RMA Insurance and Reimbursement 3 — Questions and Answers
Question 1: What does a 'deductible' represent in a health insurance plan?
- The amount the insurer pays each visit
- The amount a patient must pay before insurance begins to pay (Correct answer)
- A fixed copay per prescription
- The monthly cost of coverage
Correct answer: The amount a patient must pay before insurance begins to pay
The deductible is the amount the patient pays out of pocket before benefits kick in.
Question 2: A 'copayment' is best described as:
- A percentage of the total bill
- A fixed dollar amount paid at the time of service (Correct answer)
- The annual premium
- The amount left after insurance pays
Correct answer: A fixed dollar amount paid at the time of service
A copay is a set flat fee the patient pays for a covered service at the visit.
Question 3: What is 'coinsurance'?
- A flat fee per visit
- A percentage of allowed charges the patient pays after the deductible (Correct answer)
- A second insurance policy
- The premium paid by the employer
Correct answer: A percentage of allowed charges the patient pays after the deductible
Coinsurance is the percentage share of costs a patient pays once the deductible is met.
Question 4: What is the purpose of 'precertification' (prior authorization)?
- To verify the patient's address
- To obtain insurer approval before a service is performed (Correct answer)
- To process payment after treatment
- To assign a diagnosis code
Correct answer: To obtain insurer approval before a service is performed
Precertification confirms the insurer will cover a planned service before it is rendered.
Question 5: When a claim is denied for 'lack of medical necessity,' the medical assistant should first:
- Write off the balance immediately
- Review documentation and consider filing an appeal (Correct answer)
- Bill the patient the full amount
- Resubmit with a different patient name
Correct answer: Review documentation and consider filing an appeal
Reviewing supporting documentation and appealing is the appropriate first step for such denials.
Question 6: What does 'assignment of benefits' authorize?
- The patient to choose any provider
- Insurance payment to be sent directly to the provider (Correct answer)
- The provider to change the diagnosis
- Automatic claim denial
Correct answer: Insurance payment to be sent directly to the provider
Assignment of benefits directs the insurer to pay the provider rather than the patient.
Question 7: An 'in-network' provider has what relationship with an insurance plan?
- No contract with the plan
- A contracted agreement to accept negotiated rates (Correct answer)
- Charges the patient full price
- Only treats Medicare patients
Correct answer: A contracted agreement to accept negotiated rates
In-network providers contract with the plan to accept agreed-upon reimbursement rates.
RMA Insurance and Reimbursement 3
What does a 'deductible' represent in a health insurance plan?