#1
Which of the following is a characteristic of a fee-for-service healthcare payment system?
Providers are reimbursed based on the number of services provided.
ExplanationPayment based on services rendered.
#2
What is a deductible in health insurance?
The maximum amount the insured person has to pay out of pocket before insurance starts covering costs.
ExplanationInitial out-of-pocket payment.
#3
What is the primary purpose of coinsurance in health insurance?
To share the cost of covered healthcare services between the insured individual and the insurance company.
ExplanationCost-sharing mechanism.
#4
What does the term 'Out-of-Pocket Maximum' refer to in health insurance?
The total amount the insured person has to pay out of pocket for covered services in a year.
ExplanationMaximum annual out-of-pocket payment.
#5
What is the primary difference between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO)?
HMOs typically have a more restricted network of providers compared to PPOs.
ExplanationDifference in provider network scope.
#6
What is the main purpose of a health maintenance organization (HMO)?
To focus on preventive care and coordinate healthcare services for members.
ExplanationEmphasis on prevention and coordination.
#7
In a capitation payment model, how are healthcare providers reimbursed?
A fixed amount per patient regardless of services rendered.
ExplanationFixed payment per patient.
#8
What is a Health Savings Account (HSA) commonly used for?
To pay for healthcare expenses not covered by insurance.
ExplanationCovering non-insured medical costs.
#9
What is the main function of a Preferred Provider Organization (PPO) in healthcare insurance?
To offer a network of healthcare providers with negotiated rates for services.
ExplanationNetwork with negotiated rates.
#10
What is the main goal of value-based reimbursement in healthcare?
To improve healthcare quality and outcomes while controlling costs.
ExplanationEnhancing quality while controlling costs.
#11
What is the role of a claims adjudicator in the healthcare insurance process?
To review and process insurance claims submitted by healthcare providers.
ExplanationReview and process insurance claims.
#12
What role does utilization management play in healthcare insurance?
Reviewing and managing healthcare services to ensure appropriate use and cost-effectiveness.
ExplanationEnsuring appropriate service utilization.
#13
How does Medicaid differ from Medicare in the United States?
Medicaid is funded by federal and state governments and provides health coverage to low-income individuals, while Medicare is a federal program primarily for seniors and some disabled individuals.
ExplanationDifferences in funding and target population.
#14
What is the purpose of a Health Insurance Exchange?
To regulate the insurance market and ensure fair pricing and coverage options.
ExplanationRegulating insurance market for fairness.
#15
What role does prior authorization play in the healthcare insurance process?
Reviewing and managing healthcare services to ensure appropriate use and cost-effectiveness.
ExplanationEnsuring appropriate service utilization.