What is the term for the total amount of covered medical expenses a
policyholder must pay each year out-of-pocket before the health insurance
company begins to pay any benefits? - ANSWER A deductible is the
amount a policyholder pays for health care services before the health
insurance begins to pay.
Which type of insurance covers physicians and other healthcare
professionals for liability as to claims arising from patient treatment? -
ANSWER Medical malpractice insurance is a type of liability insurance that
covers physicians and other healthcare professionals for liability as to
claims arising from patient treatment.
Which of the following does NOT fall under group policy insurance?
I. The premium is paid for by the employee.
II. The premium is paid for (or partially paid for) by an employer.
III. The employer selects the plan(s) to offer to employees.
IV. Physical exams and medical history questionnaires are a mandatory
part of the application process.
V. Employee can make changes to the policy.
VI. The employee's spouse and children are not eligible for coverage. -
ANSWER I, IV, V, and VI, Group health insurance coverage is a type of
health policy that is purchased by an employer and is offered to eligible
employees of the company, and to eligible dependents of employees. With
group health insurance, the employer selects the plan (or plans) to offer to
employees. With an individual policy, you are the only one who can make
changes to your policy and you are the only one who can cancel the
coverage. You have full control over your own policy. Applicants for
individual health insurance will need to complete a medical history
questionnaire and have a physical exam when applying for coverage.
Dr. Wallace is in a capitation contract with Belleview Managed Care Health
Plan. He received $25,000 from the health plan to provide services for the
175 enrollees on the health plan. The services provided by Dr. Wallace to
the enrollees cost $23,000. Based on the information, what must be done?
,- ANSWER Dr. Wallace can keep the $2,000 profit under the terms of the
capitated plan
What is the deadline for filing a Medicare claim? - ANSWER One year
from the date of service
A provider sees a patient who has TRICARE Select. The provider is not
contracted with TRICARE but is certified by the regional TRICARE
Managed Care Support Contractor (MCSC). The provider charges $200 for
the office visit. TRICARE allows $160 and pays $140. How much can the
provider bill the patient for? - ANSWER . $60.00
What organization is responsible in evaluating the medical necessity,
appropriateness, and efficiency of the use of healthcare services and
procedures? - ANSWER Utilization Review Organization
Medicaid providers are forbidden by law to: - ANSWER Balance bill
patients
Which statement is FALSE about Local Coverage Determinations (LCDs)?
- ANSWER CMS develops LCDs when there is no National Coverage
Determination
When a minor procedure is performed on a Medicare patient, what is the
global period and what time frame is covered? - ANSWER 10-day global
period - the day of the procedure and 10 days following the procedure.
View Rationale
Question 11
If add-on procedure code 11103 is performed twice during an office visit,
how is it indicated on the CMS-1500 claim form? - ANSWER Code 11103
is reported once with the number 2 in box 24G
Which set of documentation guidelines can be used for E/M services
submitted to Medicare for a physician assistant (PA)? - ANSWER Either
1995 or 1997 CMS documentation guidelines
Select the scenario that meets the incident-to requirements - ANSWER
Care is delivered to an established patient by the physician assistant as
,part of the physician's treatment plan while the physician is seeing another
patient in the same office suite in a different room.
Medicare beneficiary is having a screening colonoscopy performed. How is
the service reported to Medicare? - ANSWER G0121
Which providers submit the CMS-1500 claim form?
I. Independent diagnostic testing facilities (IDTFs)
II. Emergency department physicians
III. Hospice organizations
IV. Ambulance companies submitting under their own Medicare number
V. Physicians in a group practice
VI. Ambulatory surgery centers - ANSWER I, II, IV, V and VI
According to CPT® Radiology Guidelines, if a patient is given oral contrast
for a CT scan of the abdomen which code is reported? - ANSWER 74150
Computed tomography, abdomen; without contrast material
Which of the following is NOT in the HIPAA Privacy Rule? - ANSWER
Implementing hardware, software, and/or procedural mechanisms to record
and examine access and other activity in information systems that contains
or use electronic PHI (e-PHI).
When a physician intentionally bills procedures to Medicaid that he did not
perform he is in violation of which Act? - ANSWER False Claims Act
Cardiologist Dr. W has been consistently reporting a higher E/M level than
what is documented to cover the revenue being lost in his practice. Is this
considered fraud or abuse and why? - ANSWER Fraud; the provider
intentionally over-coded to gain financially
What is a Qui tam relator? - ANSWER A person who brings civil action for
violation under the False Claims Act (FCA) for themselves and the US
government
Dr. Wilson assigns all established Medicare patients E/M level 99215
regardless of the work performed during the visit. He considers all
Medicare patients to be complicated patients and therefore, he should be
paid at the highest rate possible. Is Dr. Wilson's actions considered fraud or
, abuse? - ANSWER Fraud; he is knowingly billing patients incorrectly to
obtain higher payment
Dr. Jay is a gynecologist and has been reporting two codes for a total
abdominal hysterectomy with removal of the ovaries and fallopian tubes
(salpingo-oophorectomy), codes 58150 and 58720. - ANSWER 58150
JR had surgery on January 15, 20XX by Dr. Waters (a Medicare
participating provider). The Medicare fee schedule for the surgery is $500.
Four months later, JR and Dr. Waters each received a check from
Medicare in the amount of $400. JR signed over his $400 to Dr. Waters. JR
had previously paid the doctor $100 for the co-insurance. In total Dr.
Waters has received $900 for the surgery provided on January 15, an
overpayment of $400. What should Dr. Waters do? - ANSWER Contact
the MAC of the overpayment and provide a refund.
Which one is NOT a Nonphysician Practitioner (aka mid-level provider)? -
ANSWER Resident
Which Federal Law requires written acknowledgement of consumer billing
disputes and investigation of billing errors by creditors? - ANSWER Fair
Credit Billing Act
Mr. Doyle had seen a non-participating provider for a hernia repair in
outpatient surgery. His insurance company Telehealth provided a
reimbursement check of $400 for the anesthesia services provided to him
for the surgery. Mr. Doyle cashed the check and kept the money. Mr. Doyle
receives the bill from the anesthesiologist, but he no longer has the money
to pay it. The account becomes delinquent and is outsourced to a collection
agency. The collection agency is unable to obtain any monies from Mr.
Doyle. What is this is considered? - ANSWER Bad debt
Relative Value Units (RVUs) are payment components consisting of: -
ANSWER Physician work; Practice Expense; Professional
liability/malpractice insurance
Which of the following falls under the Prompt Payment Act? - ANSWER
Clean claims must be paid or denied within 30 days from the date of receipt
by MACs
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