) ?

answer

walkout receipt

question

Whether a physician participates in a plan or not is decided by ?

answer

the physician

question

Within a managed care organization, the gatekeeper is another name for a ?

answer

primary care physician

question

Who makes referral for patient in an HMO ?

answer

both the gatekeeper and the primary car physician

question

Which of the following do not usually file claims for patients ?

answer

non-participating physicians

question

The first step in calculating RBRVS is to determine the ?

answer

procedures codes

question

The abbreviation PPO stands for

answer

preferred provider organization

question

In some plans, a primary care physician (PCP) is assigned to ?

answer

each patient

question

What should explain what is required of the patient financially when payment is due ?

answer

Financial policy

question

Positive or negative corrections to a patient's account, such as returned check fees, are called ?

answer

adjustments

question

What does the abbreviation RVS stand for ?

answer

relative value scale

question

Out-of-pocket medical expenses are paid by the

answer

patient

question

Under a point-of-service (POS) plan, an HMO patient who does not want to be limited to network providers might have to make ?

answer

Larger payments

question

what document can the patient use to report the charges and payment to the insurance company ?

answer

walkout receipt

question

If a practice has not accepted assignment, and collects payment from the patient at the time of service and then sends a claim to the plan on behalf of the patient, what should the patient expect as the next course of action ?

answer

receive a reimbursement check from the insurance company

question

Which plan must meet a high deductible before the health plan can make a payment ?

answer

consumer-driven health plan

question

For which type of insurance plan would the medical assistant verify the patient's deductible, the coverage benefits and the coinsurance or other financial information ?

answer

high deductible plan

question

Which method does Medicare use to pay physicians in group practices ?

answer

Resources-based relative value scale

question

What percentage of the allowed charge does Medicare Part B Original Plan cover after the patient meets their annual deductible ?

answer

80%

question

What percentage of the allowed charge is the patient responsible for through the Original Medicare plan after the patient meets their annual deductible ?

answer

20%

question

Which of the following is not a typical time-of-service payment ?

answer

registration fees

question

What is not a part of the real-time claims adjudication (RTCA) ?

answer

receive real-time payment

question

After check-out, what is a next step in the billing cycle ?

answer

Send claim for insurance payments

question

In order, what are the next steps in the billing cycle after the patient checks out ?

answer

file claim, insurance payment, and patient billed for what they owe

question

Which of the following is not taken into account when determining resource-based fee structures?

answer

how many credentials the physician performing the procedures has

question

What does Real Time Claims Adjudication not generate ?

answer

" real time" payment

question

What is the goal of an effective patient checkout procedures ?

answer

the patient understands financial responsibility

question

Which is not a part of the RBRVS fee?

answer

UCR

question

Which should be paid at the time of service ?

answer

previous balance

question

Which type of payment is made during checkout based on an estimate ?

answer

partial payment

question

A preauthorization form is typically used with which type of transactions ?

answer

credit card

question

Which of the following is not a usually accepted form of payment ?

answer

wire transfer

question

What does it mean when a provider accepts assignment ?

answer

to accept the allowed charge as full payment

question

Under what condition of HIPPA is it permissible to bill a patient a reasonable charge ?

answer

copies of medical records

question

If a patient have larger bills that they must pay overtime, what can be set up for them ?

answer

payment plan

question

What is one way a practice can help patients determine why they may owe ?

answer

swipe card reader

question

which health plan has a rule that prohibits physicians from obtaining any patient payment except a copayment unit after the claim is paid ?

answer

Medicare

question

What might a contract between a health plan and a provider entail ?

answer

to prohibit balance billing

question

When are payments from the patient entered and the account updated ?

answer

after the patient's visit

question

What does the Real-Time Claims Adjudication tool not provide ?

answer

exact payment due

question

In what situation is the patient offered a walkout receipt ?

answer

the patient had made a payment at the end of a visit

question

What summarizes the services and charges for that day as well as any payment the patient made ?

answer

walkout receipt

question

If the practice accepts credit and debit cards, what standards must be followed ?

answer

PCI DSS

question

All of the following procedures are completed at the end of a patient visits, except :

answer

insurance is verified

question

What is the tool for calculating charges due at the time of service ?

answer

real-time claims adjudication (RTCA )

question

To estimate charges that patient will pay, the medical assistant verifies:

answer

Deductible amount

question

What might a health plan require if the patient has more than one covered service in a single day?

answer

multiple copayments

question

Which of these payment methods is the basis for Medicare's fees ?

answer

RBRVS

question

Which answer correctly lists the main methods (s) payers use to pay providers ?

answer

allowed charges, contracted fee schedule , and capitation

question

If a provider's charged is higher than the allowed amount, the provider's reimbursement is based on ?

answer

the amount allowed

question

If the provider's charge is lower than the allowed amount, the reimbursement is based on ?

answer

the amount billed

question

Under a contracted fee schedule, the allowed amount is _____ compared to the provider's charge

answer

the same

question

The deductible, coinsurance, and copayments patients pay are called their ?

answer

Out-of-pocket expenses

question

If a nonparticipating provider's usual fee is $600, the allowed amount is $300, and the balance billing is permitted, what amount is written off?

answer

$0

question

An option in an HMO that allows patients to use non-HMO providers is called

answer

a point-of-service option

question

If a participating provider's usual charge is higher than the allowed amount, and balance billing is not permitted, what should the difference between the two charges become?

answer

a write off

question

Before the payer begins to pay benefits, what must a policyholder pay annually under a typical indemnity plan ?

answer

deductible

question

Under most managed care plans, what must patients pay to the provider at the time of service ?

answer

copayment

question

Medical Insurance plans require patients to pay for all services that are ?

answer

Both excluded and over-limit

question

At what point in the billing process might a physician practice decide to have a policy to collect patient's payments?

answer

both claims processing and adjudication

question

Collecting the difference between a provider's usual fee and a payer's lower allowed charge from the insured is called ?

answer

balancing billing

question

What term describes a physician who does not participate in a particular plan?

answer

NON-PAR

question

The amount of a copayment is determined by

answer

the insurance carrier/health plan

question

If the participating provider's charge is higher than the allowed amount, which amount is the basis for reimbursement ?

answer

allowed amount

question

When is a capitated payment made to a provider ?

answer

before services are given

question

A capitation payment covers the services for a health plan member for

answer

a specific period of time

question

The abbreviation CDHP stands for

answer

consumer-driven health plan

question

What are patients who do not have insurance coverage called ?

answer

Self-pay

question

Discounted fee-for-service arrangements are also known as

answer

contracted fee schedules

question

A list of charges for the procedures and services a physician performs is a ?

answer

Fee schedule

question

The abbreviation HMO stands for

answer

health maintenance organization

question

What must be met before benefits from a payer begin ?

answer

deductible

question

Which of the following is not a component of a network created by a PPO ?

answer

patients

question

A PPO plan will pay lower benefits if a patient sees a provider who is ?

answer

out-of-network

Chapter 6 Insurance In The Medical Office From Patient To Payment – Flashcards

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