When the workers' compensation policy is NOT a managed care plan, fees for services are based on:
capitation rates.
charge-based fees.
the Medicare Fee Schedule.
usual and customary charges.
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Q. 2) A provider in a managed care network who does NOT provide a sufficient level of treatment to patients because of a capitation agreement is committing which type of fraud?
Underutilization
Overutilization
Internal fraud
Unbundling
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Q. 3) Workers' compensation fraud can be punishable by:
fines.
orders for restitution.
imprisonment.
all of the above.
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Q. 4) A worker who works full time at an unreported job while collecting workers' compensation benefits commits:
benefit abuse.
criminal abuse.
benefit fraud.
premium fraud.
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Q. 5) An employer who misrepresents the amount of payroll or classification of employees in order to reduce workers' compensation costs commits:
premium abuse.
premium fraud.
benefit abuse.
benefit fraud.
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Q. 6) The prospective approval of health care based solely on medical necessity is called:
preapproval.
prior approval.
preauthorization.
precertification.
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Q. 7) To qualify for Social Security Disability Insurance (SSDI), individuals must be unable to work because of a medical condition that is expected to last at least:
30 days.
60 days.
90 days.
1 year.
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Q. 8) If a workers' compensation claim is denied, the provider can request a review by:
the state workers' compensation insurance fund.
the state insurance commissioner.
a medical examination review committee.
an independent review organization.
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Q. 9) A workers' compensation insurance carrier must pay, reduce, deny, or determine to audit a claim no later than the:
30th day after receipt of the claim.
45th day after receipt of the claim.
95th day after receipt of the claim.
120th day after receipt of the claim.
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Q. 10) Workers' compensation claims must be submitted to the insurance carrier within:
30 days of the date of service.
45 days of the date of service.
95 days of the date of service.
120 days of the date of service.
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