When a concurrent review determines that the patient no longer requires services, who determines ...

When a concurrent review determines that the patient no longer requires services, who determines when the patient will be discharged?
 
  a. The physician
  b. The plan administrator
  c. The patient
  d. The discharge planner

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(Q. 2) 1996 HIPAA laws mandate that insurance companies cannot require precertification for:
 
  a. maternity hospitalizations.
  b. psychiatric hospitalizations.
  c. substance abuse treatment hospitalizations.
  d. detoxification treatment hospitalizations.

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(Q. 3) Under 1996 HIPAA laws, how many days must an insurance company authorize for a woman having a C-section?
 
  a. 10
  b. 2
  c. 4
  d. 5

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(Q. 4) The portion of a utilization review program that occurs prior to the medical procedure is called the:
 
  a. preintent review.
  b. concurrent review.
  c. prospective review.
  d. retrospective review.

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(Q. 5) When an insurance company reviews extra days that an insured remained in the hospital beyond the amount authorized by the precertification, it is called:
 
  a. an efficiency review.
  b. an extension review.
  c. a concurrent review.
  d. an effectiveness review.

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(Q. 6) If an insurance contract specifies that precertification is necessary for an inpatient procedure, what can happen if this step falls through the cracks?
 
  a. The patient may have to give back the supplies from the procedure.
  b. The insurance company may only pay a portion of the procedure or nothing.
  c. The insurance company will pay anyway.
  d. The insurance company will issue a warning letter.

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(Q. 7) The purpose behind requiring precertification of hospitalizations is:
 
  a. to prevent unnecessary hospitalizations.
  b. to reduce insurance premiums.
  c. to create more jobs in the insurance industry.
  d. to prevent elective surgery.

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(Q. 8) Within an insurance company, who determines if a surgery is certified (or approved to be paid for)?
 
  a. The claims adjuster
  b. The medical biller
  c. The controller
  d. The plan administrator

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(Q. 9) How could a physician end up getting paid less than the allowable rate for a certain service?
 
  a. The billing was done incorrectly.
  b. The UCR factors were entered incorrectly.
  c. The physician's usual fee is less than the allowable amount.
  d. The biller coded the wrong diagnosis.

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(Q. 10) What is subtracted by the insurance company from the allowable amount prior to payment?
 
  a. Deductible, coinsurance, copayments
  b. Nothing
  c. Deductible and copayments only
  d. Deductible only