Nursing Questions and Answers
Question 1
When a provider receives a fixed amount to provide only the care that an individual needs from the provider, this is known as a _____________ payment.
capitation
fixed
premium
sub-capitation
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Question 2
The healthcare industry is heavily regulated by ____ and ____ legislation.
city; local
state; city
county; state
federal; state
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Question 3
When a patient signs a release of medical information at a physician’s office, that release is generally considered to be valid
for six months
for a single visit to the physician
for one year from the date entered on the form
until the patient changes insurance companies
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Question 4
When the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to
accept assignment
assignment of benefits
authorize services
coordination of benefits
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Question 5
Which document is used to guarantee the patient’s financial and medical record?
encounter form
patient insurance form
patient ledger
patient registration form
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Question 6
The person responsible for paying the charges for services rendered by the provider is the
beneficiary
guarantor
guardian
subscriber
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Question 7
Which federal legislation was enacted in1995 to restrict the referral of patients to organizations in which providers have a financial interest?
Federal Anti-Kickback Law
Hill-Burton Act
HIPAA
Stark II laws
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Question 8
The recognized difference between fraud and abuse is the
cost
intent
payer
timing
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Question 9
The specified amount of annual out-of-pocket expenses for covered health care services that the insured must pay annually for health care is called the
coinsurance
copayment
deductible
premium
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Question 10
Which three components constitute the RBRVS payment system?
fee schedule, practice expense, and malpractice expense
physician work, practice expense, and geographical location
physician work, practice expense, and malpractice insurance espense
practice expense, malpractice insurance expense, and liability insurance expense
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Question 11
Mandates are
directives
laws
regulations
standards
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Question 12
Which type of HMO offers subscribers health care services by physicians who remain in their individual office setting?
closed panel
independent practice association
network model
staff model
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Question 13
HIPAA requires payers to implement rules called electronic __________, which result in a uniform language for electronic data interchange.
data interchanges
health records
medical records
transaction standards
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Question 14
The ambulatory payment classification prospective payment system is used to reimburse claims for what services?
inpatient
nursing facility
outpatient
rehabilitation
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Question 15
Breach of confidentiality can result from
discussing patient health care information with unauthorized sources
discussing the patient’s case in the business office
sending medical information to non-health care entities with the patient’s consent
sending patient health care information to the patient’s insurance company
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Question 16
When a patient elects to receive care from a non-PAR, the patient will accrue _____.
higher copays
higher out-of-pocket expenses
lower premiums
lower copays
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Question 17
When a number of people are grouped for insurance purposes, this is known as a(n)
adverse selection
insurance pool
member group
risk pool
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Question 18
Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment), some hospitals engaged in a practice called __________, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the purpose of illegally increasing reimbursement.
downcoding
jamming
unbundling
upcoding
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Question 19
The problem-oriented record (POR) is a systematic method of documentation that consists of
a database.
progress notes.
an initial plan.
all of the above.
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Question 20
Which of the following is an example of fraud?
billing noncovered services as covered services
falsifying certificates of medical necessity plans of treatment
reporting duplicative charges on an insurance claim
submitting claims for services not medically necessary
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Question 21
Care rendered to a patient that was not properly approved (e.g., preapproved) by the insurance company is known as
medical necessity
noncovered benefits
unapproved services
unauthorized services
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Question 22
A risk contract is defined as an arrangement among health care providers
stating that the HMO can provide services to Medicare beneficiaries only
that allows higher payments to the HMO if they treat Medicare beneficiaries
to make available capitated health care services to Medicare beneficiaries
to offer fee-for-service health care services to Medicare beneficiaries
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Question 23
Which of the following is an example of abuse?
billing noncovered services/procedures as covered services/procedures
falsifying health care certificates of medical necessity plans of treatment
misrepresenting ICD-10-CM and CPT/HCPCS codes to justify payment
submitting claims for services and procedures knowingly not provided
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Question 24
Preventive services
may result in the early detection of health problems.
are required by most insurance companies.
allow treatment options that are less dramatic and less expensive.
both a and c.
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Question 25
Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work related. Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contacting the provider, who is liable for the __________ because of the provider’s failure to disclose that the injury was work-related.
adjudication
mediation
overpayment
unbundling
