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Chapter Three
MULTIPLE CHOICE
1) Health insurance is:
A) a PPO.
B) shifting the risk of loss.
C) an HMO.
D) All of the above
2) The _____________ calculates risk and helps set premiums.
A) actuary
B) government
C) benefits manager
D) employer
3) John’s recent physician office visit was not paid by the insurance company. It was his first claim of the year. The claim totaled $200. The reason the claim was denied was likely related to John’s:
A) copayment.
B) subscriber.
C) deductible.
D) premium.
4) A deductible is the:
A) portion of services paid by the patient.
B) amount paid by the patient before the third-party payer begins to pay.
C) fee paid by employers and employees to the insurance company.
D) negotiated payment for services between the payer and the
5) The copayment is the:
A) fee paid by employers and employees to the insurance company.
B) negotiated payment for services between the payer and the provider.
C) portion of services paid by the patient.
D) amount paid by the patient before the third-party payer begins to pay.
6) Premiums are the:
A) portion of services paid by the patient.
B) amount paid by the patient before the third-party payer begins to pay.
C) negotiated payment for services between the payer and the provider.
D) fee paid by employers and employees to the insurance company.
7) The typical fee charged by providers in a geographic area is known as:
A) usual charge, reasonable cost plan.
B) usual, customary, and reasonable..
C) universal charge and reimbursement plan.
D) ordinary and customary cost program.
8) The amount paid to a provider monthly to provide health care services to an employee is:
A) premium.
B) capitation.
C) copayment.
D) deductible.
9) An HMO contracts with more than one group practice for service in which arrangement?
A) Staff model HMO
B) Network HMO
C) IPA
D) PPO
10) This organization negotiates and manages provider’s contracts.
A) Staff model HMO
B) PPO
C) Network HMO
D) IPA
11) Third-party payers are covered by both state and federal regulations. Two of the federal regulations are:
A) COBRA and PPO.
B) ERISA and HIPAA.
C) COBRA and EPO.
D) ERICA and HIPAA.
12) A policy is:
A) a binding contract between the payer and the employer.
B) the time in which employees can utilize benefits.
C) a time when employees can change providers.
D) a binding contract between the payer and the employee.
13) An enrollment period is a:
A) binding contract between the payer and the employee.
B) binding contract between the payer and employer.
C) time when employees can utilize b
D) time when employees can change providers.
14) Determining who is responsible for health claim payments is known as:
A) explanation of benefits.
B) COBRA.
C) coordination of benefits.
D) ERISA.
15) John is known as a(n) _______________ in his HMO.
A) actuary
B) enrollee
C) subscriber
D) policy holder
16) Which of the following describes Blue Cross/Blue Shield?
A) A health insurance company.
B) Blue Cross pays hospital expenses.
C) Blue Shield pays physician expenses.
D) All of the above
17) All of the following are true about the Healthcare Common Procedure Coding System (HCPCS) except:
A) it consists of two levels.
B) the current procedural terminology (CPT) is for procedures and services performed by providers.
C) it involves indemnification.
D) the national codes (HCPCS level II codes) are for procedures, services, and supplies not found in CPT.
