Moini CH14 Medical Insurance

The range of fees charged by most physicians in a community is called the (a)  

• customary fee.
• reasonable fee.
• usual fee.
• premium
• average fee.

If a child is covered by both of her parents’ insurances and the total medical charges come to $365—$280 of which is covered by the primary insurance—how are the rest of the charges handled?

• The parents are billed for $85.
• A claim is submitted to secondary insurance for $85.
• A claim is submitted to secondary insurance for $365.
• The doctor writes off $85, and no one is charged.
• A claim is submitted to secondary insurance for $280.

Which of the following is an example of fraud?

• miscoding a diagnosis unintentionally
• leaving a field blank on the CMS-1500 by mistake
• altering a patient’s chart to increase the amount reimbursed
• releasing patient’s medical records without the patient’s consent to the patient’s wife because you feel morally obligated to do so
• all of these

Which of the following Medicare programs covers hospital charges? (a)  

• Part A
• Part B
• Part C
• Part D
• both Parts A and B

Assume that John Smith got an X-ray through Dr. Jones, a participating provider in Mr. Smith’s HMO. The allowed charge for such an X-ray is $75, but Dr. Jones’s usual fee is $100. John Smith’s copayment due for each office visit is $15. How much can Dr. Jones collect from Mr. Smith?

• 25
• 10
• 15
• 0
• 75

Which of the following types of medical insurance is designed to offset medical expenses resulting from catastrophic or prolonged injury or illness?

• basic medical
• hospital coverage
• disability protection
• liability insurance
• major medical

Capitation is

• payment at the time of service.
• fixed prospective payment for services provided.
• fixed payment made for each enrolled patient rather than reimbursement based on the type and number of services provided.
• various payments for specific services provided during a specified time period.
• a reduction in payment if services are not provided to a minimum number of enrolled patients.

Providers are required by law to file which of the following for all eligible Medicare patients?

• CMS
• HCPCS
• ICD-9
• RBRVS
• CMS-1500

A patient’s medical fees come to a total of $600 from a participating provider, and the EOB lists the following information. Charges: $78 Not Eligible for Payment: List item Allowed Charge: $63 Applied to Deductible: $7 Coinsurance: $5 Amount Due from Carrier: $51 What amount is the patient required to pay?

• 7
• 5
• 27
• 12
• nothing

Answer explanation

Allowed charge-Amount Due from Carrier

$63.00-$51.00

In the staff model HMO

• providers are employees of the HMO.
• the HMO has capitation contracts with provider groups.
• contracts exist with an administrative group of physicians that in turn contracts with members.
• plan members can see out-of-network providers for additional fees.
• providers are paid on a fee-for-service basis.