Medical insurance training questions and answers
No matter in study or work, we can't do without test questions. With the help of test questions, we can test whether the examiners have the basic ability to obtain a certain qualification. Do you know what kind of test is good? The following is a small carefully organized medical insurance training questions and answers, for reference only, I hope to help you.
¡¡¡¡ 1¡¢ Fill in the blanks (2 points for each space, 60 points in total)
1. The minimum payment standard for major diseases of special disease outpatient service of urban and rural residents in secondary hospital is 300 yuan / year / person; The minimum payment standard for major diseases in the outpatient department of basic medical treatment for urban employees is 440 yuan / year / person.
2. A ceiling line should be set up for the reimbursement of urban and rural residents' medical insurance, and the standard is: 80000 yuan / year / person for one file; The second grade is 120000 yuan / year / person.
3. The maximum payment limit of medical insurance and hospitalization pooling fund for urban employees is 37000 yuan, and the minimum payment standard for hospitalization in secondary hospitals is 4400 yuan.
4. The reimbursement proportion of medical insurance and inpatient pooling fund for employees in secondary hospitals: 87% in service and 95% in retirement.
5. The reimbursement rate of adult residents in secondary hospitals: 60% in the first level and 65% in the second level. The minimum payment standard is deducted once a year for major diseases. The proportion of hospitalization reimbursement for minors increased by 5 percentage points on the basis of the same file of insured adults.
6. The inpatient medical insurance patients transferred to the upper and lower hospitals need to handle the transfer through the system when they leave the hospital, and the starting line is calculated by the highest level hospital in this hospital. For those who fail to go through the transfer procedures according to the prescribed procedures, the hospitalization starting line will be increased by 5%, and the reimbursement proportion will be reduced by 5%.
7. The designated medical institutions should strengthen the management of medical treatment for the insured, and the doctors should record the specific time, place, cause and course of injury of the insured in detail. It is not allowed to include the fees that are not paid according to the medical insurance laws, regulations and policies into the medical insurance settlement.
8. The dosage of drugs used in outpatient department of special diseases shall not exceed 33 days per month and 366 days in a year.
9. For the insured patients with the first diagnosis of single disease in the whole year, the settlement amount according to the settlement method of single disease shall not be less than 95%. For those less than 95%, 95% of the staff will be included in the annual settlement according to the standard of single disease medical insurance settlement quota.
10. Designated medical institutions should adhere to the service tenet of "taking patients as the center", strictly abide by the "medical and nursing technical operation routine" in the diagnosis and treatment service, carry out diagnosis and treatment according to the clinical path of the disease, treat according to the disease, conduct reasonable inspection, rational drug use and reasonable treatment (three reasonable), under the condition that the curative effect is basically the same, Priority should be given to the use of drugs and treatment items (including medical materials) with lower prices within the reimbursement scope of medical insurance, so as to effectively reduce the medical expenses burden of the insured.
11. Please list at least five kinds of Malpractice handling methods of medical insurance, such as prevarication of patients, over medical treatment, over limit items, transfer of charges, wrong settlement, violation of price regulations, breakdown of hospitalization, empty bed hospitalization, information system failure to meet the standard, violation of single disease agreement, collusion items, hospitalization in bed, fake treatment, false hospitalization, fictitious medical treatment, false increase in expenses, etc Obstruction of inspection, etc.
¡¡¡¡ 2¡¢ Indefinite multiple choice questions (2 points for each sub question, 20 points in total)
1. Reimbursement of chronic diseases in special disease clinic of medical insurance for urban and rural residents: (a, c)
A. limit 1000 yuan B. limit 2000 yuan C. increase 200 yuan for each additional disease
D. for each additional disease, the quota will be increased by 1000 yuan
2. 90% of the reimbursement for special diseases of urban employees in outpatient treatment are: (a, B, c)
A. radiotherapy, chemotherapy and analgesia for malignant tumors
B. dialysis treatment of renal failure
C. anti rejection therapy after organ transplantation
D. severe prostatic hyperplasia
3. How to deal with traffic accidents caused by residents' medical insurance: what conditions must be met before reimbursement by medical insurance fund£¨ A¡¢C¡¢D)
A. traffic police department issues traffic accident responsibility confirmation
B. the patient is the secondary responsibility
C. patients are the main responsibility
D. patients are the full responsibility
4. Insured inpatients discharged with medicine: (a, B, C, d)
A. the drugs required for the first diagnosis of the disease after discharge shall be given priority to, and drugs unrelated to the diseases of the insured personnel in this hospitalization are not allowed
B. no more than 5 drugs and no more than 7 days' dose
C. intramuscular injection and intravenous drugs are not allowed after discharge
D. the first diagnosis of disease after discharge is special disease, and the dosage of medication for special disease shall not exceed 14 days
5. Which of the following diseases belong to the scope of major diseases of special medical insurance for urban and rural residents: (a, B, d)
A. hemophilia B. aplastic anemia C. coronary heart disease D. opportunistic infection of AIDS
6. Which of the following diseases belong to the scope of special diseases of urban and rural residents (B, C, d)
A. malignant tumor B. diabetes C. coronary heart disease D. sequelae of cerebrovascular accident
7. Which of the following procedures belong to the declaration of special diseases of urban employees' medical insurance data (A¡¢B¡¢C¡¢D)
A. application form for special diseases of basic medical insurance for urban employees in Chongqing;
B. the original and copy of my resident ID card or social security card;
C. two recent 1-inch bareheaded photos of myself;
D. for special reasons, if I can't declare in person and need to entrust others to handle it, the original and copy of the ID card of the entrusted person and the signature of both parties shall also be provided a power of attorney ¡£
8. In the course of treatment, the insured patients need to use medical materials with value in which of the following situations should be used with the signature and consent of the insured or their family members£¨ B)
A. more than 500 yuan B. more than 600 yuan C. more than 1000 yuan D. more than 2000 yuan
9. In the process of treatment, which of the following items should be explained to the insured or their families in advance, and the consent of the insured or their families should be obtained, and the confirmation form of identity verification of insured personnel and items of self paid and high value consumables should be signed for confirmation (except for emergency, rescue and other special circumstances)£¨ A¡¢B¡¢C¡¢D)
A. using drugs that are not covered by medical insurance
B. use of medical treatment items and service facilities that are not paid by medical insurance
C. using high value consumables
D. medical materials with use value above 600 yuan
10. The specific doctors (pharmacists) of the designated medical institutions are designated for specific treatment (hereinafter referred to as "written treatment") once in a natural year by the "decision on handling violations of designated service institutions" issued by the medical insurance agency. (b) it is handled by the medical insurance agency twice in writing. (a) written processing by medical insurance agency for three times.
A. the medical insurance service qualification shall be cancelled and shall not be applied for within 3 years
B. suspend its qualification to carry out medical insurance diagnosis and treatment service for 12 months
C. designated medical institutions shall give them written warning and internal notice of criticism
¡¡¡¡ 3¡¢ True or false (2 points for each question, 20 points in total)
1. For departments that carry out single disease settlement, if the first diagnosis of inpatient medical insurance patients is a single disease, but the department fails to settle the patient according to the settlement method of single disease, it is necessary to fill in the record form of settlement for the first diagnosis of single disease and not according to the settlement method of single disease, and keep it in the medical insurance department for reference£¨ ¡Ì)
2. When the insured is hospitalized, the insured shall be clearly marked on the "list of inpatients" in the doctor's or nurse's office. At the same time, the social security card or ID card and other valid certificates of the insured shall be copied and kept in the inpatient medical record, and within 3 days after the insured person enters the hospital (and before discharge), After the doctor or nurse in charge verifies the identity of the insured, he / she shall sign on the confirmation form of identity verification of insured personnel and confirmation of self paid and high value consumables£¨ ¡Ì)
3. Medical staff should introduce the payment items of basic medical insurance to patients for selection, and give priority to recommending basic medical treatment, essential drugs and appropriate technology£¨ ¡Ì)
4. For the diagnosis and treatment items beyond the scope of basic medical insurance services, the informed consent of the insured patients should be obtained before use£¨ ¡Ì)
5. It is stipulated in the medical insurance service agreement that designated medical institutions shall implement the system of one-day list of inpatient medical expenses and list of outpatient medical expenses of insured personnel, and the drugs, diagnosis and treatment items and service facilities in the one-day list (including outpatient medical expenses list) shall be marked with medical insurance attributes (Class A, class B, self paid)£¨ ¡Ì)
6. The medical services actually provided by medical personnel to the insured personnel should be consistent with the disease diagnosis, doctor's advice, prescription and other records of the insured£¨ ¡Ì)
7. Medical staff should strictly check the valid certificates related to medical insurance of the insured personnel when they seek medical treatment, and can provide medical insurance services only after they are verified to be accurate. If the insured personnel hold invalid certificates or the medical insurance certificates are inconsistent with their personal identity, they can also provide a small amount of medical insurance services as long as they are not found£¨ ¡Á)
8. Designated medical institutions should strictly grasp the indications of various examination items, and should not list special examination items (such as CT, MRI and other unconventional examination items) as routine examination. When such examination is needed, reasons shall be explained in the medical records£¨ ¡Ì)
9. If the diagnosis and treatment department of a designated medical institution violates the regulations in a natural year, if a department is dealt with in writing by the medical insurance agency for three times, the medical insurance diagnosis and treatment service shall be suspended for three months. If a department has been dealt with by the medical insurance agency for 5 times, the medical insurance diagnosis and treatment service shall be suspended for 12 months. If a department has been dealt with by the medical insurance agency for 8 times in total, its qualification for medical insurance diagnosis and treatment service shall be cancelled and shall not be applied for within 3 years£¨ ¡Ì)
10. Restricted items of medical insurance refer to that only when they are used within the limits of medical insurance can they be included in the scope of medical insurance reimbursement according to the requirements and then be reimbursed in proportion£¨ ¡Ì)
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