Module 113 Final Review

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1. The document together with the payment voucher that is sent to a physician who has accepted assignment of benefits is referred to as a/an

Explanation

When a physician accepts assignment of benefits, it means that they agree to receive direct payment from the insurance company for the services provided to the patient. In this case, the document that is sent to the physician along with the payment voucher is referred to as an Explanation of Benefits (EOB). The EOB provides a detailed breakdown of the services rendered, the amount billed, the amount covered by insurance, and any remaining balance that may be the responsibility of the patient.

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The 'Module 113 Final Review' quiz assesses understanding of insurance claims processing, including dispute resolution, claim tracking, and compliance with financial standards. It is crucial for professionals managing insurance claims and ensures adherence to legal and procedural guidelines.

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2. What is the correct procedure to collect a copayment on a managed care plan

Explanation

The correct procedure to collect a copayment on a managed care plan is to collect the copayment when the patient arrives for the office visit. This means that the patient is expected to pay the copayment amount at the time of their appointment.

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3. The total number of levels of redetermination that exist in the Medicare program is

Explanation

In the Medicare program, there are five levels of redetermination. Redetermination is the process of reviewing and reconsidering a claim or decision that has been made. These levels include reconsideration by a Qualified Independent Contractor (QIC), hearing by an Administrative Law Judge (ALJ), review by the Medicare Appeals Council (MAC), review by a federal district court, and review by a federal appeals court. These levels provide multiple opportunities for a claim or decision to be reviewed and potentially changed.

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4. Medicare is a

Explanation

Medicare is a federal health insurance program because it is administered by the federal government and provides health insurance coverage to individuals who are 65 years old or older, as well as certain younger individuals with disabilities. It is funded through payroll taxes and premiums paid by beneficiaries, and it is available nationwide, not limited to a specific state, region, or locality.

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5. If a payment problem develops with an insurance company and the company ignores claims and exceeds time limits to pay a claim, it is prudent to contact the

Explanation

If a payment problem arises with an insurance company and they fail to address claims and surpass the time limits for claim payment, it is advisable to reach out to the state insurance commissioner. The state insurance commissioner is responsible for regulating insurance companies within a specific state and ensuring they comply with state laws and regulations. They can investigate complaints, mediate disputes, and take appropriate actions against the insurance company if necessary. Therefore, contacting the state insurance commissioner would be the appropriate course of action in this situation.

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6. What should be done to inform a new patient of office fees and payment policies

Explanation

To inform a new patient of office fees and payment policies, all of the above options should be done. Sending a patient information brochure can provide detailed information about the fees and policies, allowing the patient to review it at their convenience. Sending a confirmation letter can serve as a reminder and also include the necessary information about fees and policies. Finally, discussing fees and policies at the time of the initial contact ensures that the patient is aware of the financial aspects before proceeding with any treatment.

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7. When receiving payment from a private insurance carrier, check the amount of payment on the EOB with the

Explanation

The correct answer is to check the amount of payment on the patient's financial accounting record. This is because the financial accounting record keeps track of all the payments received from the private insurance carrier. By comparing the amount mentioned on the Explanation of Benefits (EOB) with the patient's financial accounting record, one can ensure that the correct payment has been received. The other options listed, such as the practice's day sheet, copy of the CMS-1500 form, or the patient's insurance contract, may not provide the accurate payment information needed for verification.

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8. Which type of bankruptcy is considered "wage earner's bankruptcy"

Explanation

Chapter 13 bankruptcy is considered "wage earner's bankruptcy" because it allows individuals with regular income to create a repayment plan to pay off their debts over a period of three to five years. This type of bankruptcy is designed for individuals who have a steady income and want to keep their assets while repaying their debts. It allows them to catch up on missed mortgage or car payments and avoid foreclosure or repossession. Chapter 13 bankruptcy is different from Chapter 7, Chapter 11, and Chapter 12, which have different eligibility criteria and purposes.

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9. Medicare Part A is run by

Explanation

Medicare Part A is a government program that provides hospital insurance coverage. It is run by the Center for Medicare and Medicaid Services (CMS), which is responsible for administering the Medicare program. The CMS oversees the implementation and management of Medicare Part A, ensuring that eligible individuals receive the necessary coverage for hospital stays, skilled nursing facilities, and other related services. The CMS works in collaboration with healthcare providers, beneficiaries, and other stakeholders to ensure the effective delivery of Medicare Part A benefits.

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10. Medicare provides a one-time baseline mammographic examination for women ages 35 to 39 and preventive mammograms for women 40 years and older

Explanation

Medicare provides a one-time baseline mammographic examination for women ages 35 to 39, which means they can get this examination only once during that age range. For women 40 years and older, Medicare covers preventive mammograms, which are screenings done to detect breast cancer before any symptoms appear. These preventive mammograms are covered once a year, allowing women in this age group to get a mammogram annually to ensure early detection of any potential issues.

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11. When downcoding occurs, payment will

Explanation

When downcoding occurs, payment will be less. Downcoding refers to the process of reducing the level or complexity of a billed service by a healthcare provider. This can happen when the documentation or medical records do not support the level of service that was initially billed. As a result, the insurance company or payer may reimburse the provider at a lower rate, leading to a decrease in payment.

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12. Some senior HMOs may provide services not covered by Medicare, such as

Explanation

Some senior HMOs may provide additional services that are not covered by Medicare, such as eyeglasses and prescription drugs. This means that while Medicare may not cover the cost of eyeglasses and prescription drugs, seniors who are enrolled in certain HMOs may have access to these services through their HMO plan.

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13. Employment of a billing service is called

Explanation

Outsourcing refers to the practice of hiring an external company or service to handle specific tasks or functions that were previously performed in-house. In the context of the given question, the employment of a billing service involves outsourcing the billing process to a third-party service provider. This allows the organization to delegate the responsibility of billing to a specialized service, which can help streamline operations, reduce costs, and improve efficiency.

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14. If an insurance company admits that a patient signed an assignment of benefits document and that it inadvertently paid the patient instead of the physician, the insurance company should

Explanation

The correct answer is to pay the physician within 2 to 3 weeks and honor the assignment even before the company recovers their money from the patient. This is because the insurance company admits that they made a mistake by paying the patient instead of the physician. Therefore, it is their responsibility to rectify the error by paying the physician promptly and honoring the assignment of benefits. Waiting for the company to recover the money from the patient before paying the physician would be an unnecessary delay and unfair to the physician.

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15. In a TRICARE case, a request for an independent hearing may be pursued if the amount in question is

Explanation

In a TRICARE case, a request for an independent hearing may be pursued if the amount in question is $300 or more. This means that if the disputed amount is $300 or higher, the person involved in the TRICARE case has the right to request an independent hearing to further discuss and resolve the issue.

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16. The patient is likely to be the most cooperative in furnishing details necessary for a complete registration process

Explanation

Before any services are provided, the patient is likely to be the most cooperative in furnishing details necessary for a complete registration process. This is because at this stage, the patient has not yet received any services or treatment, so they are more likely to be focused on providing accurate and complete information for the registration process. Once services are provided or after the first statement, the patient may be preoccupied with their medical condition or the treatment they have received, making it less likely for them to be as cooperative in providing the necessary details. Similarly, in a follow-up telephone call, the patient may not have the same level of attention or willingness to provide the required information as they would have before any services were provided.

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17. A medical practice has a policy of billing only for charges in excess of $50. When the medical assistant requests $45 payment for the office visit, the patient states, "just bill me." How should the medical assistant respond

Explanation

The medical assistant should state the office policy and ask for the full fee because the policy of the medical practice is to bill only for charges in excess of $50. Therefore, the patient should be informed about the policy and asked to pay the full fee for the office visit.

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18. When writing a collection letter

Explanation

When writing a collection letter, it is recommended to use a friendly tone and ask why payment has not been made. This approach helps to maintain a positive relationship with the patient while addressing the issue of non-payment. By using a friendly tone, the letter conveys concern and understanding, which may prompt the patient to provide an explanation for the delay in payment. This approach is more likely to result in a productive and respectful conversation about the outstanding payment, rather than making assumptions or accusations about the patient's intentions or oversight.

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19. If an insurance claim has been lost by the insurance carrier, the procedure(s) to follow is to

Explanation

If an insurance claim has been lost by the insurance carrier, the procedure(s) to follow would be to ask if there is a backlog of claims at the insurance office, submit a copy of the original claim, and verify the correct mailing address. These steps are necessary to ensure that the claim is properly processed and not lost again. By asking about a backlog, it allows the insured to understand if there may be delays in processing claims. Submitting a copy of the original claim helps provide the necessary documentation for the insurance carrier to review. Verifying the correct mailing address ensures that any future correspondence or payments are sent to the correct location. Therefore, all of the above options are necessary in this situation.

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20. An insurance claim with a bundled service would be

Explanation

When an insurance claim has a bundled service, it means that multiple services or treatments are combined into a single claim. In this case, the insurance company would pay for the bundled service, as long as it meets the policy's coverage criteria.

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21. How many levels of review exist for TRICARE appeal procedures?

Explanation

TRICARE appeal procedures have three levels of review. This means that if an individual is dissatisfied with the decision made at the initial level, they have the option to request a review at two additional levels. This allows for a thorough and fair assessment of the appeal, ensuring that all parties involved have the opportunity to present their case and have it reviewed multiple times if necessary.

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22. What does the insurance billing specialist need to monitor to be able to evaluate the effectiveness of the collection process

Explanation

The insurance billing specialist needs to monitor accounts receivable in order to evaluate the effectiveness of the collection process. This is because accounts receivable represents the amount of money owed to the company by its customers for services provided. By monitoring accounts receivable, the specialist can track the amount of outstanding payments and determine if the collection process is efficient in collecting these payments.

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23. What is a card called that permits bank customers to make cashless purchases from funds on deposit without incurring revolving finance charges for credit

Explanation

A debit card is a type of card that allows bank customers to make purchases using the funds they have deposited in their bank account, without incurring any revolving finance charges for credit. Unlike a credit card, which allows users to borrow money and pay it back later, a debit card deducts the purchase amount directly from the user's bank account. This means that the user is using their own money, rather than borrowing from the bank, and therefore does not have to pay any interest or finance charges.

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24. What is the name of the act designed to address the collection practices of third-party debt collectors

Explanation

The Fair Debt Collection Practices Act is the correct answer because it is the act specifically designed to regulate and address the collection practices of third-party debt collectors. This act establishes guidelines and restrictions on how debt collectors can communicate with debtors, what information they can disclose, and how they can pursue debt collection. It aims to protect consumers from abusive, deceptive, and unfair practices in debt collection. The other options listed are acts that address different aspects of consumer credit and protection, but they do not specifically target third-party debt collectors.

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25. Pending or resubmitted insurance claims may be tracked through a

Explanation

A tickler file is a system used to track pending or resubmitted insurance claims. It is a file or set of files that contains reminders or prompts for future actions or follow-ups. In the context of insurance claims, a tickler file would be used to keep track of claims that are still pending or need to be resubmitted. This helps ensure that these claims are not forgotten or overlooked and allows for timely follow-up and resolution. A tickler file is a useful tool for organizing and managing tasks and deadlines in various industries, including insurance.

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26. The correct method to send documents for a Medicare reconsideration (Level 2) is by

Explanation

The correct method to send documents for a Medicare reconsideration (Level 2) is by certified mail with return receipt requested. This method ensures that the sender has proof of mailing and delivery, as the recipient must sign for the mail and the sender receives a receipt as evidence. This is important for important and time-sensitive documents like Medicare reconsideration requests, as it provides a record of the communication and helps to ensure that the documents are received and processed in a timely manner.

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27. If an insured is in disagreement with the insurer for the settlement of a claim, a suit must begin within

Explanation

If an insured is in disagreement with the insurer for the settlement of a claim, a suit must begin within 3 years. This means that if the insured and insurer cannot come to an agreement on the claim, the insured must file a lawsuit within 3 years from the date of the disagreement. After this time period, the insured may lose their right to pursue legal action against the insurer. It is important for the insured to be aware of this time limit and take appropriate action within the specified timeframe.

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28. All collection calls should be placed

Explanation

Collection calls should be made during reasonable hours, which typically range from 8 AM to 9 PM. This allows for a reasonable window of time to contact individuals without disturbing them too early in the morning or too late at night. Therefore, the correct answer is "after 8 AM and before 9 PM".

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29. The part of the legal system that allows laypeople to settle a legal matter without use of an attorney is the

Explanation

The correct answer is small claims court. Small claims court is a part of the legal system that allows individuals to resolve legal disputes without the need for an attorney. It is designed to handle cases involving small amounts of money, typically under a certain threshold. In small claims court, the procedures are simplified and the rules of evidence are often more relaxed, making it easier for laypeople to navigate the legal process on their own. This allows individuals to represent themselves and present their case to a judge in a more informal setting.

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30. The first statement should be

Explanation

The correct answer is "presented at the time of service". This means that the first statement should be given or shown to the relevant party at the moment the service is being provided. It suggests that the statement is not meant to be sent or mailed after the service has been completed, but rather should be presented in person during the service itself.

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31. A significant contribution to HMO development was the

Explanation

The Health Maintenance Act of 1973 made a significant contribution to the development of Health Maintenance Organizations (HMOs). This act provided federal funding and support for the establishment of HMOs as a way to control healthcare costs and improve access to comprehensive healthcare services. It introduced regulations and standards for HMOs, including requirements for preventive care and patient rights. The act also encouraged the integration of healthcare services and emphasized the importance of primary care. Overall, the Health Maintenance Act of 1973 played a crucial role in promoting the growth and success of HMOs in the United States.

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32. Professional courtesy means

Explanation

Professional courtesy means making no charge to anyone, patient or insurance company, for medical care. This term refers to a situation where a healthcare provider offers their services without expecting any payment in return. It is often extended to other healthcare professionals or their family members as a professional courtesy. This practice is based on the idea of mutual respect and support within the healthcare community. By providing medical care without charge, professionals demonstrate their commitment to the well-being of their colleagues and the overall healthcare system.

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33. Accounts receivable are usually aged in time periods of

Explanation

Accounts receivable are usually aged in time periods of 30, 60, 90, and 120 days. This means that the company categorizes its outstanding invoices based on how long they have been outstanding. By aging the accounts receivable, the company can track the aging of its receivables and identify any potential issues with collecting payment from customers. The aging process helps the company prioritize its collection efforts and take appropriate actions to ensure timely payment.

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34. When insurance carriers do not pay claims in a timely manner, what effect does this have on the medical practice

Explanation

When insurance carriers do not pay claims in a timely manner, it has a negative effect on the medical practice's cash flow. This means that the practice will have less money coming in, which can lead to financial difficulties. It may result in delays in paying suppliers and employees, difficulty in purchasing necessary equipment or supplies, and overall financial instability. This can also impact the ability of the practice to provide quality care to patients and meet their needs effectively.

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35. What is the name of the federal act that prohibits discrimination in all areas of granting credit

Explanation

The correct answer is the Equal Credit Opportunity Act. This federal act prohibits discrimination in all areas of granting credit, ensuring that all individuals have equal access to credit regardless of their race, color, religion, national origin, sex, marital status, age, or receipt of public assistance. This act promotes fairness and equal opportunities in the credit industry.

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36. In a bankruptcy case, most medical bills are considered

Explanation

In a bankruptcy case, most medical bills are considered nonsecured debt. This means that they are not backed by any collateral or assets and are therefore not prioritized for repayment. Nonsecured debt is typically discharged or eliminated in bankruptcy, allowing individuals to alleviate the burden of medical bills and start fresh financially.

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37. When an HMO is paid a fixed amount for each patient served without considering the actual number or nature of services provided to each person, this is known as

Explanation

Capitation refers to a payment model in which an HMO (Health Maintenance Organization) receives a fixed amount of money for each patient they serve, regardless of the actual number or type of services provided to each individual. This means that the HMO assumes the financial risk for the healthcare costs of their patients, as they are responsible for providing all necessary services within the fixed payment received. Capitation is a common payment method used in managed care systems to incentivize healthcare providers to deliver cost-effective care and manage the health of their patient population efficiently.

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38. TRICARE appeals are normally resolved within

Explanation

TRICARE appeals are typically resolved within 60 days. This means that once an appeal is filed, it generally takes up to 60 days for a decision to be made and communicated to the individual. This timeframe allows for a thorough review of the appeal and ensures that a fair and accurate decision is reached. It also provides the necessary time for any additional information or documentation to be gathered and considered before reaching a resolution.

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39. Cash flow is

Explanation

Cash flow refers to the ongoing availability of cash in the medical practice. It represents the movement of money into and out of the practice, including revenue from patients, insurance payments, and other sources, as well as expenses such as salaries, rent, and supplies. It is important for the practice to have a positive cash flow to ensure smooth operations, pay bills on time, and have funds available for investments or emergencies. Monitoring and managing cash flow is crucial for financial stability and success in the medical practice.

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40. A plan in which employees can choose their own working hours from within a broad range of hours approved by management is called

Explanation

Flex time refers to a work arrangement where employees have the flexibility to choose their own working hours within a range of hours approved by management. This allows employees to have a better work-life balance and accommodate personal commitments. It also promotes productivity and employee satisfaction as they can work during their most productive hours. This arrangement is beneficial for both employees and employers as it fosters a more flexible and accommodating work environment.

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41. An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an

Explanation

A preferred provider organization (PPO) is an organization that allows members to have the freedom to choose among physicians and hospitals for their healthcare needs. However, if the members use providers listed on the plan, they will receive a higher level of benefits. This means that members have the flexibility to go out of network and see healthcare providers of their choice, but they can also choose to stay in network and receive additional benefits. This model promotes choice and flexibility for members while still providing incentives for using network providers.

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42. Part B of Medicare covers

Explanation

Part B of Medicare covers diagnostic tests. This means that Medicare Part B provides coverage for various medical tests that help diagnose or monitor a patient's condition. These tests can include laboratory tests, X-rays, MRIs, CT scans, and other diagnostic procedures. By covering these tests, Medicare Part B ensures that beneficiaries have access to necessary diagnostic services to help identify and treat their medical conditions.

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43. Medigap insurance may cover

Explanation

Medigap insurance is a supplementary insurance policy that helps cover the gaps in Medicare coverage. It is designed to pay for expenses that are not covered by Medicare, such as deductibles, copayments, and coinsurance. Therefore, the correct answer, "the deductible not covered under Medicare," aligns with the purpose of Medigap insurance to provide coverage for expenses that Medicare does not cover.

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44. An insurance claim with an invalid prodecure code would be

Explanation

If an insurance claim has an invalid procedure code, it would be rejected. This means that the claim will not be accepted or approved for payment by the insurance company. The invalid procedure code indicates that the medical service or treatment being claimed is not covered or recognized by the insurance policy. As a result, the claim is denied and the policyholder will not receive any reimbursement or coverage for that particular procedure.

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45. A request for a Medicare administrative law judge hearing can be made if the amount in controversy is at least

Explanation

A request for a Medicare administrative law judge hearing can be made if the amount in controversy is at least $100. This means that if the disputed amount between the Medicare beneficiary and the Medicare program is equal to or greater than $100, the beneficiary has the right to request a hearing before an administrative law judge. This allows the beneficiary to present their case and have a fair review of the decision made by the Medicare program.

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46. In making collection telephone calls to a group of accounts, how should the accounts be organized to determine where to begin

Explanation

The best approach to determine where to begin making collection telephone calls to a group of accounts is to organize the accounts according to amounts owed and start with the largest amount. This ensures that the accounts with the highest outstanding balances are prioritized, as they are likely to have a higher urgency for collection. This method maximizes the potential for successful collections and helps to efficiently allocate resources.

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47. How does an HMO receive payment for the services its physicians provide

Explanation

An HMO receives payment for the services its physicians provide through a prepaid health plan. This means that members of the HMO pay a fixed amount upfront, either monthly or annually, to access a range of healthcare services. The HMO then uses this prepaid amount to cover the cost of the services provided by its physicians. This payment model allows for a predetermined budget and encourages preventive care and cost-effective treatments within the HMO network.

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48. The letter "D" following the identification number on the patient's Medicare card indicates a

Explanation

The letter "D" following the identification number on the patient's Medicare card indicates that the patient is a widow. This suggests that the individual is receiving Medicare benefits as a result of their deceased spouse's work history. The "D" designation helps to identify the specific eligibility category for the patient and ensures that they are receiving the appropriate coverage and benefits.

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49. Referral of a patient recommened by one specialist to another specialist is known as

Explanation

Referral of a patient recommended by one specialist to another specialist is known as tertiary care. Tertiary care is the highest level of healthcare that involves specialized and advanced medical procedures and treatments. It is typically provided in specialized hospitals or medical centers by healthcare professionals who have expertise in a specific field. This level of care is usually sought when a patient's condition requires a higher level of expertise or specialized interventions that cannot be provided by primary or secondary care providers.

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50. Part A of Medicare covers

Explanation

Part A of Medicare covers hospice care, which is a type of care provided to terminally ill patients who have a life expectancy of six months or less. Hospice care focuses on providing comfort and support rather than curative treatment. It includes medical services, pain management, counseling, and assistance with daily activities. This type of care is typically provided in the patient's home, but it can also be offered in a hospice facility or hospital. Hospice care aims to improve the quality of life for patients and their families during the end-of-life stage.

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51. When collecting fees, your goal should always be to

Explanation

When collecting fees, the goal should always be to collect the full amount. This ensures that the business or organization receives the full payment for their services or products. Collecting only half the fee may result in financial loss, and collecting as much as possible may be seen as unethical or unfair. Leaving the impression of being a nice person is important, but it should not compromise the collection of the full amount owed.

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52. Messages included on statements to promote payment are called

Explanation

Dun messages are included on statements to promote payment. These messages are typically used to remind customers about their outstanding balance and urge them to make a payment. They can be seen as a form of gentle persuasion or a reminder to encourage prompt payment.

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53. A follow-up effort made to an insurance company to locate the status of an insurance claim is called a/an

Explanation

Both an inquiry and a tracer are follow-up efforts made to an insurance company to locate the status of an insurance claim. An inquiry is a request for information or clarification about the claim, while a tracer is a more formal and detailed investigation into the claim's status. Both methods aim to gather information and ensure the claim is being processed correctly.

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54. What should you do if an insurance carrier requests information about another insurance carrier?

Explanation

If an insurance carrier requests information about another insurance carrier, the correct action to take is to provide the information. This means that you should gather the necessary details and share them with the requesting insurance carrier. This could include policy numbers, coverage details, and any other relevant information that may assist in coordinating benefits or resolving any issues between the two carriers. By providing the information, you are facilitating effective communication and cooperation between the insurance carriers.

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55. The first level of appeal in the Medicare program is

Explanation

The first level of appeal in the Medicare program is redetermination. This means that if a Medicare claim is denied, the beneficiary or their healthcare provider can request a redetermination, which is a review of the claim by a different Medicare claims examiner. During the redetermination process, additional information or evidence can be submitted to support the claim. This level of appeal allows for a reconsideration of the initial decision and provides an opportunity to address any errors or misunderstandings that may have occurred.

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56. When a physician sees a patient more than is medically necessary, it is called

Explanation

Churning refers to the practice of a physician seeing a patient more than is medically necessary. This can occur when a physician schedules unnecessary appointments or repeats tests or procedures that are not needed. It is considered an unethical practice as it can lead to increased healthcare costs and potential harm to the patient.

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57. The part B Medicare annual deductible is

Explanation

The correct answer is $135. This is the annual deductible amount for Part B Medicare. The deductible is the amount that the beneficiary must pay out of pocket before their Medicare coverage begins to pay for services. This deductible applies to outpatient services and medical equipment. Once the deductible is met, Medicare will cover 80% of the approved amount for services, and the beneficiary is responsible for the remaining 20%.

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58.  Accounts that are 90 days or older should not exceed

Explanation

Accounts that are 90 days or older should not exceed 15% to 18% of the total accounts receivable. This means that a company should aim to keep the amount of overdue accounts within this range to maintain a healthy cash flow and minimize the risk of bad debts. If the percentage exceeds 18%, it may indicate a problem with the company's credit policies or collection procedures, and if it falls below 15%, it may suggest that the company is too strict in its credit policies, potentially losing out on sales opportunities.

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59. The reason for a fee reduction must be documented in the patient's

Explanation

The reason for a fee reduction must be documented in the patient's financial accounting record because this record is specifically used to track and document all financial transactions related to the patient's healthcare services. It includes details about fees charged, payments made, and any adjustments or discounts applied. By documenting the reason for a fee reduction in the financial accounting record, healthcare providers can ensure transparency and accuracy in their financial records, as well as provide a clear audit trail for any future reference or verification.

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60. How many installments (excluding a down payment) must a payment plan have to require full written disclosure

Explanation

A payment plan must have four or more installments (excluding a down payment) in order to require full written disclosure. This means that if a payment plan has three or fewer installments, it does not need to provide full written disclosure. However, if the payment plan has four or more installments, it is required to provide full written disclosure to ensure transparency and protect the consumer.

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61. In an independent practice association (IPA), physicians are

Explanation

In an independent practice association (IPA), physicians are not employees and are not paid salaries. This means that physicians who are part of an IPA are not considered as employees of any particular organization or association. Instead, they operate independently and are compensated based on their own practice and the services they provide. This arrangement allows physicians to have more control over their own practice and financial arrangements, rather than being tied to a specific employer or receiving a fixed salary.

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62. What is the type of billing system in which practice management software is used

Explanation

The correct answer is computer billing. This type of billing system involves the use of practice management software to automate and streamline the billing process. It allows healthcare providers to generate and submit electronic claims, track payments, and manage patient billing information efficiently. This eliminates the need for manual billing methods and increases accuracy and efficiency in the billing process.

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63. The frequency of Pap tests that may be billed for a Medicare patient who is low risk is

Explanation

The correct answer is once every 24 months. This means that Medicare patients who are low risk should have a Pap test done once every 24 months. This frequency is determined based on the patient's risk level and is a guideline for healthcare providers to follow when billing for Pap tests for Medicare patients.

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64. The average amount of accounts receivable should be

Explanation

The correct answer is 1.5 to 2 times the charges for 1 month of services. This means that the average amount of accounts receivable should be between 1.5 and 2 times the charges for 1 month of services. This range allows for a reasonable amount of outstanding payments while still maintaining a healthy cash flow for the business. Having a higher average amount of accounts receivable could indicate that the business is struggling to collect payments, while having a lower average could suggest that the business is not maximizing its revenue potential.

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65. When the physician's office receives notice that a check was not honored, the first thing to do is to

Explanation

When the physician's office receives notice that a check was not honored, the first thing to do is to call the bank or the patient. This is necessary to clarify the situation and determine the reason for the dishonored check. By contacting the bank or the patient, the physician's office can gather information about any potential issues with the check, such as insufficient funds or an error in processing. This step allows the office to address the problem promptly and find a resolution, whether it involves requesting a new payment method or resolving any banking issues.

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66. An insurance claims register provides a/an

Explanation

An insurance claims register provides follow-up procedures for insurance claims. This means that it includes a systematic process or set of steps that are followed after an insurance claim has been submitted. These procedures may include tasks such as verifying the claim, investigating the details, communicating with the insured party, processing the claim, and making the necessary payments or settlements. The register helps to ensure that all claims are properly handled and followed up on, allowing for efficient and effective claims management within the insurance company.

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67. What should be done if an insurance claim denial is received because a billed service was not a program benefit?

Explanation

If an insurance claim denial is received because a billed service was not a program benefit, the appropriate action would be to send the patient a statement with a notation of the response from the insurance company. This is necessary to inform the patient about the denial and provide them with an explanation from the insurance company. It also allows them to understand the reason for the denial and take necessary actions, such as appealing the decision or seeking alternative payment options.

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68. The most common method of payment in the medical office is

Explanation

The most common method of payment in the medical office is a personal check. This is because personal checks are widely accepted and provide a convenient way for patients to pay for their medical expenses. Additionally, personal checks offer a paper trail and can be easily tracked for record-keeping purposes. They also eliminate the need for patients to carry large amounts of cash or rely solely on electronic payment methods such as credit or debit cards.

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69. Kaiser Permanente's medical plan is a closed panel program, which means

Explanation

Kaiser Permanente's medical plan is a closed panel program, which means it limits the patient's choice of personal physicians. In a closed panel program, patients are typically required to choose a primary care physician from a network of providers approved by the insurance plan. This primary care physician then coordinates the patient's care and referrals to specialists within the network. Patients may have limited or no coverage for services received outside of this network, which restricts their ability to choose their own personal physicians.

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70. A program that offers a combination of HMO-style cost management and PPO-style freedom of choice is a/an

Explanation

A point of service (POS) plan is a program that combines the cost management features of a Health Maintenance Organization (HMO) with the freedom to choose out-of-network providers, similar to a Preferred Provider Organization (PPO). In a POS plan, members have the flexibility to see any healthcare provider they choose, but they will receive higher coverage and lower out-of-pocket costs if they stay within the network. This option allows individuals to have more control over their healthcare decisions while still benefiting from cost-saving measures.

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71. The letters preceding the number on the patient's Medicare identification care indicate

Explanation

The letters preceding the number on the patient's Medicare identification card indicate railroad retiree.

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72. When a Medicare beneficiary has employer supplemental coverage that is determined as the primary payer, Medicare is referred to as

Explanation

When a Medicare beneficiary has employer supplemental coverage that is determined as the primary payer, Medicare is referred to as MSP, which stands for Medicare Secondary Payer. This means that Medicare will only cover the costs that are not covered by the employer's supplemental insurance.

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73. Which group of accounts would a collector target when he or she begins making telephone calls

Explanation

A collector would target 60-90 day accounts when making telephone calls because these accounts are relatively recent and have a higher likelihood of being collectible. Accounts that are too new (30-60 days) may still be within the grace period, while accounts older than 90 days may have already been handed over to a collections agency or deemed uncollectible. Therefore, focusing on 60-90 day accounts allows the collector to prioritize their efforts on accounts that are more likely to yield successful collections.

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74. What should be done if an insurance company denies a service stating it was not medically necessary and the physician believes it was?

Explanation

If an insurance company denies a service stating it was not medically necessary and the physician believes it was, the appropriate action would be to appeal the decision with a statement from the physician. This is because the physician can provide additional information and evidence to support their belief that the service was indeed medically necessary. By appealing the decision, there is a chance that the insurance company may reconsider and approve the claim.

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75. What plan allows memebers of Kaiser Permanente Medical Care Program to seek medical help from non-Kaiser physicians

Explanation

The point of service (POS) plan allows members of the Kaiser Permanente Medical Care Program to seek medical help from non-Kaiser physicians. This means that individuals have the flexibility to choose healthcare providers outside of the Kaiser network and still receive coverage for their medical expenses. The POS plan typically requires members to select a primary care physician within the network who will coordinate their care and provide referrals to specialists when needed. This option is beneficial for those who prefer to have a wider range of healthcare options and want the freedom to see providers outside of the Kaiser network.

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76. "Netback" is a term used to describe

Explanation

The term "netback" refers to a collection agency's performance. It is a measure of the agency's effectiveness in collecting money owed by delinquent accounts. A high netback indicates that the agency has successfully recovered a significant portion of the outstanding debts, while a low netback suggests that the agency has not been successful in collecting the money owed. This term is commonly used in the financial industry to assess the performance and efficiency of collection agencies.

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77. Practitioners in an HMO program may come under peer review by a professional group called

Explanation

In an HMO program, practitioners may be subject to peer review by a professional group known as a quality improvement organization. This organization is responsible for evaluating the quality and effectiveness of healthcare services provided by practitioners within the HMO program. They aim to identify areas for improvement and ensure that patients receive high-quality care. The peer review process allows for feedback and assessment from fellow professionals in order to maintain and enhance the overall quality of healthcare services within the HMO program.

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78. Medicare Part A benefit period ends when a patient

Explanation

The correct answer is "has not been a bed patient in any hospital or nursing facility for 60 consecutive days." This means that the Medicare Part A benefit period will end if the patient has not been admitted as an inpatient in a hospital or nursing facility for a continuous period of 60 days. This indicates that the patient's need for acute care or skilled nursing services has ended, and therefore, their Medicare Part A coverage for these services will also end.

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79. America's oldest privately owned, prepaid medical group is the

Explanation

The correct answer is the Ross-Loos Medical Group. This group is known for being the oldest privately owned, prepaid medical group in America. It has a long history of providing medical care and services to its members.

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80. What is the name of an organization of a physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care

Explanation

A foundation for medical care is an organization of physicians sponsored by a state or local medical association. It focuses on the development and delivery of medical services, as well as the cost of healthcare.

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81. A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is a/an

Explanation

A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is referred to as a PPG (Physician Practice Group). PPGs are medical practices that are owned and operated by physicians, giving them the ability to negotiate contracts with various insurance companies and also provide their own healthcare plans. This allows them to have more control and flexibility in managing patient care and insurance arrangements.

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82. How are physicians paid who work for a prepaid group practice model

Explanation

Physicians who work for a prepaid group practice model are paid a salary by an independent group. In this model, the physicians are employed by a group or organization that is separate from any health plan. The independent group pays the physicians a fixed salary, regardless of the number of patients they see or the services they provide. This payment structure ensures that physicians are compensated consistently and removes the financial incentive to provide unnecessary or excessive medical services.

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