Exam 1 Chapters 1 – 4

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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 True

B False

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

Providers who do NOT achieve the HITECH meaningful use standards in 2017 will face penalties that consist of a:

A 3 % reduction of Medicare reimbursement.

B 2 % reduction of Medicare reimbursement.

C 4 % reduction of Medicare reimbursement.

D 1% reduction of Medicare reimbursement.

Question #6

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

A Medicare incentive payments.

B Medicare and Medicaid incentive payments.

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

D Medicaid incentive payments.

Question #7

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

A friends and family of patients.

B business associates of covered entities.

C corporate owners of covered entities.

D friends and family of providers.

Question #8

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

A $400,000

B $150,000

C $250,000

D $100,000

Question #9

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

A technical, training, and administrative.

B administrative, physical, and electronic.

C physical, technical, and procedural.

D physical, administrative, and technical.

Question #10

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

A code sets.

B claim forms.

C modifiers.

D descriptors.

Question #11

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

A 450

B 350

C 500

D 400

Question #12

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 individuals whose records were affected.

B insurance carriers whose claims were affected.

C Consumer Protection Agency.

D Centers for Medicare and Medicaid Services (CMS).

Question #13

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 at least 10 free copies.

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

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

Question #14

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 All of these

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

Question #15

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

A designation for release of medical information form.

B designation of beneficiary form.

C assignment of benefits form.

D acknowledgment of informed consent form.

Question #16

Under the HIPAA Privacy Rule, a physician can discuss a patient’s medical condition or treatment with a family member or friend without written consent when:

A the patient has given verbal consent.

B both the patient is unconscious and the patient has given verbal consent.

C the payment for services is past due.

D the patient is unconscious.

Question #17

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

A claim status requests and reports

B All of these

C health insurance claims

D eligibility requests and verifications

Question #18

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 #19

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

A True

B False

Question #20

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 #21

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

A False

B True

Question #22

ACOs are a group of insurance providers.

A True

B False

Question #23

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 #24

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 26

B 19

C 25

D 21

Question #25

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

A MCOs must be accredited to operate.

B accredited MCOs are always better than nonaccredited MCOs.

C some MCOs are accredited, and some are not.

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

Question #26

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

A service fees.

B medical credentials.

C workplace environment.

D All of these.

Question #27

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

A managers.

B physicians.

C actuaries.

D accountants.

Question #28

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 #29

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 take legal action against the MCO.

B bill the patient directly.

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

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

Question #30

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

A reduced per-case rate.

B discounted per-diem rate.

C reduced percentage of usual and customary charges.

D per-member-per-month rate.

Question #31

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 how the physician will be paid for services.

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

Question #32

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

A active provider.

B permanent provider.

C MCO provider.

D participating provider.

Question #33

A managed care contract is considered a legal document between the:

A insurer and employer.

B provider and insurer.

C patient and insurer.

D provider and patient.

Question #34

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 #35

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

A major medical insurance.

B special risk insurance.

C short-term health insurance.

D long-term care insurance.

Question #36

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

A employees and children only.

B employees only.

C employees and all their dependents.

D employees and spouses only.

Question #37

Physician-hospital organizations (PHOs) may include:

A laboratories.

B All of these.

C nursing homes.

D surgery centers.

Question #38

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

A a flexible benefit design.

B payment by capitation.

C a limited provider network.

D gatekeepers.

Question #39

Advantages of managed care include all of the following EXCEPT:

A Data is collected and analyzed to measure health outcomes.

B Providers strive to improve the quality of their care.

C Hospitals and physicians provide services more efficiently.

D Physicians run the risk of unfavorable evaluations by enrollees.

Question #40

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

A Members must obtain referrals to see a specialist.

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

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

D It includes a contracted network of providers.

Question #41

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

A It requires people to prove citizenship before receiving services.

B It is also known as Obamacare.

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

D It offers five different types of government plans.

Question #42

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

A open access model.

B individual practice association.

C preferred provider model.

D group model.

Question #43

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

A deliver MCO-required preventive care.

B maintain their income.

C minimize malpractice suits.

D enroll more members in the health plan.

Question #44

Which is true regarding health reimbursement arrangements (HRAs)?

A unused reimbursements cannot be accessed.

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

C participation ends upon termination of employment.

D expenses must have incurred during the coverage period.

Question #45

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

A patient or carrier.

B policyholder or member.

C member or provider.

D employer or policyholder.

Question #46

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

A acting as a gatekeeper to services.

B referring patients to specialists.

C coordinating patient care.

D All of these.

Question #47

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

A family practitioner.

B dermatologist.

C internal medicine doctor.

D general practitioner.

Question #48

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

A adjusted amount.

B diagnostic code.

C allowed amount.

D billed amount.

Question #49

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

A provider networks and discounted fees for services.

B provider networks and regular premium increases.

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

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

Question #50

To avoid the higher costs of healthcare, employers:

A decreased the number of health plans available to employees.

B refused to extend health insurance to employees.

C hired younger employees.

D increased employee premium contributions.

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Exam 1 Chapters 1 – 4

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