Deck 8: Private Payers/BlueCross BlueShield

Question 1

What entity generally hires a utilization review organization (URO) to evaluate the medical necessity of planned procedures?

A) payer
B) physician
C) provider
D) patient

Answer 1

payer

Question 2

A member in an indemnity BCBS plan has a deductible of $700, with a coinsurance rate of 90-10 after the deductible has been met, up to an annual maximum out-of-pocket amount of $2,000. Calculate the total amount the patient owes if his/her charges for the year total $2,400.

A) $870
B) $2,400
C) $700
D) $2,000

Answer 2

$870

Question 3

What type of private payer offers lower costs, but also has the most stringent guidelines and the narrowest choice of providers?

A) health maintenance organizations (HMOs)
B) indemnity plans
C) point-of-service (POS) plans
D) preferred provider organizations (PPOs)

Answer 3

health maintenance organizations (HMOs)

Question 4

How often do open enrollment periods usually occur?

A) twice per year
B) once per month
C) every other year
D) once per year

Question 5

A repricer is a company that

A) works for hospitals and sets up their networks.
B) works for the GHP and sets medical necessity guidelines.
C) works for a health plan and sets the discounts for out-of-network visits.
D) works for the federal government to monitor fraud and abuse.

Question 6

Which of the following could represent a member in a closed-panel HMO?

A) closed panel HMOs do not exist
B) a member can see any provider in or out-of-network
C) a physician of a group with a contract with the HMO
D) a non-member physician who meets the HMO's standards of care

Question 7

Name the electronic format used to obtain approval for preauthorizations and referrals.

A) HIPAA 837
B) HIPAA 278
C) HIPAA 271
D) HIPAA 270

Question 8

What type of managed care program does BCBS offer?

A) PPO and POS
B) POS and HMO
C) HMO, POS, and PPO
D) HMO and PPO

Question 9

Which section of a managed care participation contract includes information about a claim turnaround time?

A) compensation and billing guidelines section
B) introductory section
C) physician's responsibilities section
D) managed care plan obligations section

Question 10

What billing information is summarized by the plan summary grid?

A) list of patient names, addresses, and copayments
B) referral and preauthorization requirements
C) patient financial responsibility, billing information, and referral requirements
D) billing information and financial responsibilities

Question 11

How can TPAs help self-funded health plans?

A) by handling the process and paying of claims and keeping list of members only
B) by keeping lists of members up-to-date only
C) by handling collection of premiums, processing claims, and keeping list of members
D) by handling the collection of premiums and paying claims only

Question 12

What term refers to the payer's process for determining medical necessity?

A) utilization review
B) audit
C) acceptance
D) stop-loss provision

Question 13

What is the electronic format used to verify benefits?

A) HIPAA 278
B) HIPAA 270/271
C) HIPAA 837
D) HIPAA 276/277

Question 14

Identify the additional component that should be included in a contract when a payer's fee schedule is based on the MPFS.

A) the services from the MPFS that are going to be accepted
B) which year's MPFS is going to be used
C) the prepayment of the MPFS
D) the rate at which MPFS is going to be used

Question 15

Which section of a managed care participation contract covers protection against loss?

A) managed care plan obligations section
B) physician's responsibilities section
C) compensation and billing guidelines section
D) introductory section

Question 16

Which is the most appropriate method in handling the termination of patients a medical practice within an HMO?

A) The payer decides to terminate the relationship, sends a certified letter to the patient and the PCP, then receives the signed letters back from both patient and PCP.
B) The PCP sends a certified letter to the patient and the patient sends the signed letter back.
C) The PCP asks the payer for permission, then sends a certified letter to the patient, and receives the signed letter back from the patient.
D) The payer sends a certified letter to the patient and receives the signed letter back from the patient.

Question 17

The health insurance program for federal government employees is

A) HCFA.
B) FEHB.
C) BEDOR.
D) ERISA.

Question 18

Which type of consumer-driven health plan funding option is set up and funded by employers?

A) a flexible savings account (FSA)
B) a health savings account (HSA)
C) a health reimbursement account (HRA)
D) a medical home model

Question 19

What type of plan is structured to permit the funding of premiums with pretax payroll deductions?

A) Section 125 cafeteria plan
B) formulary plan
C) tiered network
D) creditable coverage

Question 20

Identify the type of managed care structure that is usually the first component of a consumer-driven health plan.

A) fee-for-service
B) preferred provider organization (PPO)
C) health maintenance organization (HMO)
D) episode-of-care

Question 21

Identify what may be used to modify the terms of an insurance contract.

A) section guideline
B) rider
C) stop-loss provision
D) provider withhold

Question 22

Which section of a managed care participation contract covers balance-billing rules?

A) physician's responsibilities section
B) compensation and billing guidelines section
C) introductory section
D) managed care plan obligations section

Question 23

Which of the following steps comes second in the standard revenue cycle

A) Check billing compliance.
B) Establish financial responsibility for a visit.
C) Preregister patients.
D) Prepare and transmit claims.

Question 24

Which of the following describes a consultation?

A) a patient independently seeks the opinion of another physician
B) a patient must be admitted to a hospital for medical review
C) a physician examines the patient at the request of another physician and provides report to requesting physician
D) care for a patient is transferred to another physician

Question 25

Which of the following is one of the nation's largest health insurers?

A) Anthem
B) Kaiser Permanente
C) UnitedHealth Group
D) Aetna

Question 26

Careful attention must be paid to __________ when the practice has a capitated contract.

A) encounter reports and referral requirements
B) all of these
C) referral requirements and billing procedures
D) patient eligibility and claim write offs

Question 27

Identify the type of deductible that can be met by combining payments.

A) maximum deductible
B) individual deductible
C) late deductible
D) family deductible

Question 28

A plan pays 75 percent of the provider's usual charge and requires the copayment of $15 to be applied toward the provider's payment. Calculate what the plan pays the provider when the usual charge is $380?

A) $255
B) $270
C) $380
D) $15

Question 29

Name the structure that emphasizes communication among the patient's physicians.

A) episode-of-care option
B) medical home model
C) open-panel HMO
D) independent practice association

Question 30

Which term describes the periodic verification that a provider or facility meets professional standards?

A) credentialing
B) P4P
C) regulating
D) certifying

Question 31

Providers bill patients for services not covered by the cap rate under a(n)

A) encounter report.
B) capitated contract.
C) referral.
D) plan summary grid.

Question 32

Which of these is the best method for determining if a patient is eligible for services?

A) Check the monthly enrollment list.
B) Verify the patient's insurance coverage.
C) Check the patient roster.
D) Check the provider patient listing.

Question 33

Identify an insurance service that private payers supply.

A) decreasing enrollment
B) processing claims
C) eliminating paperwork
D) increasing fees

Question 34

Identify the local BCBS plan in the provider's service area, where a claim is submitted after providing treatment.

A) house plan
B) host plan
C) home plan
D) hold plan

Question 35

Which term refers to an individual who enrolls in a health plan after the original enrollment date?

A) late enrollee
B) group enrollee
C) COBRA enrollee
D) waiting period

Question 36

Identify a reason why the best situation for medical practices is an integrated CDHP in which the same plan runs both the HDHP and the funding options.

A) reduced paperwork
B) slower payments
C) the HSA has to be billed separately
D) less patients

Question 37

What information is included in a formulary?

A) how drug dosages are calculated and pricing
B) the improper dosages for the plan's drugs
C) the list of a plan's selected drugs and proper dosages
D) pricing on drugs

Question 38

It is common for physicians to participate in more than __________ health plans.

A) twenty
B) fifteen
C) ten
D) five

Question 39

Which of the following types of provider performance would be reimbursed at the highest level in a tiered network?

A) Practice provides quality health care at a high cost.
B) Practice provides average health care at a low cost.
C) Practice provides average health care at a high cost.
D) Practice provides quality health care at a low cost.

Question 40

What should be prepared or updated for each participation contract?

A) repricer
B) stop-loss provision
C) plan summary grid
D) formulary

Question 41

Explain the benefit that COBRA offers to employees who are leaving a job.

A) the right to skip the waiting period
B) the right to freedom from a maximum benefit limit
C) the right to parity in selecting their next health plan
D) the right to continue health coverage under the employer's plan for a limited time at their own expense

Question 42

Which of the following is a method a practice can use to avoid major problems with payers?

A) Routinely meet with payers to question the fee schedule.
B) Contact the employers to file complaint.
C) Use good communication skills in working with payers.
D) Use the patients as an intermediary in helping to communicate.

Question 43

Which of these is the primary factor that providers examine to decide whether to participate in managed care plans?

A) the type of patients served
B) the duties of the PCP
C) the medical necessity guidelines
D) the financial arrangements

Question 44

Which of the following examples demonstrates subcapitation?

A) an ancillary provider prepays a capitated provider
B) the patient prepays a capitated provider
C) the HMO pays a capitated provider
D) a capitated provider prepays an ancillary provider

Question 45

A physician practice lists a service at $130, but in the participating contract it has with a payer, the service is listed at $95. Calculate the amount that the practice will need to write off if balance billing is not permitted.

A) $95
B) $35
C) $130
D) $225

Question 46

Identify the document self-funded plan members receive that states their benefits and legal rights.

A) SPD
B) IHP
C) TPA
D) ERISA

Question 47

BlueCross and BlueShield companies also offer a consumer-driven health plan called

A) BlueFlex.
B) Flexible Blue.
C) BlueCDHP.
D) FlexiBlue.

Question 48

Identify the type of deductible which must be met for each separate enrollee.

A) family deductible
B) individual deductible
C) late deductible
D) maximum deductible

Question 49

Which type of consumer-driven health plan funding option can be funded by both employers and employees?

A) a flexible savings account (FSA)
B) a health reimbursement account (HRA)
C) a health savings account (HSA)
D) a medical home model

Question 50

What type of plan requires premium, deductible, and coinsurance payments and typically covers 70 to 80 percent of costs for covered benefits after deductibles are met?

A) preferred provider organizations (PPOs)
B) indemnity plans
C) health maintenance organizations (HMOs)
D) point-of-service (POS) plans

Question 51

Whether a practice can routinely waiving copayments should be covered in its ______.

A) Office encounter form
B) Patient information form
C) Financial policy
D) Secondary payer agreement

Question 52

Which of the following steps comes first in the standard revenue cycle?

A) Check billing compliance.
B) Prepare and transmit claims.
C) Establish financial responsibility for a visit.
D) Preregister patients.

Question 53

Which of the following type of plan do employers or employee organizations offer to their employees?

A) URO
B) individual health plan
C) group health plan
D) FEHB plan

Question 54

A government-regulated marketplace offering insurance plans to individuals is known as

A) IHP.
B) host plan.
C) EHB.
D) HIX.

Question 55

Which section of a managed care participation contract covers referrals and preauthorization rules?

A) compensation and billing guidelines section
B) physician's responsibilities section
C) introductory section
D) managed care plan obligations section

Question 56

In submitting paper claims, the best practice is to

A) check with HIPAA for specific instructions regarding a payer.
B) check with the employer on payer requirements.
C) check the NUCC instructions.
D) check with each payer for specific information required on the form as well as the NUCC notes.

Question 57

The type of payment structure that PPOs usually offer in their contracts with providers is called

A) episode-of-care.
B) fee-for-service.
C) discounted fee-for-service.
D) capitated.

Question 58

Self-funded health plans pay premiums to

A) insurance carriers.
B) no one because they assume the risk.
C) third-party administrators.
D) managed care organizations.

Question 59

Identify the type of contract under which an insurance carrier works as a third-party claim administrator for a self-funded health plan.

A) episode-of-care contract
B) summary plan description contract
C) administrative services only contract
D) BCBS contract

Question 60

What type of surgery is a procedure that can be scheduled ahead of time, but which may or may not be medically necessary?

A) elective surgery
B) experimental surgery
C) voluntary surgery
D) emergency surgery

Question 61

A member of a consumer-driven health care (CDHP) plan has a health savings account (HSA) fund of $500 and a deductible of $1,000 (which has not yet been met), and the HDHP has an 80-20 coinsurance. Calculate the total amount this patient would owe if the bill for their services is $1,800.

A) $660
B) $360
C) $1,800
D) $1,500

Question 62

Name the term used to describe participating providers in BCBS plans.

A) qualifying physicians
B) member physicians
C) registered physicians
D) active physicians

Question 63

Determine what law a practice would follow if a state law is more restrictive than the related federal law.

A) the federal law is followed
B) the state law is followed
C) none of these are correct; this scenario does not occur
D) the practice can decide which law it wants to follow

Question 64

Who may be covered under a GHP?

A) employees, families, and former employees
B) employees' families only
C) former employees only
D) employees and their families

Question 65

What type of contract binds a third-party administrator to provide administrative services to an employer for a fixed fee per employee?

A) IHP
B) TPA
C) ASO
D) SPD

Question 66

Eligible members of a capitated plan are listed on the

A) plan summary grid.
B) patient medical record.
C) monthly enrollment list.
D) annual membership list.

Question 67

Which of the following is a time between the date of an employee's hire and the earliest effective date of insurance coverage?

A) a waiting period
B) a deductible
C) a limit
D) a premium

Question 68

A female member of a CDHP has an HSA fund of $820 and a deductible of $500 (which has not yet been met), and the HDHP has a 75-25 coinsurance. Calculate the amount this patient would owe after drawing down her HSA if the bill for her services is $2,100.

A) $400
B) $500
C) $80
D) $2,100

Question 69

A member in an indemnity BCBS plan has a family deductible of $500, with a coinsurance rate of 70-30 after the deductible has been met, up to an annual maximum out-of-pocket amount of $2,000. Calculate the total amount the patient owes for charges of the year that total $3,200.

A) $500
B) $3,200
C) $810
D) $1,310

Question 70

Approximately what percentage of all consumers with health insurance are enrolled in a PPO?

A) 25%
B) 75%
C) 50%
D) 10%

Question 71

What type of plan is a hybrid of two networks where members may choose from a primary or secondary network?

A) point-of-service (POS) plans
B) health maintenance organizations (HMOs)
C) preferred provider organizations (PPOs)
D) indemnity plans

Question 72

Which type of consumer-driven health plan funding option is set up by individuals rather than employers?

A) a health savings account (HSA)
B) a flexible savings account (FSA)
C) a medical home model
D) a health reimbursement account (HRA)

Question 73

Which of the following is a way that an employer can reduce prices for their GHPs?

A) Eliminate the open enrollment period to lock in prices.
B) Carve out benefits during negotiations to change the coverage.
C) Apply options to the plan.
D) Apply riders to the plan.

Question 74

What is precertification?

A) certification that is awarded pending the successful completion of an exam
B) requirement for office consultation
C) preauthorization for hospital admission or outpatient procedures
D) preauthorization for a practice to join a managed care organization

Question 75

Third-party claims administrators are classified as

A) a participating member of an insurance plan.
B) a managing company for IHPs.
C) a component of a medical practice tasked with handling collections and claims processing.
D) a separate company, often a managed care organization or insurance carrier.

Question 76

Describe the features of managed care organizations that practices review when deciding about entering a participation contract.

A) its business history and licensure status
B) its licensure status, accreditation standing, and business history
C) none of these are required when deciding on participation
D) its accreditation standing only

Question 77

A patient's __________ processes the BCBS claim and sends it back to the host plan.

A) heart plan
B) home plan
C) hold plan
D) house plan

Question 78

What might private payers use for a major course of treatment, such as surgery, chemotherapy, and radiation for a patient with cancer?

A) SPD
B) URO
C) IPA
D) P4P

Question 79

Which of the following is normally not included on the monthly enrollment list?

A) the type of plan or program
B) patients' dates of birth
C) the name of the employer
D) patients' identification numbers

Question 80

What term is used to describe the four types of insurance plans offered by the ACA's public health insurance exchanges?

A) essential health plans
B) bronze plans
C) metal plans
D) individual health plans