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

COBRA (Consolidated Omnibus Budget Reconciliation Act) requires applicable employers to offer continued health coverage for up to 18-36 months after qualifying events, at the beneficiary's expense.

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

Capitation pays providers a fixed per-member-per-month (PMPM) amount to cover all contracted services for enrolled patients, shifting financial risk to the provider.

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

Upcoding is a fraudulent practice of billing a code that represents a more expensive service than what was actually documented and performed.

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

The global surgical package includes the pre-operative visit the day before surgery (for major procedures) and all routine post-operative care during the 10- or 90-day global period.

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

The patient only owes the remaining $200 needed to reach the $2,000 out-of-pocket maximum; the payer covers the remaining $300 of the coinsurance.

(HAC) Healthcare Accounting Certification Practice Test

(HAC) Healthcare Accounting Certification Practice Test

HAC Healthcare Insurance & Claims Processing 5