Reimbursement Questions

Sample/Practice/Free Coding REIMBURSEMENT Questions

1. The terms "allowed charge" and "allowable charge" have the same meaning.

TRUE/FALSE

2. The allowed charge is the minimum that the third-party payer will pay for a specific service or procedure.

TRUE/FALSE

3. Balance billing is not permitted under some payers' contracts/agreements with physicians.

TRUE/FALSE

4. If balance billing is allowed, the part of a provider's usual fee not paid by the insurance company may be collected from the insured.

TRUE/FALSE

5. The birthday rule is applied to determine which parent's insurance is primary for a child.

TRUE/FALSE

6. Under the birthday rule, the parent whose day of birth is later in the calendar year is considered primary.

TRUE/FALSE

7. A capitated payment is made to a provider before services are given.

TRUE/FALSE

8. The capitation payment covers the services for a health plan member for a specified period, such as a month.

TRUE/FALSE

9. A capitated payment is sent to the provider by the insurance plan when an invoice for provided services is received.

TRUE/FALSE

10. COB is the abbreviation for capitation or benefits.

TRUE/FALSE

11. A coordination of benefits clause is included in medical insurance policies to explain how the policy will pay if more than one policy applies to a claim.

TRUE/FALSE

12. The term "determination" is used to describe the third-party payer's decision about paying an insurance claim.

TRUE/FALSE

13. Excluded services are usually listed in the medical insurance plan.

TRUE/FALSE

14. An insurance company reimburses the insured for excluded services.

TRUE/FALSE

15. The term "gatekeeper" is used in connection with health maintenance organizations.

TRUE/FALSE

16. A gatekeeper is a primary care physician who makes referrals for patients in an HMO.

TRUE/FALSE

17. Under a group model HMO, the providers are employees of the managed care plan.

TRUE/FALSE

18. Providers who work with a group model HMO may offer their services to non-HMO patients.

TRUE/FALSE

19. HMO is the abbreviation for health maintenance organization.

TRUE/FALSE

20. HMO members are usually allowed to receive medical services from any provider that they choose without additional cost.

TRUE/FALSE

21. An HMO typically makes fixed periodic payments to providers, who in turn agree to provide care for the plan's members.

TRUE/FALSE

22. IPA is the abbreviation for independent practice association.

TRUE/FALSE

23. Physicians in IPAs are employees of the managed care plan.

TRUE/FALSE

24. In a network model HMO, providers remain self-employed and may provide services to both HMO members and nonmembers.

TRUE/FALSE

25. Participation in a plan is a choice the physician makes.

TRUE/FALSE

26. Participating physicians are called nonPAR.

TRUE/FALSE

27. PAR is an abbreviation for participating or participation.

TRUE/FALSE

28. A preexisting condition is one that the patient has had since birth.

TRUE/FALSE

29. Preexisting conditions are often excluded from medical insurance coverage.

TRUE/FALSE

30. PPO is the abbreviation for providing physician order.

TRUE/FALSE

31. Members in a PPO plan can receive medical services from non-network doctors for a higher cost.

TRUE/FALSE

32. PPO plan members may see physicians who are not listed in their network for the same cost as seeing their regular providers.

TRUE/FALSE

33. PCP is the abbreviation for primary care physician.

TRUE/FALSE

34. A primary care physician is also known as a gatekeeper.

TRUE/FALSE

35. RVS is the abbreviation for related vaccination services.

TRUE/FALSE

36. The term "self-insured employer" describes a company that creates its own insurance plan for its employees.

TRUE/FALSE

37. A self-insured employer assigns the insurance risks to a third-party payer.

TRUE/FALSE

38. Physicians who work for a staff model HMO are employees of the plan.

TRUE/FALSE

39. Staff model HMO providers offer their services to both plan members and nonmembers.

TRUE/FALSE

40. UCR is the abbreviation for usual, customary, and reasonable.

TRUE/FALSE

41. To write off an amount is to subtract it from the monies that are expected to be collected.

TRUE/FALSE

42. The insurance company subtracts the patient's copayment or deductible from the allowed charge when calculating a provider's payment.

TRUE/FALSE

43. In a capitated HMO, providers are allowed to bill patients for services they provide that are not part of the contracted services covered by the capitation rate.

TRUE/FALSE

44. The term "cap rate" means the capitation rate.

TRUE/FALSE

45. The allowed charge is 80 percent of the amount that a third-party payer will pay for a particular procedure.

TRUE/FALSE