This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
The CAHIMS Exam Preparation Course
and the CAHIMS exam are the result of
collaboration between the Life Science
Informatics Center at Bellevue College
and the Healthcare Information and
Management Systems Society (HIMSS).
Significant content found in the CAHIMS
Exam Preparation Course stems from the
Office of the National Coordinator for
Health Information Technology. Creation
of the CAHIMS Exam Preparation Course
and the CAHIMS exam was made
possible through support from the National
Science Foundation (NSF).
Curriculum Team:
Margaret Schulte, DBA
Michèle Royer, PhD
Nathan Savage, MLIS
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Section 1 - Healthcare Environment
Lesson 1.2 - Healthcare Payment Systems
Assessment Questions Answer Key
Lectures 1, 3 & 4
1. Most people in the US get health insurance through:
*a. An employer
b. Their county health department
c. Their state health department
d. The federal government
Answer: a. Healthcare payers include public and private sources. Most people
(55%) get their healthcare insurance from an employer.
Lecture(s)/Slide(s): 1/14
2. All of the following are privately funded EXCEPT:
a. BlueCross Blue Shield
b. Commercial insurers
c. Managed care organizations
*d. The Children’s Health Insurance Program
Answer: d. The Children’s Health Insurance Program (CHIP) is a federally
funded program administered by the states.
Lecture(s)/Slide(s): 1/15-16
3. BlueCross BlueShield is:
a. A managed care organization
*b. An association of private companies
c. Funded by the federal government
d. Funded by all 50 states
Answer: b. Blue Cross Blue Shield is an association of companies originally
formed to avoid state insurance regulations to provide hospital and physician
services, that now operates as a commercial health insurer.
Lecture(s)/Slide(s): 1/15, 3/10
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
1
4. Managed care plans:
a. Are much less common today than they were 50 years ago
*b. Combine health insurance and healthcare services
c. Pay doctors on a fee-for-service basis
d. All of the above
Answer: b. Managed care organizations combine health insurance with the
delivery of healthcare services to keep costs low and provide quality care.
Lecture(s)/Slide(s): 3/13-18
5. Of the following types of plans, costs for the patient are lowest, but choice of
providers is most restricted, in a:
*a. Health maintenance organization
b. Indemnity plan
c. Preferred provider organization
d. Point-of-service plan
Answer: a. The Health Maintenance Organization (HMO) provides the lowest
cost but restricts the patient’s choice of providers.
Lecture(s)/Slide(s): 3/15
6. What group determines whether someone is eligible for Medicare and
processes their premium payments?
a. The Centers for Medicare & Medicaid Services
b. The Federal Insurance Contributions Agency
*c. The Social Security Administration
d. The US Department of Health & Human Services
Answer: c. Medicare is Title XVIII of the Social Security Act.
Lecture(s)/Slide(s): 4/5
7. Choose the best statement about Medicaid and Medicare coverage:
a. Medicaid covers older adults; Medicare covers people with low incomes.
b. Medicaid covers people with low incomes; Medicare covers children and
pregnant women in families that earn too much for Medicaid.
*c. Medicare covers older adults; Medicaid covers people with low incomes.
d. Medicare covers all uninsured children and pregnant women; Medicaid covers
older adults.
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
2
Answer: c. Medicare is for the elderly over age 65 and certain people with
disability. Medicaid is for the individuals with low incomes.
Lecture(s)/Slide(s): 1/11, 19
8. Which of the following statements is/are TRUE?
a. Medicaid has different names in different states.
b. Medicaid is funded by federal income taxes;
c. Medicare is partially funded by individuals and their employers through payroll
taxes;
d. Some people on Medicaid also qualify for Medicare.
*e. All of the above
Answer: e. Medicaid is a healthcare program operated by each state with
individual state eligibility requirements and benefits according to rules
established by the Federal government. The Federal government partially funds
each program. The elderly poor may qualify for both Medicare and Medicaid.
Lecture(s)/Slide(s): 4/12-15
Lectures 5 & 6
9. Samples of and electronic data interchange transaction include (choose all that
apply):
a. a fax copy of the claim
b. CMS Form 1500
c. CMS Form 1450
*d. 837 transaction for healthcare claims
Answer: d. Faxes and CMS forms 1450 and 1500 are paper based.
Lecture/Slide(s): 5/22
10. Which of the following is currently used to code claims for healthcare
services (choose all that apply):
*a. CPT
*b. ICD-9-CM
*c. NDC - National Drug Codes
*d. ICD-10-PCS
Answer: a, b, c, d. All are code sets that can be used for claims processing.
Lecture/Slide(s): 5/14-17
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
3
11. Which of the following is used for diagnosis coding and reporting on claims
regardless of the provider?
*a. ICD-9
b. CPT
c. HCPCS
d. CDT
Answer: a. The ICD-9 is used by all providers to code a diagnosis.
Lecture/Slide(s): 5/16
12. Fee-for-service payment type include (choose all that apply):
a. episode-of-care
*b. traditional retrospective
c. prospective payment
d. global payment
*e. self-pay
Answer: b, e. Traditional retrospective and self-pay are two types of fee-forservice payments. Prospective payment and global payment are types of
episode-of-care payments.
Lecture/Slide(s): 5/25-27
13. The third party payer is
a. the insured
b. the provider
*c. the insurance company
d. all of the above
Answer: c. The insured is the first party, the provider is the second party, and the
insurance company is the third party.
Lecture/Slide(s): 5/4
14. Episode of care reimbursement types include all of the following except:
*a. self-pay
b. prospective payment
c. capitation
d. global payment
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
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Answer: a. Self-pay is a fee-for-service type payment.
Lecture/Slide(s): 5/27, 28
15. Managed care reimbursement may be paid using which of the following
methods:
a. fee-for-service
b. episode-of-care
*c. either fee-for-service or episode-of-care
d. none of the above
Answer: c. Both fee-for-service or episode-of-care methodologies are used by
managed care organizations to pay providers.
Lecture/Slide(s): 5/34
16. The sectors of healthcare spending that utilize the most resources include
(choose all that apply):
*a. hospitals
*b. physician services
*c. pharmaceutical costs
d. nursing homes
Answer: a,b,c. Hospital cost, physician services, and pharmaceutical expenses
account for approximately 60% of all healthcare costs.
Lecture/Slide(s): 6/9, 12, 14
17. Which of the following is not considered a chronic disease?
a. hypertension or high blood pressure
b. diabetes
c. asthma
*d. influenza
Answer: d. Influenza is an acute illness that is expected to resolve.
Hypertension, diabetes, and asthma are chronic diseases that will require
ongoing care.
Lecture/Slide(s): 6/17
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
5
18. The age group associated with the highest medical expenses is:
a. children <5
b. adults age 25-44
c. adults age 45-64
*d. adults > 65
Answer: d. Adults age 65 and older average more than $9000 in annual
expenses in 2009.
Lecture/Slide(s): 6/2
19. The EMTALA act requires hospitals receiving federal funds to evaluate
individuals presenting to the emergency department
a. only if they have insurance
*b. regardless of their ability to pay
c. only if they pay in advance
d. only if it is a true emergency
Answer: b. Under the emergency treatment and active labor act, any individual
presenting to the emergency department must be evaluated to see if an
emergency exists regardless of their ability to pay.
Lecture/Slide(s): 6/27
20. (Choose all that apply) Factors that contribute to escalating healthcare
expenditures in the US include:
*a. Technology.
*b. Chronic disease.
*c. Increased demand and utilization.
d. An excess of primary care doctors.
*e. New pharmaceutical treatments.
*f. Administrative costs.
*g. The uninsured.
Answer: a, b, c, e, f, g. All of the above contribute to rising healthcare
expenditures in the US except for answer d - an excess of primary care doctors.
The shortage of primary care doctors in the US (the so called “primary care
crisis”) may contribute to overutilization of more expensive services, such as the
hospital emergency department or specialists for healthcare services that could
be provided in the primary care setting.
Lecture/Slide(s): 6/8-29
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
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