AAPC CPB - Chapter 2 Review

What is the largest health program in the United States?

a. Blue Cross Blue Shield

b. Medicare

c. Medicaid

d. TRICARE

b. Medicare

Which of the following services is NOT covered under Medicare Part B?

a. Cardiovascular disease screening

b. Diabetes self-management

c. Nutrition therapy services

d. Home Health services

d. Home Health services

Health Savings Account (HSA) is ____________________ to employees.

a. tax-free income

b. taxed income

c. a monthly contribution only made by employers

d. only for medical coverage, excluding dental and vision expense

a. tax-free income

Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient and are reimbursed by:

a. Capitation

b. Fee-for-service

c. Reimbursement account

d. Patient payments

a. Capitation

A Medicare patient presents after slipping and falling in a neighbor's walkway. The cement had a large crack, which caused the pavement to raise and be unsteady. The neighbor has contacted his homeowner's insurance and they are accepting liability and have initiated a claim. How should the visit be billed?

a. Bill the Homeowner's insurance only. Medicare will not pay anything.

b. Bill Medicare, then the Homeowner's insurance as secondary.

c. File to both at the same time and see which pays more.

d. Bill the Homeowner's first, then Medicare secondary if it is not paid within 120 days.

d. Bill the Homeowner's first, then Medicare secondary if it is not paid within 120 days.

What are some of the ways that managed care organizations (MCOs) offer provisions that provide insurers with ways to manage the cost, use, and quality of healthcare services received by a member?

I. Utilization review

II. Coverage restrictions

III. Arbitration

IV. Non-emergency weekend admission restrictions

a. I, IV

b. I, II, IV

c. II, III, IV

d. II, IV

a. I, IV

The 2019 Medicare deductible and co-insurance amount for outpatient services on Part B is

a. $185 per calendar year and 20% of approved amount

b. $185 per calendar year and 20% of the billed amount

c. $185 per hospitalization and 20% of approved amount

d. $185 per calendar year

a. $185 per calendar year and 20% of approved amount

A group contracts with a third party administrator to manage paperwork. This group pays for the operation of the insurance plan and the costs of administration. What type of plan does this represent?

a. Fully Insured Employer Group

b. Self - Funded ERISA

c. Association Group

d. Management Service Organization

b. Self - Funded ERISA

Which of the following statements is true regarding the key provisions of coverage under the Affordable Care Act (ACA)?

a. Children under the age of 21 may be eligible to be covered under their parent's health plan if they are in college.

b. There are 30 covered preventive services for women.

c. Patients have the right to appeal a health plan's decision to deny payment for a claim or termination of health coverage.

d. Lifetime limits are not banned on any health plans issued.

c. Patients have the right to appeal a health plan's decision to deny payment for a claim or termination of health coverage.

Which type of HMO contracts with multiple specialty groups, individual practice groups, and individual physicians?

a. Group Model HMO

b. Mixed Model HMO

c. Network Model HMO

d. Hybrid Model HMO

c. Network Model HMO

A new physician comes into the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans?

a. Credentialing

b. Privileging

c. Contract negotiations

d. Board certification

a. Credentialing

The following is a capitation schedule for a pediatric practice.

Member's Age Capitation per Member, per Month

0-1 $25.00

2-4 $10.00

5-20 $5.00

The practice has 300 members age 0-1, 500 members age 2-4, and 2000 members age 5-20 that stay with the practice for an entire year. If the practice also performs "carve-out" services worth $20,000, how much money will they earn over the course of a year?

a. 270,000

b. 250,000

c. 290,000

d. 300,000

c. 290,000

A patient needs to see a specialist for a cardiac condition. She references her insurance handbook for a list of network providers that belong to that specialty. She may choose any physician she wishes and does not need a referral from her Internist to see the specialist. If she chooses an out-of-network physician, she will have to pay a higher co-insurance amount to see them. What type of insurance does this patient have?

a. HMO

b. PPO

c. Medicare

d. Medicaid

b. PPO

NPI is an abbreviation for a unique number that is required by HIPAA. What does NPI stand for?

a. National Physician Identifier

b. National Provider Insurance

c. National Provider Identifier

d. National Participating Identifier

c. National Provider Identifier

Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct?

a. CMS reviews all state plans to make sure they offer federal regulations.

b. Individual states establish their own rates based on the multiple criteria.

c. All Medicaid plans offer HMO options.

d. States have the option to charge co-pays and deductibles.

c. All Medicaid plans offer HMO options.

What Medicaid services are eligible for reimbursement for an individual that is not a citizen or does not have eligible immigration status?

a. No services are covered

b. All services are covered

c. Emergency services

d. Outpatient services only

c. Emergency services

A patient presents for an immunization. When the patient pays his bill, he asks for a receipt so that he may turn it in to meet his spenddown. What type of coverage does this patient have?

a. Medicare

b. Commercial insurance

c. Medicaid

d. TRICARE

c. Medicaid

Dr. Williams is enrolled in a capitated plan. For his list of covered lives, he received a check for $100,000. During the year, the cost of treating the covered lives was $125,000. Which statement below is TRUE?

a. Dr. Williams will receive payment for the overage cost of $25,000 from the insurance carrier.

b. Dr. Williams has a loss of $25,000 on the capitated contract for the year.

c. Dr. Williams can file claims for all services provided under the capitated plans and will be paid fee-for-service because his cost was more than the contracted payment.

d. Dr. Williams will be reimbursed an additional $125,000 for his services.

b. Dr. Williams has a loss of $25,000 on the capitated contract for the year.

A Medicare patient is seen in the Internist's office for a check-up. The office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician?

a. Non-limiting

b. Opt-out

c. Participating

d. Non-participating

d. Non-participating

Which option is not considered an MCO?

a. Exclusive Provider Organizations (EPOs)

b. Health Maintenance Organizations (HMOs)

c. Preferred Provider Organizations (PPOs)

d. Health Savings Account (HSA)

d. Health Savings Account (HSA)

A patient presents to his internist for a visit. The patient has a Medicare HMO. To which part of the Medicare program does the patient belong?

a. Part A

b. Part B

c. Part C

d. Part D

c. Part C

When a patient is enrolled in an HMO, which options below are the responsibilities of the primary care physician (PCP)?

I. Manage the member's treatment

II. Be the only provider for all of the patient's healthcare

III. Provide referrals to specialists

IV. Approve emergency department visits

V. Provide referrals for inpatient admissions

a. I, II

b. I, II, III

c. I, III, IV

d. I, III, V

d. I, III, V

Which of the following is NOT evaluated in the credentialing process?

a. Physician's education

b. Physicians residency

c. Physician's request for privileges

d. Physician's license(s)

c. Physician's request for privileges

What type of plan allows an insurer to administer straight indemnity insurance, an HMO, or a PPO insurance plans to its members?

a. Triple option plan

b. Full option plan

c. Integrated provider plan

d. Management service organization

a. Triple option plan

If a provider decides not to participate with Medicare what is one of the disadvantages?

a. Services provided by non-participating providers are not paid by Medicare.

b. Providers who do not participate with Medicare cannot see Medicare patients.

c. Non-participating providers do not have to file a claim.

d. The patient receives the reimbursement.

d. The patient receives the reimbursement.