Chapter 2

Question 1

A patient presents to be seen in the office. He does not pay at the time the services are rendered as the provider is his primary care provider, or gatekeeper. The large group practice has 800 covered members under this plan and is paid on a monthly basis with a set amount that is based on the number of members covered and their ages. What type of plan is this?

PPO

Capitation

Fee-for-service

Indemnity

Answer 1

Capitation

Question 2

What are the options for a provider in regard to participation with Medicare?

It is mandatory for every provider to participate in Medicare

Providers may participate, may choose not to participate, or may opt-out of Medicare

Providers are automatically opted-out

Only participating providers must file claims

Answer 2

Providers may participate, may choose not to participate, or may opt-out of Medicare

Question 3

A patient has receipts for her dental cleaning, vision exam, and contact lenses. Her employer has set up special accounts for each employee, there is no limit to the amount the employer can contribute and the balances roll over from year to year. What type of account is this?

Answer 3

Traditional HRA

Question 4

Key provisions for individual health plans under the ACA include:

1. Cannot limit, deny or charge more for benefits to anyone with a pre-existing condition.
2. Children under the age of 26 can be covered.
3. Lifetime limits on most benefits are banned.
4. Patients have more appeal rights if coverage is denied.
5. Expanded preventative health coverage.

Question 5

Four common types of group health insurance include:

Answer 5

1. Fully insured employer group - everything is paid
2. Insurance companies may group certain industries together and then gather small employers to form a larger group, which enables the insurance company to better predict the cost of insurance.
3. Self-Funded ERISA—The group contracts with the insurance company or third-party administrator to handle the paperwork. This is available to large groups, which pays for the operation of the insurance plan itself and the costs for administration. With this type of plan, the employer pays for each out-of-pocket claim as it
4. Association Group—This is offered by a different type of group other than an employer, like a credit card company offering insurance benefits to its cardholders.

Question 6

When it comes to billing, what is the difference between the PAR and non-PAR provider?

Answer 6

A PAR provider accepts assignment and agrees to accept the negotiated contracted rate. A Non-par provider does not accept assignment and can charge the patient the difference between what the insurance company pays and what the bill is.

Question 7

If a provider participates with Medicare, how much higher is the fee schedule rate?

Answer 7

5%

Question 8

If a provider sees a Medicare patient and is not participating, what happens?

Answer 8

1. The non-participating provider can charge 115% of the fee scheduled rate. Medicare usually pays the patient.

If the fee schedule is $100 then the provider could charge $115

Question 9

What does it mean if a provider opts-out of a Medicare program?

Answer 9

The provider is not limited to the fee schedule, and has their patient sign a cash pay contract. They do not submit claims to Medicare as Medicare will not pay them or the patient.

Question 10

What is an HMO?

Answer 10

HMOs are entities which provide basic health services to their enrollees for a fixed monthly payment. An HMO must also provide the option of supplemental health services to its enrollees.

Question 11

What is a group model HMO?

Answer 11

HMO contracts with a multi-specialty group that provides care to the members.

Question 12

What is a staff model HMO?

Answer 12

HMO that employs the physicians on salary to provide care to the members in the clinics and other facilities owned by the HMO. It is also called a closed-panel HMO, as the physicians are contracted to provide medical services to only HMO patients.

Question 13

What is a Network Model HMO

Answer 13

HMO that employs the physicians on salary to provide care to the members in the clinics and other facilities owned by the HMO. It is also called a closed-panel HMO, as the physicians are contracted to provide medical services to only HMO patients.

Question 14

What is an IPA?

Answer 14

IPA stands for Individual/Independent Practice Association. HMO contracts with independent physicians who maintain their offices and provide services to HMO and non-HMO patients for which they receive a fixed amount per patient.

Question 15

What is a mixed model HMO?

Answer 15

HMO t h at combines features of the IPA and group models together. This gives the biggest variety of choices and the largest geographic coverage area to its members.

Question 16

How does a PCP function in an HMO?

Answer 16

Also referred to as the gatekeeper, they are the primary contact with the health plan. Most plans require a referral or the member is responsible for cost of treatment.

Question 17

What is an MCO?

Answer 17

MCO is an umbrella term for organizations that are affiliated with or own hospitals, physician groups, and other providers which provide a wide range of coordinated health services.

Question 18

What is an EPO?

Answer 18

An EPO is an organization that has entered into contracts with medical care providers or groups of medical care providers to provide healthcare services to members. An EPO differs from an HMO. In an EPO if the member does not receive services from an in-network provider or facility, the member pays for all costs incurred.

Question 19

What is a PPO?

Answer 19

A PPO is a type of insurance plan that allows members to choose the doctors and hospitals they want to visit from providers within the network (preferred providers). Unlike HMOs, patients are not required to obtain prior approval or go through a gatekeeper if they wish to see a specialist. They are also not required to choose a PCP.

Question 20

Medicare has 4 parts - what are they?

Answer 20

Part A - Hospital Insurance
Part B - Medical insurance for things not covered by hospital insurance.
Part C - Medicare Advantage plans, which are private plans run through Medicare and must be equivalent to at least Part A + Part B
Part D - Prescription Drug coverage

Question 21

A family practitioner sees a Medicare patient and bills a 99213. This provider has opted-out of Medicare. His fee for the service is $125.00. Medicare’s approved amount is $73.08, and the patient has met $0 of his deductible. What can the provider bill the patient?

A.$125.00

B.$73.08

C.$14.62

D.$58.46

Answer 21

A - Providers that opt-out of Medicare are not limited to any specific charge limit on their patients.

Question 22

What is a Flexible Spending Account (FSA)?

Answer 22

A Flexible Spending Account (FSA) is a tax-advantaged financial account that allows employees to set aside pre-tax dollars for eligible healthcare expenses.

Question 23

Fill in the blank: The maximum contribution limit for an FSA in 2023 is ______.

Answer 23

$3,050

Question 24

Which of the following is NOT an eligible expense for FSA reimbursement? A) Prescription medications B) Over-the-counter drugs without a prescription C) Cosmetic surgery

Answer 24

C) Cosmetic surgery

Question 25

What happens to unused FSA funds at the end of the plan year?

Answer 25

Unused FSA funds typically do not carry over and are forfeited at the end of the plan year, unless the employer offers a grace period or carryover option.

Question 26

True or False: You can have both a Health Savings Account (HSA) and an FSA at the same time.

Answer 26

True, but only if the FSA is a limited-purpose FSA.

Question 27

Which of the following expenses is NOT eligible for FSA reimbursement? A) Childbirth classes B) Health insurance premiums C) Prescription glasses

Answer 27

B) Health insurance premiums

Question 28

What types of expenses can be reimbursed through a healthcare FSA?

Answer 28

Eligible expenses include co-pays, deductibles, prescription medications, and certain medical supplies.

Question 29

What is an example of an eligible expense for a dependent care FSA?

Answer 29

Daycare costs for a child while the parent is at work.

Question 30

What is an HSA?

Answer 30

An HSA combines high deductible health insurance with a tax-advantaged savings account.

Question 31

What is an HRA?

Answer 31

With an HRA, an employer can offer tax free reimbursement of an employee’s health insurance premiums paid for by an employer. It is an IRS-approved, tax-advantaged health benefit plan.

Question 32

What is capitation?

Answer 32

Capitation payments are used by managed care organizations (MCOs) to control healthcare costs by putting the physicians at financial risk for services provided to patients. Payments are based on a per-person rate, rather than a fee-for-service rate.

Question 33

A Medicaid patient presents for services on the first day of the month. He has a $50 spenddown and has had no services this month. The visit for today was $100.00. If the patient wants to be covered as long as possible from today’s visit, what can he do?

Answer 33

A. Turn the receipt in to his caseworker and be eligible for two months of coverage Rationale: A bill that is larger than the spenddown may be used to meet multiple month’s spenddown. If a patient wants the most coverage possible, $100 would meet two month’s coverage spenddown.

Question 34

A patient has receipts for her dental cleaning, vision exam, and contact lenses. Her employer has set up special accounts for each employee, there is no limit to the amount the employer can contribute, and the balances roll over from year to year. What type of account is this?

Answer 34

Answer: D. Traditional Healthcare Reimbursement Arrangement (HRA) Rationale: With an HRA, the employer has full power over structuring the employee’s use of HRA funds. Unlike an HSA or FSA, there is no limit to the amount an employer can contribute to an employee’s healthcare reimbursement account. The account balances may also roll over from year to year.

Question 35

A patient presents to be seen in the office. He does not pay at the time the services are rendered as the provider is his primary care provider, or gatekeeper. The large group practice has 800 covered members under this plan and is paid on a monthly basis with a set amount that is based on the number of members covered and their ages. What type of plan is this?

Answer 35

Capitation - Capitation payments are used by managed care organizations (MCOs) to control healthcare costs by putting the physicians at financial risk for services provided to patients. Payments are based on a per-person rate, rather than a fee-for-service rate.

Question 36

What is the largest health program in the United States? Blue Cross Blue Shield Medicare Medicaid TRICARE

Answer 36

Medicare

Question 37

Which type of HMO contracts with multiple specialty groups, individual practice groups, and individual physicians? Group Model HMO Mixed Model HMO Network Model HMO Hybrid Model HMO

Answer 37

Network Model HMO

Question 38

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? Part A Part B Part C Part D

Answer 38

Part C

Question 39

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? Fully Insured Employer Group Self-Funded ERISA Association Group Management Service Organization

Answer 39

Self-Funded ERISA – The group contracts with the insurance company or third-party administrator to handle the paperwork. This is available to large groups, which pays for the operation of the insurance plan itself and the costs for administration.

Question 40

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

Answer 40

I, III, V

Question 41

A patient is age 65 and Medicare eligible. The patient signs up for a Medicare Managed Care plan. When the patient presents for care, where are claims sent? The Medicare Administrative Contractor The patient The Managed Care Plan Both the Managed Care Plan and Medicare Administrative Contractor

Answer 41

The managed care plan

Question 42

Insurance coverage provided by an organization that is not an employer (such as a membership organization or credit card company that offers benefits to its members) is what kind of group insurance?

Answer 42

Association Group – This is offered by a different type of group other than an employer, like a credit card company offering insurance benefits to its cardholders.

Question 43

A patient is scheduled in your office for Botox injections in her face for her smile lines. She has not met her deductible and states that she is going to use money from her Healthcare Reimbursement Account to pay for it. Is this possible?

Answer 43

No, cosmetic procedures are ineligible expenses.

Question 44

What is an IPO in a health organization?

Answer 44

A corporate umbrella for management of diversified healthcare delivery systems

Question 45

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?

Answer 45

Medicaid

Question 45

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

Answer 45

Network Model HMO

Question 46

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

Answer 46

Home Health services

Question 47

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 115 percent of the Medicare fee schedule amount. What type of Medicare provider is this physician?

Answer 47

Non-participating

Question 48

What components make up the Medicare Physician Fee Schedule?

Answer 48

Relative value units for physician work, practice expense, and professional liability insurance; the Geographical Practice Cost Index; and the conversion factor