Sample Questions and Answers
In the context of healthcare billing, what is “medically necessary” treatment?
A) Any treatment that the healthcare provider deems essential to the patient’s recovery
B) Treatment that is covered by an insurance policy
C) The treatment for which the patient has pre-authorization from their insurance
D) A treatment required for reimbursement under the patient’s healthcare plan
Answer: A
What is a “payment plan” in healthcare billing?
A) An agreement between the healthcare provider and the patient regarding how medical bills will be paid over time
B) A document that lists all charges the insurance company will cover
C) A policy that requires insurance companies to pay upfront for all services rendered
D) A method of offering patients a discount for early payments
Answer: A
What does “medical necessity” refer to in the billing process?
A) The use of medical procedures that are cost-effective for the insurance company
B) Treatments and services required for the diagnosis or treatment of a condition, and covered by the patient’s insurance
C) The ability of a healthcare provider to access a patient’s insurance information
D) The billing of medical services that are considered elective by the patient
Answer: B
What is the “Uniform Bill 04” (UB-04) used for?
A) It is used for coding procedures in the physician’s office
B) It is used for submitting claims for inpatient hospital services to insurance providers
C) It is used for submitting claims for outpatient services
D) It is used for determining the amount a patient will need to pay for medical services
Answer: B
What is a “payer” in the context of healthcare billing?
A) The person who receives healthcare services
B) The entity that reimburses the healthcare provider for services rendered
C) The government agency that oversees all health insurance plans
D) The healthcare provider who submits a claim for payment
Answer: B
In healthcare billing, what does “coordination of benefits” mean?
A) The process of determining which insurance company pays first when a patient has coverage under multiple policies
B) The process of ensuring that all medical providers involved in a patient’s care are paid equally
C) The method by which a healthcare provider sets a payment schedule with an insurance company
D) The decision to deny claims that do not meet medical necessity criteria
Answer: A
What does “bundling” mean in the context of healthcare billing?
A) Combining related services or procedures into a single code to be billed at a flat rate
B) Offering discounts when multiple insurance plans are combined
C) Submitting individual charges for every service rendered, regardless of grouping
D) Offering patients the option to pay for multiple services together at a reduced rate
Answer: A
What is a “provider network” in healthcare insurance?
A) A list of healthcare providers that have agreed to provide services to insurance policyholders at negotiated rates
B) A collection of healthcare providers that offer discounted services to uninsured patients
C) A group of providers who share office space but operate independently
D) A list of government-approved providers who can prescribe medications
Answer: A
Which of the following is an example of a “premium” in healthcare insurance?
A) The portion of medical bills the patient must pay out-of-pocket
B) The monthly amount paid by the insured individual to maintain their health insurance coverage
C) The annual deductible that a patient must meet before insurance starts to pay
D) The fixed co-payment required when visiting a specialist
Answer: B
What is the main purpose of the ICD-10 code system in healthcare billing?
A) To provide a standard set of codes for describing medical treatments and services
B) To identify the specific medications prescribed to patients
C) To classify healthcare providers according to specialty and location
D) To specify the amount of reimbursement a healthcare provider will receive
Answer: A
What is a “co-payment” in healthcare billing?
A) A fixed amount that a patient must pay for each visit or service, typically due at the time of service
B) The amount that the insurance company agrees to cover for a medical service
C) The amount a healthcare provider is paid after insurance has made its payment
D) The amount a patient pays toward their deductible after treatment
Answer: A
What is the “benefits verification” process in healthcare insurance?
A) The process of confirming that a healthcare provider is authorized to bill an insurance company
B) The process of verifying that a patient’s insurance plan covers a specific treatment or service
C) The process of ensuring a claim is submitted correctly before it is processed by the payer
D) The method by which insurance companies pay for services provided to uninsured patients
Answer: B
In healthcare billing, what is “claims adjudication”?
A) The process of denying claims for services that are deemed unnecessary
B) The process of reviewing claims to determine whether they are approved, denied, or modified based on the policy terms
C) The act of sending bills directly to the patient after insurance payments have been made
D) The process of submitting claims to a clearinghouse for coding validation
Answer: B
What does “medically necessary” mean in terms of insurance coverage?
A) A treatment or service that is required to maintain health but is not essential for recovery
B) Any treatment that is covered under the patient’s insurance policy
C) A service or treatment required to diagnose or treat a patient’s medical condition and covered by their insurance plan
D) A procedure performed on an outpatient basis
Answer: C
What is “insurance verification” in the healthcare billing process?
A) The process of checking if a patient’s insurance coverage is active and valid before providing services
B) The process of verifying a patient’s diagnosis before submitting a claim
C) The process of confirming a patient’s co-payment amount for a given service
D) The process of checking if an insurance policy will cover any medical expenses
Answer: A
What is the “medicare secondary payer” rule?
A) The rule that Medicare will only pay when no other insurance is available
B) The rule that Medicare will pay secondary to private insurance when both are in play
C) The rule that Medicare will always pay first regardless of other insurance coverage
D) The rule that limits Medicare payments for medical procedures deemed unnecessary
Answer: B
What is a “secondary insurance” in healthcare billing?
A) Insurance that provides coverage for the medical costs not covered by a primary insurance policy
B) A backup insurance policy that covers costs after all deductible amounts have been met
C) The insurance used to cover out-of-network charges when primary insurance does not
D) An insurance policy used to cover only emergency medical procedures
Answer: A
What is a “capitated payment model”?
A) A reimbursement structure where providers receive a fixed amount per patient, per month, regardless of the services rendered
B) A fee-for-service model where patients pay out-of-pocket for each visit
C) A method of charging patients based on the number of days they are hospitalized
D) A payment model based on the number of prescriptions a patient receives
Answer: A
What is “denial management” in healthcare billing?
A) The process of adjusting claims to meet coding standards before submission
B) The process of managing patient inquiries regarding claims status
C) The practice of reviewing and addressing denied insurance claims through appeal or correction
D) The process of denying medical services that are deemed nonessential by the insurance company
Answer: C
Which of the following is true about the “Affordable Care Act” (ACA)?
A) It allows insurers to reject applicants based on pre-existing conditions
B) It requires all Americans to maintain health insurance or pay a penalty (individual mandate)
C) It eliminates the need for insurance companies to offer essential health benefits
D) It makes health insurance optional for all individuals
Answer: B
What is the “out-of-pocket maximum” in a health insurance policy?
A) The total amount a patient can be billed for a service
B) The amount a patient must pay toward covered healthcare services before the insurance company pays 100%
C) The fixed cost for emergency services, regardless of insurance coverage
D) The cost of medications prescribed for a specific condition
Answer: B
What is the purpose of “prior authorization” in healthcare billing?
A) To ensure that a patient is eligible for healthcare services before they are provided
B) To confirm that a patient’s medical bills will be paid by their insurance company
C) To verify that all required medical services are covered under a patient’s insurance policy
D) To approve or deny claims based on the type of treatment being provided
Answer: A
What is the purpose of a “claim clearinghouse” in the healthcare billing process?
A) To handle all insurance payments directly from the insurer to the healthcare provider
B) To process claims and ensure they are correctly formatted before submitting to insurance carriers
C) To manage the medical records of patients covered by health insurance
D) To validate the eligibility of a patient’s insurance coverage
Answer: B
Which of the following is a “capitation” payment method?
A) Payment is made to a healthcare provider for each individual service rendered.
B) Payment is made to a healthcare provider for each member of a health plan, regardless of services rendered.
C) Payment is made based on the severity of the patient’s condition.
D) Payment is made based on the number of treatments administered during a calendar year.
Answer: B
What does the term “coordination of benefits” refer to?
A) A method of determining which insurance provider pays first when a patient has multiple insurance plans
B) The coordination of appointments and procedures between healthcare providers
C) The process of verifying patient eligibility for multiple insurance policies
D) A system for determining whether a patient should be denied certain benefits under a health plan
Answer: A
Under HIPAA regulations, which of the following is considered “protected health information” (PHI)?
A) Patient’s appointment date
B) Patient’s medical history, including diagnoses and treatments
C) The names of healthcare providers involved in patient care
D) A list of patient contacts at a healthcare facility
Answer: B
What is the “balanced billing” practice in healthcare insurance?
A) Charging patients the balance between what the insurance company pays and the total amount owed for services
B) Billing patients in full for services rendered, regardless of insurance coverage
C) Offering a payment plan for services that exceed the patient’s deductible amount
D) A process where a patient is billed only if their insurance company refuses to cover the service
Answer: A
What is the “Medically Necessary” standard used by insurance companies?
A) A service that is not typically covered under the terms of a health insurance policy
B) A treatment that is required for the diagnosis or treatment of a specific medical condition, according to established guidelines
C) A service that is optional for a patient, but recommended by the healthcare provider
D) A treatment based on patient preference, without medical necessity
Answer: B
Which of the following would likely be included in a patient’s “explanation of benefits” (EOB)?
A) A detailed bill for all services rendered to the patient
B) A summary of the patient’s claims, including what was covered, denied, and the amount owed by the patient
C) A breakdown of the patient’s premium payments
D) The total amount of taxes paid by the healthcare provider
Answer: B
What is “claim submission” in the healthcare billing process?
A) The process of submitting a patient’s information for preauthorization
B) The process of submitting a healthcare provider’s claim to the insurance company for payment
C) The act of collecting payment from the patient directly after a procedure
D) The process of creating a patient’s medical records for insurance coverage purposes
Answer: B
How does the “fee-for-service” (FFS) model work in healthcare?
A) Providers are paid a set amount for each individual service rendered to the patient
B) Providers are paid based on the quality of care and patient outcomes
C) Providers receive a lump sum per patient regardless of services used
D) Providers are paid monthly premiums for providing services
Answer: A
What does the term “out-of-network” mean in health insurance billing?
A) A provider or healthcare facility that is contracted with the patient’s insurance plan
B) A provider or healthcare facility that is not contracted with the patient’s insurance plan
C) A service that is only covered by insurance after prior authorization
D) A healthcare provider that only accepts cash payments
Answer: B
Which of the following is a responsibility of a medical coder in the billing process?
A) Sending claims to insurance companies
B) Assigning codes to diagnoses and procedures to ensure accurate billing
C) Determining the patient’s eligibility for insurance coverage
D) Reviewing insurance claims for fraud or errors
Answer: B
In healthcare billing, what does “pre-authorization” refer to?
A) Obtaining approval from the insurance company before a patient receives a specific service or treatment
B) The process of verifying a patient’s eligibility for healthcare coverage
C) The confirmation that a service has been billed correctly before submission to the insurer
D) Determining the patient’s eligibility for government-sponsored insurance programs
Answer: A
What is the purpose of the “Health Insurance Portability and Accountability Act” (HIPAA) in healthcare billing?
A) To prevent overbilling by healthcare providers
B) To standardize coding practices for healthcare billing
C) To protect patient privacy and ensure the security of their health information
D) To establish regulations for the payment of medical claims
Answer: C
What does “out-of-pocket expense” refer to in healthcare insurance?
A) The amount the insurance company will pay for medical services
B) The amount a patient must pay for medical expenses that aren’t covered by insurance
C) The total amount of premiums a patient must pay annually
D) The costs covered by Medicare for a specific medical procedure
Answer: B
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