Exam 1

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Question #1

The Omnibus Rule requires standards for the disclosure and use of protected health information (PHI), including established standards of enforcement for penalties and breach notification.

A FALSE

B TRUE

Question #2

Patients have the right to access and copy their medical records, but they cannot dispute anything in the record.

A FALSE

B TRUE

Question #3

When patients ask a family member to remain with them in a treatment room, this implies that they have given permission for the doctor and/or staff to discuss their condition in front of the family member.

A TRUE

B FALSE

Question #4

A healthcare provider is not allowed to discuss a patient’s medical condition or payment with a person over the phone.

A FALSE

B TRUE

Question #5

Healthcare providers who achieve the standards of each HITECH stage by a designated date are eligible for:

A Medicare incentive payments.

B Medicaid incentive payments.

C free license renewals as long as they remain in practice.

D Medicare and Medicaid incentive payments.

Question #6

The HITECH Act expands the privacy provisions of HIPAA to include:

A corporate owners of covered entities.

B business associates of covered entities.

C friends and family of providers.

D friends and family of patients.

Question #7

Criminal penalties for HIPAA violations can include prison time and financial penalties up to what maximum amount?

A $150,000

B $250,000

C $100,000

D $400,000

Question #8

The three types of safeguards that must be in place to be in compliance with the HIPAA Security Rule are:

A physical, administrative, and technical.

B technical, training, and administrative.

C physical, technical, and procedural.

D administrative, physical, and electronic.

Question #9

HIPAA requires that diagnoses and services be reported in a standard, consistent manner; this is accomplished by using uniform:

A descriptors.

B claim forms.

C code sets.

D modifiers.

Question #10

Approximately how many different formats are currently being used for electronic health claims?

A 450

B 350

C 400

D 500

Question #11

In the event of a security breach in regard to protected health information (PHI), providers and other covered entities must notify both the Office for Civil Rights (OCR) and the:

A insurance carriers whose claims were affected.

B Consumer Protection Agency.

C Centers for Medicare and Medicaid Services (CMS).

D individuals whose records were affected.

Question #12

HIPAA guidelines grant patients the right to access their own medical records and the right to:

A designate a specific person at an insurance company who may also have access.

B request corrections of any inaccuracies in the records.

C file a complaint about how long it takes to get a claim paid.

D at least 10 free copies.

Question #13

Protected health information (PHI) can be disclosed in which of the following circumstances?

A The U.S. Food and Drug Administration requests it in relation to a product recall.

B A coroner requests it to assist in identifying a body.

C An organ procurement organization requests it to facilitate the donation and transplantation of organs.

D All of these

Question #14

The document used to authorize permission for the release of protected health information (PHI) is the:

A assignment of benefits form.

B designation for release of medical information form.

C acknowledgment of informed consent form.

D designation of beneficiary form.

Question #15

HIPAA guidelines apply to which of the following types of healthcare administrative transactions?

A claim status requests and reports

B health insurance claims

C All of these

D eligibility requests and verifications

Question #16

A managed care organization will contract with physicians, laboratories, pharmacies, hospitals, clinics, and other healthcare facilities in building a provider network.

A TRUE

B FALSE

Question #17

Patients are typically very familiar with their health plan benefits when discussing claims issues with the medical office specialist.

A TRUE

B FALSE

Question #18

In order to receive National Committee for Quality Assurance (NCQA) accreditation, a managed care organization (MCO) must demonstrate that it has a thorough credentialing process.

A FALSE

B TRUE

Question #19

Most managed care contracts allow an unlimited time frame for submitting claims.

A TRUE

B FALSE

Question #20

ACOs are a group of insurance providers.

A FALSE

B TRUE

Question #21

Types of payment arrangements in managed care contracts include discounted fee-for-service, per diem, per case, percentage of premiums, and capitation.

A FALSE

B TRUE

Question #22

In the Patient’s Bill of Rights under the Affordable Health Care Act, young adults who are not offered coverage at work are covered by their parents’ plan until they reach:

A 19

B 26

C 21

D 25

Question #23

With respect to National Committee for Quality Assurance (NCQA) accreditation:

A some MCOs are accredited, and some are not.

B MCOs have all asked to be accredited, but some do not qualify.

C accredited MCOs are always better than nonaccredited MCOs.

D MCOs must be accredited to operate.

Question #24

A managed care organization (MCO) uses a credentialing process to evaluate a provider’s:

A workplace environment.

B medical credentials.

C service fees.

D All of these.

Question #25

In MCOs, the business aspects of healthcare are not being controlled by:

A managers.

B physicians.

C actuaries.

D accountants.

Question #26

In plans that require the primary care physician (PCP) to play a gatekeeper role, the PCP is given incentives to:

A treat the patient as much as possible without a specialist referral unless absolutely necessary.

B make frequent referrals to contracted network specialists.

C see as many patients each day as possible, even if this means less time with each patient.

D expand office hours and/or staff to permit more patients to be seen each day.

Question #27

According to some contract terms, if an MCO does not pay a claim within the time limit specified in the contract, the provider may be able to:

A charge the usual and customary fee instead of the discounted fee.

B take legal action against the MCO.

C terminate the MCO contract after filing a written notice of intention.

D bill the patient directly.

Question #28

Under a discounted fee-for-service arrangement, covered services are compensated at a:

A discounted per-diem rate.

B reduced percentage of usual and customary charges.

C reduced per-case rate.

D per-member-per-month rate.

Question #29

A managed care contract will include a:

A list of patients covered by the plan.

B list of physicians in the network.

C description of what types of employer groups are offered coverage.

D description of how the physician will be paid for services.

Question #30

A provider who enters into a contract with an MCO is referred to as a(n):

A participating provider.

B permanent provider.

C active provider.

D MCO provider.

Question #31

Contracts between the physician and managed care organization (MCO) are generally negotiated by the:

A physician or upper management.

B account manager or business manager.

C medical office specialist.

D attorney.

Question #32

The type of policy that would provide coverage for custodial care in a nursing home is:

A special risk insurance.

B major medical insurance.

C long-term care insurance.

D short-term health insurance.

Question #33

Group insurance is issued to an employer to provide coverage for:

A employees and spouses only

B employees only.

C employees and children only.

D employees and all their dependents.

Question #34

Physician-hospital organizations (PHOs) may include:

A nursing homes.

B surgery centers.

C laboratories.

D All of these.

Question #35

An exclusive provider organization (EPO) is similar to a preferred provider organization (PPO) because they both have:

A a flexible benefit design.

B gatekeepers.

C payment by capitation.

D a limited provider network.

Question #36

Advantages of managed care include all of the following EXCEPT:

A Physicians run the risk of unfavorable evaluations by enrollees.

B Hospitals and physicians provide services more efficiently.

C Providers strive to improve the quality of their care.

D Data is collected and analyzed to measure health outcomes.

Question #37

Which of the following is a characteristic of a preferred provider organization (PPO)?

A Members must obtain referrals to see a specialist.

B Members select a primary care physician (PCP) as a gatekeeper.

C It includes a contracted network of providers.

D The plan is more restrictive than a health maintenance organization (HMO).

Question #38

All the following are true regarding the Affordable Care Act EXCEPT:

A It cannot deny coverage due to a pre-existing condition.

B It requires people to prove citizenship before receiving services.

C It offers five different types of government plans.

D It is also known as Obamacare.

Question #39

All of the following are types of health maintenance organizations (HMOs) EXCEPT the:

A individual practice association.

B group model.

C preferred provider model.

D open access model.

Question #40

By accepting lower payments from MCOs, physicians are forced to see more patients each day in order to:

A enroll more members in the health plan.

B minimize malpractice suits.

C maintain their income.

D deliver MCO-required preventive care.

Question #41

Which is true regarding health reimbursement arrangements (HRAs)?

A the funds cannot be used for dental and vision care.

B participation ends upon termination of employment.

C expenses must have incurred during the coverage period.

D unused reimbursements cannot be accessed.

Question #42

The subscriber in a health maintenance organization (HMO) can also be called a(n):

A employer or policyholder.

B member or provider.

C policyholder or member.

D patient or carrier.

Question #43

The duties of a primary care physician (PCP) in a health maintenance organization (HMO) include:

A referring patients to specialists.

B All of these.

C coordinating patient care.

D acting as a gatekeeper to services.

Question #44

In a managed care organization (MCO), a primary care physician (PCP) is any of the following EXCEPT:

A dermatologist.

B internal medicine doctor.

C general practitioner.

D family practitioner.

Question #45

To determine the amount due from a patient, it is necessary to know the:

A diagnostic code.

B allowed amount.

C adjusted amount.

D billed amount.

Question #46

Managed care systems ensure the delivery of high-quality care while managing costs through:

A provider networks and regular premium increases.

B provider networks and discounted fees for services.

C discounted fees for services and mandatory high deductibles across all health plans.

D prohibiting the use of out-of-network providers.

Question #47

To avoid the higher costs of healthcare, employers:

A refused to extend health insurance to employees.

B decreased the number of health plans available to employees.

C hired younger employees.

D increased employee premium contributions.

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