Exam (elaborations)
MEDICAL BILLING AND CODING QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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MEDICAL BILLING AND CODING QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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MEDICAL BILLING AND CODINGQUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
Medical Insurance - ANSWER Financial plan (the payer) that covers the cost of hospital and medical care
Policyholder - ANSWER Person who buys an insurance plan; the insured, subscriber, or guarantor
Health Plan - ANSWER Individual or group plan that provides or pays for the cost of medical care
Benefits - ANSWER What a health plan pays for services covered in an insurance policy; listed in the
schedule of benefits.
Medical Necessity - ANSWER Reasonable services of provider (doctor or facility) consistent with
professional medical standards.
Covered Services - ANSWER Determined as being medically necessary and both reasonable and
consistent with the standards for the diagnosis or treatment of injury or illness.
Non-covered Services - ANSWER Medical procedures not covered in a plans benefits.
Individual Health Plan (I H P) - ANSWER contract between individual and the plan
known as direct pay.
Group Health Plan (G H P) - ANSWER contract between an employer or organization and the plan,
the group members are insured as "subscribers".
Disability Insurance - ANSWER Replaces income lost because the insured cannot work
Workers' Compensation Insurance - ANSWER Provides benefits for an insured injured on the job
,Indemnity Insurance - ANSWER Payment method is fee-for-service based on the contract's schedule of
benefits,fee is paid AFTER the patient receives services from the physician.
Managed care - ANSWER A system that combines the financing and the delivery of appropriate, cost-
effective health care services to its members.
Premium - ANSWER Periodic payment the patient is required to make to keep the policy in effect.
Deductible - ANSWER Amount that the insured pays on covered services before benefits begin.
Coinsurance - ANSWER Percentage of each claim that the insured pays; states the health plan's
percentage of the charge, followed by the insured's percentage.
Health Maintenance Organizations (HMOs) - ANSWER A manged health care system in which providers
agree to offer healthcare to the organization's members for fixed periodic payments from the plan.
capitation Method - ANSWER a fixed prepayment made to the medical provider for all necessary
contracted services provided to each patient who is a plan member no matter how much medical care is
received during the determined time period.
Per member per month, (PMPM) - ANSWER (per member per month): The "capitated rate" Capitation
this amount is paid to the health care provider based on the schedule of benefits, no matter how much
medical care is received during the determined time period.
Point of Service Plan (PPO) - ANSWER Combines features of both HMOs and PPOs Also called an "open
access HMO "Allows members to see providers in or out of HMO's network Members pay more for out-
of-network providers.
Preferred Provider Organizations (PPO) - ANSWER A managed care organization structured as a network
of health care providers who agree to perform services for plan members at discounted fees; usually,
plan members can receive services from non-network providers for a higher charge. PPOs control the
cost of health care by:
Directing patients' choices of providers
, Controlling use of services
Requiring preauthorization for services
Requiring Cost-sharing
Consumer-Driven Health
Plans (CDHP) - ANSWER Combine two elements:
A health plan, usually a PPO, that has a high deductible (such as $1,000) and low premiums
A special "savings account" that is used to pay medical bills before the deductible has been met
Cost containment plan based on consumerism:
Idea that patients who pay for health care services become more careful consumers.
Private Payers - ANSWER Have contracts with businesses to provide benefits for their employees...better
rates
self-funded health plans - ANSWER The organization "insures itself"
a company creates its own insurance plan for its employees, rather than using a carrier; the plan
assumes payment risk, contracts with physicians, and pays for claims from its funds.
Medicare - ANSWER Coverage for those age 65 and older, people with certain disabilities, and people
with permanent kidney failure.
Medicaid - ANSWER Coverage for low-income people who cannot afford medical care
TRICARE - ANSWER (was CHAMPUS): Coverage for active-duty military personnel, their spouses, children,
and other dependents; also retired military personnel and their dependents, as well as family members
of deceased active-duty personnel
CHAMPVA - ANSWER Coverage for veterans with permanent service-related disabilities and their
dependents.
Payer Adjudication - ANSWER Payers review claims by following the adjudication process
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