HIMA 240 FINAL EXAM HEALTHCARE
PAYMENT SYSTEMS AND PRACTICE
QUESTIONS ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
Section A: Multiple Choice Questions (40 Questions)
(Choose the best answer. Each question has one correct answer with rationale
provided.)
1. A patient receives hospital care and is billed based on a fixed payment per
diagnosis rather than individual services. This payment system is best described as:
A. Fee-for-Service
B. Capitation
C. Diagnosis-Related Groups (DRGs)
D. Cost-Based Reimbursement
Answer: C
Rationale: DRG payments provide a fixed amount based on diagnosis and
expected resource use, not individual services.
2. Which form is primarily used by physicians for outpatient billing?
A. UB-04
B. CMS-1500
C. ADA Form
D. DRG Form
Answer: B
Rationale: CMS-1500 is used for professional services such as physician
outpatient billing.
,3. A patient pays a fixed monthly amount for healthcare services regardless of
usage. This model is called:
A. Deductible system
B. Capitation
C. Fee-for-service
D. Coinsurance
Answer: B
Rationale: Capitation pays providers a fixed amount per member per period.
4. Which term refers to the portion of healthcare costs a patient must pay before
insurance begins covering services?
A. Copayment
B. Coinsurance
C. Deductible
D. Premium
Answer: C
Rationale: A deductible is the amount paid out-of-pocket before insurance
coverage begins.
5. A claim is rejected because required authorization was not obtained before
service delivery. This is known as:
A. Coding error
B. Pre-certification failure
C. Fraud
D. Bundling error
Answer: B
Rationale: Pre-certification is required approval before services; failure leads to
claim denial.
,6. Which system classifies inpatient hospital services into payment categories?
A. CPT
B. HCPCS Level II
C. MS-DRG
D. ICD-10-PCS
Answer: C
Rationale: Medicare Severity DRGs classify inpatient stays for reimbursement.
7. A provider is paid a single bundled amount for all services related to a surgical
procedure. This is:
A. Fee-for-service
B. Bundled payment
C. Capitation
D. Charge master billing
Answer: B
Rationale: Bundled payments cover all services in one payment for a care episode.
8. Which document explains how insurance payments were applied to a patient’s
bill?
A. UB-04
B. EOB (Explanation of Benefits)
C. CMS-1500
D. DRG worksheet
Answer: B
Rationale: EOB details how insurance processed a claim.
, 9. Which organization primarily administers Medicare payments?
A. CDC
B. CMS
C. WHO
D. FDA
Answer: B
Rationale: Centers for Medicare & Medicaid Services (CMS) manages Medicare.
10. A provider is audited due to unusually high billing for services not supported
by documentation. This is:
A. Utilization review
B. Fraud investigation
C. Coding optimization
D. Capitation audit
Answer: B
Rationale: Billing without documentation suggests potential fraud or abuse.
11. Which system is used to code inpatient procedures?
A. CPT
B. ICD-10-PCS
C. HCPCS Level II
D. DRG
Answer: B
Rationale: ICD-10-PCS is used for inpatient procedural coding.
PAYMENT SYSTEMS AND PRACTICE
QUESTIONS ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
Section A: Multiple Choice Questions (40 Questions)
(Choose the best answer. Each question has one correct answer with rationale
provided.)
1. A patient receives hospital care and is billed based on a fixed payment per
diagnosis rather than individual services. This payment system is best described as:
A. Fee-for-Service
B. Capitation
C. Diagnosis-Related Groups (DRGs)
D. Cost-Based Reimbursement
Answer: C
Rationale: DRG payments provide a fixed amount based on diagnosis and
expected resource use, not individual services.
2. Which form is primarily used by physicians for outpatient billing?
A. UB-04
B. CMS-1500
C. ADA Form
D. DRG Form
Answer: B
Rationale: CMS-1500 is used for professional services such as physician
outpatient billing.
,3. A patient pays a fixed monthly amount for healthcare services regardless of
usage. This model is called:
A. Deductible system
B. Capitation
C. Fee-for-service
D. Coinsurance
Answer: B
Rationale: Capitation pays providers a fixed amount per member per period.
4. Which term refers to the portion of healthcare costs a patient must pay before
insurance begins covering services?
A. Copayment
B. Coinsurance
C. Deductible
D. Premium
Answer: C
Rationale: A deductible is the amount paid out-of-pocket before insurance
coverage begins.
5. A claim is rejected because required authorization was not obtained before
service delivery. This is known as:
A. Coding error
B. Pre-certification failure
C. Fraud
D. Bundling error
Answer: B
Rationale: Pre-certification is required approval before services; failure leads to
claim denial.
,6. Which system classifies inpatient hospital services into payment categories?
A. CPT
B. HCPCS Level II
C. MS-DRG
D. ICD-10-PCS
Answer: C
Rationale: Medicare Severity DRGs classify inpatient stays for reimbursement.
7. A provider is paid a single bundled amount for all services related to a surgical
procedure. This is:
A. Fee-for-service
B. Bundled payment
C. Capitation
D. Charge master billing
Answer: B
Rationale: Bundled payments cover all services in one payment for a care episode.
8. Which document explains how insurance payments were applied to a patient’s
bill?
A. UB-04
B. EOB (Explanation of Benefits)
C. CMS-1500
D. DRG worksheet
Answer: B
Rationale: EOB details how insurance processed a claim.
, 9. Which organization primarily administers Medicare payments?
A. CDC
B. CMS
C. WHO
D. FDA
Answer: B
Rationale: Centers for Medicare & Medicaid Services (CMS) manages Medicare.
10. A provider is audited due to unusually high billing for services not supported
by documentation. This is:
A. Utilization review
B. Fraud investigation
C. Coding optimization
D. Capitation audit
Answer: B
Rationale: Billing without documentation suggests potential fraud or abuse.
11. Which system is used to code inpatient procedures?
A. CPT
B. ICD-10-PCS
C. HCPCS Level II
D. DRG
Answer: B
Rationale: ICD-10-PCS is used for inpatient procedural coding.
