HAC Healthcare Insurance & Claims Processing 5

Question 1

Which federal law requires employers with 20 or more employees to offer continuation of group health coverage to qualified beneficiaries after a qualifying event such as job loss?

Accepted Answer

COBRA

Answer

HIPAA

Answer

ERISA

Answer

ACA

Question 2

A payer uses a 'capitation' payment model. How does this differ from a fee-for-service model?

Accepted Answer

Providers receive a fixed monthly payment per enrolled member regardless of services used

Answer

Providers are paid per service rendered, creating volume incentives

Answer

Providers are paid a percentage of the patient's premium

Answer

Providers receive bundled payments for episodes of care

Question 3

In the context of claim auditing, what does 'upcoding' refer to?

Accepted Answer

Billing for a higher-complexity or higher-cost service than was actually provided

Answer

Submitting claims with outdated diagnosis codes

Answer

Using unlisted procedure codes when a specific code exists

Answer

Submitting claims electronically rather than on paper

Question 4

When a claim is subject to a global surgical period, which services are typically included in the global fee and should NOT be billed separately?

Accepted Answer

Pre-operative visits one day before surgery and post-operative care during the global period

Answer

Anesthesia services and hospital room charges

Answer

Diagnostic imaging ordered after the procedure

Answer

Treatment of complications unrelated to the surgical procedure

Question 5

A patient's plan has a $2,000 out-of-pocket maximum. They have already paid $1,800 in cost-sharing. For a subsequent covered service with a $500 coinsurance, how much does the patient owe?

Accepted Answer

$200

Answer

$500

Answer

$0

Answer

$300

Question 6

Which of the following best describes the role of a clearinghouse in the claims process?

Accepted Answer

It translates and validates claims from provider format to payer-specific EDI format, checking for errors before transmission

Answer

It adjudicates and pays claims on behalf of the payer

Answer

It negotiates contracted rates between providers and payers

Answer

It manages the provider's accounts receivable and collections

Question 7

What is the significance of the National Provider Identifier (NPI) on a healthcare claim?

Accepted Answer

It is a unique, standardized 10-digit number that identifies covered healthcare providers for electronic transactions

Answer

It identifies the patient's insurance policy number

Answer

It designates the payer's network tier for reimbursement

Answer

It indicates the type of facility where service was rendered