CCA Medical Claims and Healthcare Coverage 2

Question 1

What does 'reasonable and customary' refer to in medical claims evaluation?

Accepted Answer

The typical range of fees charged for a service in a specific geographic area

Answer

The amount Medicare pays for a specific service

Answer

The actual amount charged by the treating physician

Answer

The maximum amount allowed under state law

Question 2

Under HIPAA regulations, a claims adjuster can obtain a claimant's medical records:

Accepted Answer

With the claimant's written authorization or a valid legal process such as a subpoena

Answer

Without authorization since adjusters are considered healthcare professionals

Answer

Only through a court order in all circumstances

Answer

Only if the claimant's attorney submits a formal request

Question 3

A 'peer review' in medical claims handling involves:

Accepted Answer

A qualified medical professional evaluating the appropriateness of another physician's treatment

Answer

Injured workers reviewing each other's claims for accuracy

Answer

Insurance adjusters reviewing medical bills with their supervisors

Answer

A claimant reviewing their own medical records for errors

Question 4

What is a medical lien in personal injury claims?

Accepted Answer

A healthcare provider's legal right to share in settlement proceeds for unpaid medical bills

Answer

A type of supplemental health insurance policy

Answer

A document authorizing emergency medical treatment

Answer

A court order requiring ongoing medical treatment

Question 5

What is the significance of establishing 'causation' when evaluating a medical claim?

Accepted Answer

It establishes the connection between the incident and the claimant's medical condition or injury

Answer

It determines which physician a claimant must use for treatment

Answer

It sets the statute of limitations for filing the medical claim

Answer

It determines the geographic jurisdiction governing the claim

Question 6

An 'aggravation' of a pre-existing condition in claims handling means:

Accepted Answer

A prior condition was worsened by the incident, potentially creating additional compensable liability

Answer

The claimant is exaggerating the severity of their injuries

Answer

The medical treatment itself has made the condition worse over time

Answer

The adjuster is escalating claim denial efforts

Question 7

What is the purpose of a 'life care plan' in serious injury claims?

Accepted Answer

To outline and project costs for all future medical and care needs of a catastrophically injured person

Answer

To determine the claimant's eligibility for life insurance benefits

Answer

To establish life expectancy for settlement valuation purposes only

Answer

To schedule the claimant's return-to-work program