HIMA 240 FINAL EXAM AND PRACTICE
QUESTIONS ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
1. Healthcare Payment System Purpose
The primary purpose of healthcare payment systems is to:
A. Increase hospital profits
B. Ensure fair reimbursement for services rendered
C. Reduce patient care
D. Limit provider services
Answer: B
Rationale: Payment systems are designed to ensure providers are fairly
reimbursed for healthcare services delivered.
2. Fee-for-Service Model
In a fee-for-service system, providers are paid:
A. A fixed monthly salary
B. Based on each service provided
C. Only for outcomes
D. Per patient outcome rating
Answer: B
Rationale: Fee-for-service compensates providers for each individual service
rendered.
,3. Scenario: Insurance Claim Denial
A hospital claim is denied due to missing documentation. The BEST corrective
action is:
A. Resubmit without changes
B. Provide complete supporting documentation and resubmit
C. Ignore denial
D. Bill patient directly immediately
Answer: B
Rationale: Denials due to documentation require correction and resubmission with
proper records.
4. Capitation Payment Model
Under capitation, providers are paid:
A. Per procedure
B. Per patient enrolled per period
C. Only for surgeries
D. Based on hospital size
Answer: B
Rationale: Capitation provides a fixed amount per patient regardless of services
used.
5. DRG System Purpose
Diagnosis Related Groups (DRGs) are used to:
A. Set drug prices
B. Standardize hospital reimbursement based on diagnosis
C. Eliminate insurance
D. Pay nurses directly
Answer: B
Rationale: DRGs group diagnoses to standardize hospital payments.
,6. Scenario: Upcoding Risk
A coder assigns a higher-paying diagnosis than supported by records. This is:
A. Bundling
B. Upcoding
C. Capitation
D. Compliance
Answer: B
Rationale: Upcoding is unethical and involves inflating diagnosis codes for higher
reimbursement.
7. Prospective Payment System (PPS)
Under PPS, payments are determined:
A. After treatment
B. Before services are delivered
C. Randomly
D. Based on patient satisfaction
Answer: B
Rationale: PPS sets payment amounts in advance based on classification systems.
8. Healthcare Claim Submission
The first step in claim processing is:
A. Payment issuance
B. Patient discharge
C. Claim creation and submission
D. Insurance denial
Answer: C
Rationale: Claims must be created and submitted to insurers for processing.
, 9. Scenario: Claim Rejection
A claim is rejected due to incorrect patient ID. The coder should:
A. Ignore issue
B. Correct demographic data and resubmit
C. Bill patient directly
D. Cancel service record
Answer: B
Rationale: Demographic errors must be corrected before resubmission.
10. Managed Care Objective
Managed care systems aim to:
A. Increase costs
B. Control healthcare costs while maintaining quality
C. Eliminate insurance
D. Reduce access to care
Answer: B
Rationale: Managed care balances cost control and quality service delivery.
11. Bundled Payment System
Bundled payments cover:
A. Single service only
B. Multiple services under one payment
C. Only physician fees
D. Only medications
Answer: B
Rationale: Bundled payments combine multiple services into one payment
package.
QUESTIONS ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
1. Healthcare Payment System Purpose
The primary purpose of healthcare payment systems is to:
A. Increase hospital profits
B. Ensure fair reimbursement for services rendered
C. Reduce patient care
D. Limit provider services
Answer: B
Rationale: Payment systems are designed to ensure providers are fairly
reimbursed for healthcare services delivered.
2. Fee-for-Service Model
In a fee-for-service system, providers are paid:
A. A fixed monthly salary
B. Based on each service provided
C. Only for outcomes
D. Per patient outcome rating
Answer: B
Rationale: Fee-for-service compensates providers for each individual service
rendered.
,3. Scenario: Insurance Claim Denial
A hospital claim is denied due to missing documentation. The BEST corrective
action is:
A. Resubmit without changes
B. Provide complete supporting documentation and resubmit
C. Ignore denial
D. Bill patient directly immediately
Answer: B
Rationale: Denials due to documentation require correction and resubmission with
proper records.
4. Capitation Payment Model
Under capitation, providers are paid:
A. Per procedure
B. Per patient enrolled per period
C. Only for surgeries
D. Based on hospital size
Answer: B
Rationale: Capitation provides a fixed amount per patient regardless of services
used.
5. DRG System Purpose
Diagnosis Related Groups (DRGs) are used to:
A. Set drug prices
B. Standardize hospital reimbursement based on diagnosis
C. Eliminate insurance
D. Pay nurses directly
Answer: B
Rationale: DRGs group diagnoses to standardize hospital payments.
,6. Scenario: Upcoding Risk
A coder assigns a higher-paying diagnosis than supported by records. This is:
A. Bundling
B. Upcoding
C. Capitation
D. Compliance
Answer: B
Rationale: Upcoding is unethical and involves inflating diagnosis codes for higher
reimbursement.
7. Prospective Payment System (PPS)
Under PPS, payments are determined:
A. After treatment
B. Before services are delivered
C. Randomly
D. Based on patient satisfaction
Answer: B
Rationale: PPS sets payment amounts in advance based on classification systems.
8. Healthcare Claim Submission
The first step in claim processing is:
A. Payment issuance
B. Patient discharge
C. Claim creation and submission
D. Insurance denial
Answer: C
Rationale: Claims must be created and submitted to insurers for processing.
, 9. Scenario: Claim Rejection
A claim is rejected due to incorrect patient ID. The coder should:
A. Ignore issue
B. Correct demographic data and resubmit
C. Bill patient directly
D. Cancel service record
Answer: B
Rationale: Demographic errors must be corrected before resubmission.
10. Managed Care Objective
Managed care systems aim to:
A. Increase costs
B. Control healthcare costs while maintaining quality
C. Eliminate insurance
D. Reduce access to care
Answer: B
Rationale: Managed care balances cost control and quality service delivery.
11. Bundled Payment System
Bundled payments cover:
A. Single service only
B. Multiple services under one payment
C. Only physician fees
D. Only medications
Answer: B
Rationale: Bundled payments combine multiple services into one payment
package.
