2025 HIC TEST QUESTIONS WITH ACCURATE
AND VERIFIED ANSWERS
◉ An employee paying for 40 percent of the insurance premium
through payroll processing is an example of a transaction between
________ and ________. Answer: Patient; employer
◉ Why do health insurers pool premium payments for all the
insureds in a group and use actuarial data to calculate the group's
premiums? Answer: To assure that the pool is large enough to pay
losses of the entire group
◉ A physician office submitting an invoice (claim) for payment when
the patient has health insurance is an example of a transaction
between _____ and ____. Answer: Provider; third-party payer
◉ All of the following activities are steps in medical necessity and
utilization review except: Answer: Administrative review
◉ All of the following functions are ways that MCOs work toward
their goal of controlling cost except: Answer: Use of evidence based
clinical practice guidelines
,◉ All of the following occurrences are considered "qualifying life
events" except: Answer: Car accident
◉ Jung Hwa was married on July 1, 20XX. She had worked for the
organization for the past 8 years and has been covered under its
group health insurance policy during the entire period. When can
Jung Hwa add her new spouse to her insurance plan? Answer:
Immediately, as marriage is a qualifying life event
◉ Compare the social insurance model and the private health
insurance model. Discuss similarities and differences. Answer: Both
the social and private insurance models require employees and
employers to contribute funds to a type of insurance company. In the
social insurance model, the "insurance company" is called a sickness
fund. They are heavily regulated by the government, including the
determination of how much an individual must pay into the sickness
fund. In the private health model, the insurance company follows
some regulations established by the federal government. Still, in this
model, the insurance company determines the individual's amount
to obtain coverage. In both models, individuals may choose from
which sickness fund or insurance company to obtain insurance
coverage.
Another main difference is that the social insurance model calls for
universal healthcare coverage for a set of government-defined
benefits. The private health model does not include universal
coverage for all citizens.
,◉ Describe the concept of revenue integrity. Answer: Revenue
integrity is performing revenue cycle duties to obtain operational
efficiency, compliance adherence, and legitimate reimbursement.
The foundation of revenue integrity is transparency and honesty.
This translates to the every day saying, "doing the right thing." The
goal of revenue integrity is to produce a claim for reimbursement
that is clean, complete, and compliant.
◉ Describe why cost-sharing is a limitation in a health insurance
policy. Answer: Cost-sharing is a limitation because it limits the
extent of the benefit. The benefit is limited because the beneficiary is
required to bear some of the costs of the healthcare that they
consume. The concept is designed to decrease the effect of moral
hazard. For example, if a beneficiary has a $250 copayment
associated with emergency department visits, the beneficiary may
think twice about using the emergency department instead of urgent
care for minor illnesses and injuries such as respiratory infections,
sprained ankles, etc.
◉ One managed care concept that has carried over to most
insurance plans is utilization management. A key component of
utilization management is utilization review. Describe utilization
review. Provide an example of when utilization review would be
used. Answer: Utilization review is a process that determines the
medical necessity of a service and the appropriateness of the setting
for the healthcare service in the continuum of care. An example
would be a patient that needs to have a coronary artery stent placed.
First, the insurance company will determine if the stent placement is
, medically necessary—for example, for coronary artery disease.
Second, the insurance company will determine if the patient is
healthy enough to have the stent placed in the same-day surgery
unit or if the patient should be admitted as an inpatient because of
comorbid conditions or the patient's overall health status.
◉ Which part of the Medicare program does not include a premium?
Answer: Part A
◉ In states where there is not a mandated fund for workers'
compensation, which of the following is an option for employers?
Answer: Purchase workers' compensation insurance from a private
carrier
◉ All of the following are true of state Medicaid programs except:
Answer: Services offered to beneficiaries are the same in each state.
◉ Clyde is enrolled in Medicare Parts A and B. He had a knee
arthroscopy in January. This is Clyde's first health encounter for the
year so he has not met his deductible. The approved amount for his
surgeon is $550. How much does Clyde owe in cost sharing for the
surgeon's services. Use the following excerpt from table 3.2, Part B
Services 2020. Answer: $308
◉ Which of the following is(are) true of CHIP? Answer: It is a federal
and state program
AND VERIFIED ANSWERS
◉ An employee paying for 40 percent of the insurance premium
through payroll processing is an example of a transaction between
________ and ________. Answer: Patient; employer
◉ Why do health insurers pool premium payments for all the
insureds in a group and use actuarial data to calculate the group's
premiums? Answer: To assure that the pool is large enough to pay
losses of the entire group
◉ A physician office submitting an invoice (claim) for payment when
the patient has health insurance is an example of a transaction
between _____ and ____. Answer: Provider; third-party payer
◉ All of the following activities are steps in medical necessity and
utilization review except: Answer: Administrative review
◉ All of the following functions are ways that MCOs work toward
their goal of controlling cost except: Answer: Use of evidence based
clinical practice guidelines
,◉ All of the following occurrences are considered "qualifying life
events" except: Answer: Car accident
◉ Jung Hwa was married on July 1, 20XX. She had worked for the
organization for the past 8 years and has been covered under its
group health insurance policy during the entire period. When can
Jung Hwa add her new spouse to her insurance plan? Answer:
Immediately, as marriage is a qualifying life event
◉ Compare the social insurance model and the private health
insurance model. Discuss similarities and differences. Answer: Both
the social and private insurance models require employees and
employers to contribute funds to a type of insurance company. In the
social insurance model, the "insurance company" is called a sickness
fund. They are heavily regulated by the government, including the
determination of how much an individual must pay into the sickness
fund. In the private health model, the insurance company follows
some regulations established by the federal government. Still, in this
model, the insurance company determines the individual's amount
to obtain coverage. In both models, individuals may choose from
which sickness fund or insurance company to obtain insurance
coverage.
Another main difference is that the social insurance model calls for
universal healthcare coverage for a set of government-defined
benefits. The private health model does not include universal
coverage for all citizens.
,◉ Describe the concept of revenue integrity. Answer: Revenue
integrity is performing revenue cycle duties to obtain operational
efficiency, compliance adherence, and legitimate reimbursement.
The foundation of revenue integrity is transparency and honesty.
This translates to the every day saying, "doing the right thing." The
goal of revenue integrity is to produce a claim for reimbursement
that is clean, complete, and compliant.
◉ Describe why cost-sharing is a limitation in a health insurance
policy. Answer: Cost-sharing is a limitation because it limits the
extent of the benefit. The benefit is limited because the beneficiary is
required to bear some of the costs of the healthcare that they
consume. The concept is designed to decrease the effect of moral
hazard. For example, if a beneficiary has a $250 copayment
associated with emergency department visits, the beneficiary may
think twice about using the emergency department instead of urgent
care for minor illnesses and injuries such as respiratory infections,
sprained ankles, etc.
◉ One managed care concept that has carried over to most
insurance plans is utilization management. A key component of
utilization management is utilization review. Describe utilization
review. Provide an example of when utilization review would be
used. Answer: Utilization review is a process that determines the
medical necessity of a service and the appropriateness of the setting
for the healthcare service in the continuum of care. An example
would be a patient that needs to have a coronary artery stent placed.
First, the insurance company will determine if the stent placement is
, medically necessary—for example, for coronary artery disease.
Second, the insurance company will determine if the patient is
healthy enough to have the stent placed in the same-day surgery
unit or if the patient should be admitted as an inpatient because of
comorbid conditions or the patient's overall health status.
◉ Which part of the Medicare program does not include a premium?
Answer: Part A
◉ In states where there is not a mandated fund for workers'
compensation, which of the following is an option for employers?
Answer: Purchase workers' compensation insurance from a private
carrier
◉ All of the following are true of state Medicaid programs except:
Answer: Services offered to beneficiaries are the same in each state.
◉ Clyde is enrolled in Medicare Parts A and B. He had a knee
arthroscopy in January. This is Clyde's first health encounter for the
year so he has not met his deductible. The approved amount for his
surgeon is $550. How much does Clyde owe in cost sharing for the
surgeon's services. Use the following excerpt from table 3.2, Part B
Services 2020. Answer: $308
◉ Which of the following is(are) true of CHIP? Answer: It is a federal
and state program
