Question 1

The type of health insurance that offers the most choices of providers, in which patients can choose any provider they want and change providers at any time is, a (n):

Accepted Answer

Indemnity plan 
FFS plan

Question 2

Group insurance is typically:

Accepted Answer

A contract between an insurance company and an employer

Question 3

The best type of healthcare plan is a (n):

Accepted Answer

No one type is universally best

Question 4

Identify which of the following is not true under the Patient Protection and Affordable Care Act of 2009 (PPACA)

Accepted Answer

Everyone who enrolls in a plan under PPACA pays the same premium

Question 5

The amount of money the policyholder has to pay out of pocket for healthcare in any 1 year is limited by:

Accepted Answer

Insurance Cap

Question 6

A provider who signs a contractual arrangement with a third-party insurance contractor and agrees to accept the amount paid by the carrier as payment in full is referred to as a

Accepted Answer

participating provider

Question 7

when the employer-not an insurance company- is responsible for the cost of its employees' medical services, the employer has a :

Accepted Answer

Self- insured program

Question 8

A person or organization that processes claims and performs other contractual administrative services is commonly referred to as a

Accepted Answer

Third- party administrator (TPA)

Question 9

Prior to the Affordable Care Act, a person's health insurance coverage that has been in effect for a period of 63 days or more before enrolling in a new health plan is called:

Accepted Answer

credible coverage

Question 10

The Affordable Care Act states that by 2014, everyone in the United States should have access to a comprehensive set of healthcare benefits, which is referred to as:

Accepted Answer

Minimum essential coverage

Question 11

True or False:   
With managed healthcare, patients can choose any physician they want and change physicians at any time

Accepted Answer

False.

Question 12

True or False:
Group insurance is generally more expensive because it covers more individuals.

Accepted Answer

False.

Question 13

True or False:
With FFS insurance, the policyholder controls the choice of physician and facility.

Accepted Answer

True.

Question 14

True or False;
"Reasonable and customary" is a term used to refer to the commonly charged or prevailing fees for health services within a 
geographic area

Accepted Answer

True.

Question 15

True or False;
Most organizations that are self-insured are large entities, which can draw from hundreds or thousands of enrollees

Accepted Answer

True.

Question 16

True or False:
Blue Cross policies cover inpatient hospital care; Blue Shield covers physicians' services

Accepted Answer

False.

Question 17

True or False: 
If an individual belongs to a BlueCard PPO, the initials PPO appear inside a blue globe.

Accepted Answer

False.

Question 18

True or False:
It is important to consult all types of insurance plans for their specific guidelines to avoid claim delays and rejections.

Accepted Answer

True.

Question 19

True or False:
An explanation of benefits (EOB) is a document prepared by the carrier that gives details of how the claim was adjudicated.

Accepted Answer

True.

Question 20

True or False:
Filing CMS-1500 paper claims for commercial carriers is much the same as with all other carriers.

Accepted Answer

True.

Question 21

True or False:
One of the provisions of healthcare reform was the removal of lifetime caps on insurance

Accepted Answer

True.

Question 22

True or False:
Self-insured plans are not as closely regulated as conventional insurance plans.

Accepted Answer

True.

Question 23

True or False:
A consumer-directed health plan (CDHP) often involves pairing a high- deductible PPO plan with a tax- advantaged account, such as a health savings account (HSA)

Accepted Answer

True.

Question 24

Individuals belonging to a managed healthcare plan are commonly referred to as:

Accepted Answer

Enrollees

Question 25

A specific provider who oversees an HMO member's total healthcare treatment is called a (n):

Accepted Answer

Primary Care Physician (PCP)

Question 26

A multispecialty group practice where all healthcare services are provided within the building(s) owned by the HMO is called a

Accepted Answer

Staff model

Question 27

A managed care system composed of individual healthcare providers who offer healthcare services for HMO and non- HMO patients, but maintain their own offices and identities, is called a (n):

Accepted Answer

Open-panel IPA

Question 28

A system designed to determine the medical necessity and appropriateness of a requested medical service, procedure, or hospital admission prior, concurrent, or retrospective to the event is called:

Accepted Answer

Utilization review

Question 29

A procedure required by third-party payers that requires permission before a provider can carry out specific procedures and treatments in a (n):

Accepted Answer

preauthorization

Question 30

It is predicted that under the Affordable Care Act, managed care organizations will increase rapidly- particularly with the expansion of:

Accepted Answer

Medicaid

Question 31

Most MCOs are regulated from three areas. What are they?

Accepted Answer

States, local government agencies, Federal government

Question 32

An independent nonprofit organization that measures, assesses, and reports on the quality of care and service in MCOs is the:

Accepted Answer

NCQA

Question 33

True or False:
PPOs typically do not require authorization from a from a PCP for a referral to a specialist.

Accepted Answer

True.

Question 34

True or False:
HMOs typically have no deductibles or plan limits.

Accepted Answer

True.

Question 35

True or False: 
HMOs are neither accredited nor certified.

Accepted Answer

False.

Question 36

True or False:
Precertification involves collecting information before inpatient admissions or performance of selected ambulatory procedures and services

Accepted Answer

True.

Question 37

In all managed care situations, for the healthcare plan to recognize the referral, it must come from the patient's designated PCP.

Accepted Answer

False.

Question 38

True or False:
Healthcare reform will likely eliminate most managed care arrangements

Accepted Answer

False.

Question 39

An interrelated system in which people and facilities communicate with one another and work together as a unit is referred to as a(n)____________.

Accepted Answer

Network

Question 40

The two most common types of MCOs are ________ and _________.

Accepted Answer

HMO and PPO

Question 41

A(n)_________ is a specific provider who oversees an HMO member's total healthcare treatment.

Accepted Answer

PCP

Question 42

_________ typically have no deductibles or plan limits

Accepted Answer

HMO

Question 43

A(n)____________ HMO is a multispecialty group practice in which all healthcare services are provided within the building(s) owned by the HMO

Accepted Answer

Staff Model

Question 44

_____________ is a fixed fee per member per specified time period (usually monthly)

Accepted Answer

Capitation

Question 45

The____________ HMO is one that has multiple provider arrangements, including staff, group, or IPA structures.

Accepted Answer

Network Model

Question 46

The_______________ HMO is similar to an IPA except the HMO contracts directly with the individual physicians.

Accepted Answer

DCM

Question 47

The _______________ is a "hybrid" type of managed care (also referred to as an open-ended HMO) that allows patients to use the HMO provider to go outside the plan and use any provider they choose.

Accepted Answer

UT

Question 48

____________________ is a system designed to determine the medical necessity and appropriateness of a medical service, procedure, or hospital admission.

Accepted Answer

Utilization Review

Question 49

A(n)_______________ is when the PCP requests another physician to provide his or her expert opinion regarding the patients condition.

Accepted Answer

Consultation

Question

Question

Question

Chapter 6 and 7

Insurance and Coding

Question	Answer
The type of health insurance that offers the most choices of providers, in which patients can choose any provider they want and change providers at any time is, a (n):	Indemnity plan FFS plan
Group insurance is typically:	A contract between an insurance company and an employer
The best type of healthcare plan is a (n):	No one type is universally best
Identify which of the following is not true under the Patient Protection and Affordable Care Act of 2009 (PPACA)	Everyone who enrolls in a plan under PPACA pays the same premium
The amount of money the policyholder has to pay out of pocket for healthcare in any 1 year is limited by:	Insurance Cap
A provider who signs a contractual arrangement with a third-party insurance contractor and agrees to accept the amount paid by the carrier as payment in full is referred to as a	participating provider
when the employer-not an insurance company- is responsible for the cost of its employees' medical services, the employer has a :	Self- insured program
A person or organization that processes claims and performs other contractual administrative services is commonly referred to as a	Third- party administrator (TPA)
Prior to the Affordable Care Act, a person's health insurance coverage that has been in effect for a period of 63 days or more before enrolling in a new health plan is called:	credible coverage
The Affordable Care Act states that by 2014, everyone in the United States should have access to a comprehensive set of healthcare benefits, which is referred to as:	Minimum essential coverage
True or False: With managed healthcare, patients can choose any physician they want and change physicians at any time	False.
True or False: Group insurance is generally more expensive because it covers more individuals.	False.
True or False: With FFS insurance, the policyholder controls the choice of physician and facility.	True.
True or False; "Reasonable and customary" is a term used to refer to the commonly charged or prevailing fees for health services within a geographic area	True.
True or False; Most organizations that are self-insured are large entities, which can draw from hundreds or thousands of enrollees	True.
True or False: Blue Cross policies cover inpatient hospital care; Blue Shield covers physicians' services	False.
True or False: If an individual belongs to a BlueCard PPO, the initials PPO appear inside a blue globe.	False.
True or False: It is important to consult all types of insurance plans for their specific guidelines to avoid claim delays and rejections.	True.
True or False: An explanation of benefits (EOB) is a document prepared by the carrier that gives details of how the claim was adjudicated.	True.
True or False: Filing CMS-1500 paper claims for commercial carriers is much the same as with all other carriers.	True.
True or False: One of the provisions of healthcare reform was the removal of lifetime caps on insurance	True.
True or False: Self-insured plans are not as closely regulated as conventional insurance plans.	True.
True or False: A consumer-directed health plan (CDHP) often involves pairing a high- deductible PPO plan with a tax- advantaged account, such as a health savings account (HSA)	True.
Individuals belonging to a managed healthcare plan are commonly referred to as:	Enrollees
A specific provider who oversees an HMO member's total healthcare treatment is called a (n):	Primary Care Physician (PCP)
A multispecialty group practice where all healthcare services are provided within the building(s) owned by the HMO is called a	Staff model
A managed care system composed of individual healthcare providers who offer healthcare services for HMO and non- HMO patients, but maintain their own offices and identities, is called a (n):	Open-panel IPA
A system designed to determine the medical necessity and appropriateness of a requested medical service, procedure, or hospital admission prior, concurrent, or retrospective to the event is called:	Utilization review
A procedure required by third-party payers that requires permission before a provider can carry out specific procedures and treatments in a (n):	preauthorization
It is predicted that under the Affordable Care Act, managed care organizations will increase rapidly- particularly with the expansion of:	Medicaid
Most MCOs are regulated from three areas. What are they?	States, local government agencies, Federal government
An independent nonprofit organization that measures, assesses, and reports on the quality of care and service in MCOs is the:	NCQA
True or False: PPOs typically do not require authorization from a from a PCP for a referral to a specialist.	True.
True or False: HMOs typically have no deductibles or plan limits.	True.
True or False: HMOs are neither accredited nor certified.	False.
True or False: Precertification involves collecting information before inpatient admissions or performance of selected ambulatory procedures and services	True.
In all managed care situations, for the healthcare plan to recognize the referral, it must come from the patient's designated PCP.	False.
True or False: Healthcare reform will likely eliminate most managed care arrangements	False.
An interrelated system in which people and facilities communicate with one another and work together as a unit is referred to as a(n)____________.	Network
The two most common types of MCOs are ________ and _________.	HMO and PPO
A(n)_________ is a specific provider who oversees an HMO member's total healthcare treatment.	PCP
_________ typically have no deductibles or plan limits	HMO
A(n)____________ HMO is a multispecialty group practice in which all healthcare services are provided within the building(s) owned by the HMO	Staff Model
_____________ is a fixed fee per member per specified time period (usually monthly)	Capitation
The____________ HMO is one that has multiple provider arrangements, including staff, group, or IPA structures.	Network Model
The_______________ HMO is similar to an IPA except the HMO contracts directly with the individual physicians.	DCM
The _______________ is a "hybrid" type of managed care (also referred to as an open-ended HMO) that allows patients to use the HMO provider to go outside the plan and use any provider they choose.	UT
____________________ is a system designed to determine the medical necessity and appropriateness of a medical service, procedure, or hospital admission.	Utilization Review
A(n)_______________ is when the PCP requests another physician to provide his or her expert opinion regarding the patients condition.	Consultation

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