HIM 2330 Healthcare Reimbursement Review Questions and Correct Answers
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Course
Healthcare Reimbursement
Institution
Healthcare Reimbursement
Why do health insurers pool premium payments for all the insureds in a group and use actuarial data to calculate the group's premiums? To assure that the pool is large enough to pay losses of the entire group
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for...
HIM 2330 Healthcare Reimbursement
Review Questions and Correct Answers
Why do health insurers pool premium payments for all the insureds in a group and use
actuarial data to calculate the group's premiums? ✅To assure that the pool is large
enough to pay losses of the entire group
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for
spinal fusion was cancelled after the patient was diagnosed with mononucleosis. On
today's visit the patient is started on prednisone for severe sore throat and difficulty
swallowing. The patient was accompanied by his parents who have healthcare
insurance through the mother's employment at the State Department of Treasury.
Who is the first party in this healthcare reimbursement scenario? ✅The parents
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for
spinal fusion was cancelled after the patient was diagnosed with mononucleosis. On
today's visit the patient is started on prednisone for severe sore throat and difficulty
swallowing. The patient was accompanied by his parents who have healthcare
insurance through the mother's employment at the State Department of Treasury.
Who is the second party in this healthcare reimbursement scenario? ✅Dr. Gilbert
Dr. Gilbert sees a 14-old-male with adolescent idiopathic thoracic scoliosis. Surgery for
spinal fusion was cancelled after the patient was diagnosed with mononucleosis. On
today's visit the patient is started on prednisone for severe sore throat and difficulty
swallowing. The patient was accompanied by his parents who have healthcare
insurance through the mother's employment at the State Department of Treasury.
Who is the third party in this healthcare reimbursement scenario? ✅Insurance
company
The goal of revenue integrity is to produce a claim that is __________. ✅Clean,
complete, and compliant
Which of the following is not a component of the revenue cycle? ✅Revenue calculation
Which of the following is a key factor in establishing highly ethical culture promotes
honesty and openness? ✅Transparency
Patient 89423 is seen in the outpatient clinic at Happy Hospital for a pneumonia follow-
up visit. The charges for the encounter total $135.00. Which payer will reimburse the
hospital the lowest amount? ✅Payer D
, 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
What is the term for the set fee that a policyholder or certificate holder must periodically
pay a health insurance plan in return for healthcare coverage? ✅Premium
A worker had group health insurance coverage through her employer. The worker's
household included her spouse, two natural children (ages 28 and 12), an adopted child
(age 8), and the worker's mother (age 58). Who may be included under dependent
coverage in the health insurance policy? ✅Spouse; natural child, age 12; and adopted
child, age 8
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 events
All of the following occurrences are considered "qualifying life events" except: ✅Car
accident
All of the following types of procedures and services typically require prior authorization
except: ✅Emergency services for suspected stroke
Which of the following characteristics is the greatest advantage of group health
insurance? ✅Greater benefits for lower premiums
Which of the following types of care represent healthcare services not delivered by
MCOs? ✅Experimental devices
Juan belongs to a managed care plan. He wants to make an appointment with an out-
of-network specialist. The plan has approved the appointment as "out-of-network." What
should Juan expect? ✅The patient's out-of-pocket costs will be increased
In regards to healthcare insurance, the percentage that the guarantor pays is called the:
✅Coinsurance
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
Which of the following services has the highest likelihood of being a "covered service"?
✅Medically necessary
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