Comprehensive Test- Principals of Healthcare
Reimbursement and Revenue Cycle Management Review
2023 with complete solution
The US healthcare sector represents a significant portion of the US economy. The
trend of _________ spending on healthcare has been consistent for more than a
decade.
increased
The goal of revenue integrity is to produce a claim that is __________.
Clean, complete, and compliant
A physician office submitting an invoice (claim) for payment when the patient has
health insurance is an example of a transaction between ________ and ________.
Provider; third-party payer
In the US, what is health insurance?
Reduction of a person's or a group's exposure to risk for unknown healthcare costs by
the assumption of that risk by an entity
An employee paying for 40 percent of the insurance premium through payroll
processing is an example of a transaction between ________ and ________.
Patient; employer
Which of the following is not a principle of revenue integrity?
No oversight
In this healthcare delivery model, the insurance company determines that
contribution amount that is not based on the policyholder's income:
Private health insurance model
Successful RCM programs use this type of approach, which promotes
collaboration amount various clinical departments and emphasizes and
education strategy for all members:
Multidisciplinary model
In this healthcare delivery model, employees and employers contribute an
income-based amount of money to funds that are regulated by the government:
Social insurance model
Which of the following is a key factor in establishing a highly ethical culture that
promotes honesty and openness?
Transparency
Which of the following types of care represent healthcare services not delivered
by MCOs?
Experimental devices
What is the term that means evaluating, for a healthcare service, the
appropriateness of its setting and its level of service?
Utilization review
In the healthcare sector, what is the term for a group of individual entities, such
as individual persons, employers, or associations, whose healthcare costs are
combined for evaluating financial history and estimating future costs?
Risk pool
, All of the following activities are steps in medical necessity and utilization review
except:
Administrative review
All of the following functions are ways that MCOs work toward their goal of
controlling cost except:
Use of evidence based clinical practice guidelines
Medicare has four criteria to define medically necessary services. Which of the
following is not one of the four criteria?
Considered to be good medical practice by the physician providing the service
Once the maximum out-of-pocket benefit is activated, all covered healthcare
services for that policyholder or beneficiary are paid at 100 percent by the health
insurance plan. The policyholder is not liable for _________ beyond the maximum
out-of-pocket amount.
Cost sharing amounts
Managed care plans control beneficiary choice of provider. On the continuum of
control, which type of managed care organization has the most control and,
therefore, has the greatest limitations on a beneficiary seeing a provider that is
not in-network?
Health maintenance organization
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?
Immediately, as marriage is a qualifying life event
All of the following types of procedures and services typically require prior
authorization except:
Emergency services for suspected stroke
The Civilian Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA) is available for:
Spouse, widow(er), or children of a veteran meeting specific criteria
Which government-sponsored program provides coverage for active-duty service
members of the armed forces (ADSM)?
TRICARE
Wes is enrolled in Medicare Part A. He had his first hospital encounter this March.
He was admitted for congestive heart failure and stayed three days? Which of the
following will Wes need to pay?
Deductible and copayment amount
Which of the following is(are) true of CHIP?
It is a federal and state program
In states where there is not a mandated fund for workers' compensation, which of
the following is an option for employers?
Purchase workers' compensation insurance from a private carrier
All of the following are true of state Medicaid programs except:
Services offered to beneficiaries are the same in each state.
Which part of the Medicare program does not include include a premium?
Part A
Reimbursement and Revenue Cycle Management Review
2023 with complete solution
The US healthcare sector represents a significant portion of the US economy. The
trend of _________ spending on healthcare has been consistent for more than a
decade.
increased
The goal of revenue integrity is to produce a claim that is __________.
Clean, complete, and compliant
A physician office submitting an invoice (claim) for payment when the patient has
health insurance is an example of a transaction between ________ and ________.
Provider; third-party payer
In the US, what is health insurance?
Reduction of a person's or a group's exposure to risk for unknown healthcare costs by
the assumption of that risk by an entity
An employee paying for 40 percent of the insurance premium through payroll
processing is an example of a transaction between ________ and ________.
Patient; employer
Which of the following is not a principle of revenue integrity?
No oversight
In this healthcare delivery model, the insurance company determines that
contribution amount that is not based on the policyholder's income:
Private health insurance model
Successful RCM programs use this type of approach, which promotes
collaboration amount various clinical departments and emphasizes and
education strategy for all members:
Multidisciplinary model
In this healthcare delivery model, employees and employers contribute an
income-based amount of money to funds that are regulated by the government:
Social insurance model
Which of the following is a key factor in establishing a highly ethical culture that
promotes honesty and openness?
Transparency
Which of the following types of care represent healthcare services not delivered
by MCOs?
Experimental devices
What is the term that means evaluating, for a healthcare service, the
appropriateness of its setting and its level of service?
Utilization review
In the healthcare sector, what is the term for a group of individual entities, such
as individual persons, employers, or associations, whose healthcare costs are
combined for evaluating financial history and estimating future costs?
Risk pool
, All of the following activities are steps in medical necessity and utilization review
except:
Administrative review
All of the following functions are ways that MCOs work toward their goal of
controlling cost except:
Use of evidence based clinical practice guidelines
Medicare has four criteria to define medically necessary services. Which of the
following is not one of the four criteria?
Considered to be good medical practice by the physician providing the service
Once the maximum out-of-pocket benefit is activated, all covered healthcare
services for that policyholder or beneficiary are paid at 100 percent by the health
insurance plan. The policyholder is not liable for _________ beyond the maximum
out-of-pocket amount.
Cost sharing amounts
Managed care plans control beneficiary choice of provider. On the continuum of
control, which type of managed care organization has the most control and,
therefore, has the greatest limitations on a beneficiary seeing a provider that is
not in-network?
Health maintenance organization
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?
Immediately, as marriage is a qualifying life event
All of the following types of procedures and services typically require prior
authorization except:
Emergency services for suspected stroke
The Civilian Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA) is available for:
Spouse, widow(er), or children of a veteran meeting specific criteria
Which government-sponsored program provides coverage for active-duty service
members of the armed forces (ADSM)?
TRICARE
Wes is enrolled in Medicare Part A. He had his first hospital encounter this March.
He was admitted for congestive heart failure and stayed three days? Which of the
following will Wes need to pay?
Deductible and copayment amount
Which of the following is(are) true of CHIP?
It is a federal and state program
In states where there is not a mandated fund for workers' compensation, which of
the following is an option for employers?
Purchase workers' compensation insurance from a private carrier
All of the following are true of state Medicaid programs except:
Services offered to beneficiaries are the same in each state.
Which part of the Medicare program does not include include a premium?
Part A
