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 TRUE

B FALSE

Question #5

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

A Medicare incentive payments.

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

C Medicare and Medicaid incentive payments.

D Medicaid incentive payments.

Question #6

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

A business associates of covered entities.

B friends and family of providers.

C friends and family of patients.

D corporate owners of covered entities.

Question #7

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

A $400,000

B $250,000

C $100,000

D $150,000

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 administrative, physical, and electronic.

C technical, training, and administrative.

D physical, technical, and procedural.

Question #9

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

A claim forms.

B descriptors.

C modifiers.

D code sets.

Question #10

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

A 450

B 400

C 500

D 350

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 Centers for Medicare and Medicaid Services (CMS).

B individuals whose records were affected.

C insurance carriers whose claims were affected.

D Consumer Protection Agency.

Question #12

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

A request corrections of any inaccuracies in the records.

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

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

D at least 10 free copies.

Question #13

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

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

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

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

D All of these

Question #14

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

A acknowledgment of informed consent form.

B assignment of benefits form.

C designation of beneficiary form.

D designation for release of medical information form.

Question #15

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

A claim status requests and reports

B All of these

C eligibility requests and verifications

D health insurance claims

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 TRUE

B FALSE

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 21

B 25

C 26

D 19

Question #23

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

A accredited MCOs are always better than nonaccredited MCOs.

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

C some MCOs are accredited, and some are not.

D MCOs must be accredited to operate.

Question #24

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

A All of these.

B medical credentials.

C workplace environment.

D service fees.

Question #25

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

A physicians.

B managers.

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

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

D make frequent referrals to contracted network specialists.

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 bill the patient directly.

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

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

D take legal action against the MCO.

Question #28

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

A reduced per-case rate.

B reduced percentage of usual and customary charges.

C per-member-per-month rate.

D discounted per-diem rate.

Question #29

A managed care contract will include a:

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

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

C list of physicians in the network.

D list of patients covered by the plan.

Question #30

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

A active provider.

B participating provider.

C MCO provider.

D permanent provider.

Question #31

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

A attorney.

B account manager or business manager.

C physician or upper management.

D medical office specialist.

Question #32

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

A long-term care insurance.

B major medical insurance.

C short-term health insurance.

D special risk insurance.

Question #33

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

A employees and all their dependents.

B employees only.

C employees and spouses only

D employees and children only.

Question #34

Physician-hospital organizations (PHOs) may include:

A surgery centers.

B laboratories.

C nursing homes.

D All of these.

Question #35

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

A gatekeepers.

B a limited provider network.

C payment by capitation.

D a flexible benefit design.

Question #36

Advantages of managed care include all of the following EXCEPT:

A Data is collected and analyzed to measure health outcomes.

B Hospitals and physicians provide services more efficiently.

C Physicians run the risk of unfavorable evaluations by enrollees.

D Providers strive to improve the quality of their care.

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

D It includes a contracted network of providers.

Question #38

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

A It offers five different types of government plans.

B It is also known as Obamacare.

C It requires people to prove citizenship before receiving services.

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

Question #39

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

A individual practice association.

B preferred provider model.

C group 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 maintain their income.

C minimize malpractice suits.

D deliver MCO-required preventive care.

Question #41

Which is true regarding health reimbursement arrangements (HRAs)?

A unused reimbursements cannot be accessed.

B expenses must have incurred during the coverage period.

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

D participation ends upon termination of employment.

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 acting as a gatekeeper to services.

C All of these.

D coordinating patient care.

Question #44

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

A general practitioner.

B family practitioner.

C dermatologist.

D internal medicine doctor.

Question #45

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

A adjusted amount.

B diagnostic code.

C billed amount.

D allowed amount.

Question #46

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

A provider networks and discounted fees for services.

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

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

D provider networks and regular premium increases.

Question #47

To avoid the higher costs of healthcare, employers:

A hired younger employees.

B increased employee premium contributions.

C decreased the number of health plans available to employees.

D refused to extend health insurance to employees.

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