Deck 15: Explanation of Benefits and Payment Adjudication

Question 1

The two main methods used by providers to determine their fees are:

A) capitation-based and resource-based fee structures.
B) profit-based and charge-based fee structures.
C) charge-based and resource-based fee structures.
D) resource-based and usual-and-customary fee structures.

Answer 1

charge-based and resource-based fee structures.

Question 2

The first step that the medical office specialist is responsible for before submitting a medical claim is:

A) verifying patient insurance benefits.
B) obtaining correct and complete patient information.
C) entering patient information data into the computer.
D) posting charges and diagnoses.

Answer 2

obtaining correct and complete patient information.

Question 3

After a claim is processed, an explanation of benefits (EOB) is sent to the:

A) provider only.
B) patient only.
C) provider and the patient.
D) carrier's headquarters.

Answer 3

provider and the patient.

Question 4

No matter what amount a provider charges for a given service, each third-party payer will establish the amount they will pay based on what is considered:

A) medically appropriate.
B) usual and ordinary.
C) usual, customary, and reasonable.
D) average.

Question 5

If an insurance carrier does NOT reconsider a downcoded claim that has been appealed, the medical office specialist can:

A) request assistance from the state insurance commissioner.
B) file a complaint with the Department of Health and Human Services (DHHS).
C) file a complaint with the Centers for Medicare and Medicaid Services (CMS).
D) bill the patient for the remaining balance.

Question 6

When providers determine what fee to charge by considering what other providers charge for similar services, this method is:

A) charge based.
B) research based.
C) resource based.
D) comparison based.

Question 7

Claims processing involves the verification of medical necessity for the reported procedures; this task is performed by:

A) medical office specialists.
B) medical directors.
C) medical review examiners.
D) automated claims processors.

Question 8

Which are steps for processing reimbursements when an EOB/ERA is received from an insurance carrier?

A) determine any write-offs or adjustments required
B) compare the EOB/ERA with the claim filed
C) check the accuracy of mathematical calculations
D) all of the above

Question 9

A claim that is removed from a payer's automated processing system for additional review is subject to:

A) preauthorization.
B) manual review.
C) medical-necessity examination.
D) claims edit.

Question 10

The notification sent by the insurance carrier to the patient and provider after a claim has been processed is known as a(n):

A) patient registration form.
B) encounter form.
C) charge slip.
D) explanation of benefits.

Question 11

If the reported services are deemed NOT medically necessary at the level reported, the claim will be:

A) denied.
B) downcoded.
C) upcoded.
D) pended.

Question 12

When third-party payers determine reimbursement, they consider UCR, which means :

A) usual, customary, and reasonable charges.
B) usual and common rates.
C) uniform, customary reimbursement.
D) usual and customary resources.

Question 13

Resource-based fee structures consider all of the following factors EXCEPT the:

A) provider's location.
B) work involved.
C) overhead (expense) involved.
D) malpractice risk.

Question 14

Medicare conversion factor updates are based on all the following EXCEPT:

A) expenditure target.
B) adjustments for budget neutrality.
C) the Medicare economic.
D) the number of denied claims.

Question 15

During the patient's care, all procedures and tests are documented on the:

A) encounter form.
B) explanation of benefits.
C) claim form.
D) registration form.

Question 16

An appeal for reconsideration of a carrier's decision on a claim must be made:

A) online.
B) in writing.
C) by phone and in writing.
D) with the help of an attorney.

Question 17

When treatment is determined to be appropriate for the diagnosis, the care is considered:

A) medically necessary.
B) medically appropriate.
C) medically reasonable.
D) medically feasible.

Question 18

If a carrier downcodes a claim and the provider maintains that the reported services were medically necessary, the medical office specialist should:

A) send a bill to the patient for the remaining balance.
B) write off the remaining balance.
C) file an appeal with the insurance carrier.
D) send a complaint to the state insurance commissioner.

Question 19

The steps that result in an insurance carrier's decision to either pay or deny a claim are known as:

A) allocation.
B) adjudication.
C) determination.
D) justification.

Question 20

Which of the following dictates how long patient records are to be kept and stored?

A) retention schedule
B) turnaround time
C) record retention
D) storage schedule

Question 21

In regard to the RBRVS system, the overhead of a physician's office is referred to as the:

A) provider's work.
B) practice expense.
C) professional liability insurance.
D) payroll expense.

Question 22

In regard to the RBRVS system, the time it takes to perform a service is considered to be part of the:

A) provider's work.
B) practice expense.
C) time factor.
D) staff expense.

Question 23

The cost of malpractice insurance is highest for physicians in which of the following specialties?

A) Obstetrics and gynecology
B) Cardiology
C) Dermatology
D) Neurosurgery

Question 24

Under Medicare Part B, reimbursement to a participating provider is based on:

A) 80% payment by Medicare and 20% by the patient after a deductible.
B) 20% payment by Medicare and 80% by the patient after a deductible.
C) 80% payment by Medicare and 20% by the patient without a deductible.
D) 20% payment by Medicare and 80% by the patient without a deductible.

Question 25

Under an 80/20 plan, if a participating provider's usual charge is $200 for a procedure and the allowed amount is $150, the provider can collect:

A) $150 from the insurance carrier and $50 from the patient.
B) $120 from the insurance carrier and $30 from the patient.
C) $120 from the insurance carrier and $80 from the patient.
D) $160 from the insurance carrier and $40 from the patient.

Question 26

In regard to the RBRVS system, the risk of harm posed to the patient by a particular service or procedure is considered to be part of the:

A) provider's effort and stress level.
B) practice expense.
C) cost of liability insurance.
D) risk factor for a given specialty.

Question 27

A provider's usual charge for a procedure or service can be:

A) higher than the allowed charge.
B) lower than the allowed charge.
C) equal to the allowed charge.
D) all of the above.

Question 28

Before the Omnibus Budget Reconciliation Act (OBRA) of 1989, Medicare payments to providers were based on:

A) the resources used to perform the procedure or services.
B) a Medicare-developed reasonable fee schedule.
C) physicians' charge-based fees.
D) a capitation arrangement.

Question 29

A provider who is able to balance-bill a patient for the amount over the carrier's allowed charge is a(n):

A) contracted provider.
B) independent provider.
C) nonparticipating provider.
D) participating provider.

Question 30

The Medicare RBRVS system first implemented in 1992 is the:

A) relative basis for resource-valued services.
B) relative-based resource value scale.
C) resource-based relative value scale.
D) resource-based relative value services.

Question 31

It is not unusual for an annual deductible to be as high as:

A) $500-$1,000.
B) $1,000-$2,500.
C) $2,000-$5,000.
D) $5,000-$8,000.

Question 32

The RBRVS system establishes the nationally uniform relative value of a service based on which three cost elements?

A) The cost of payroll, the cost of supplies, and the cost of liability insurance
B) The physician's specialty, the physician's work, and the location of the practice
C) The location of the practice, the overhead, and the cost of liability insurance
D) The physician's work, the practice expense, and the cost of liability insurance

Question 33

What percentage of a physician's work value is adjusted based on geographic cost differences?

A) 25%
B) 45%
C) 55%
D) 75%

Question 34

The National uniform conversion factor is updated annually by:

A) independent insurance carriers.
B) the Centers for Medicare and Medicaid Services (CMS).
C) the legislature.
D) the Federal Register.

Question 35

The largest cost element in determining the nationally uniform relative value of a service is the:

A) provider's work.
B) practice expense.
C) cost of professional liability insurance.
D) location of the practice.

Question 36

The nationally uniform relative values are adjusted by:

A) physician training and specialty.
B) geographic practice cost differences.
C) liability insurance cost differences.
D) the number of employees of the practice.

Question 37

The physician's work element accounts for what percentage of the total relative value for each service?

A) 25%
B) 32%
C) 52%
D) 75%

Question 38

The allowed charge includes the amount that will be paid by:

A) the insurance carrier only.
B) the patient only.
C) the insurance carrier and the patient.
D) none of the above.

Question 39

Under a capitation arrangement, a provider is paid a per-member-per-month (PMPM) fee for all enrolled members:

A) who are seen that month.
B) whether or not they are seen that month.
C) who are not referred to specialty care that month.
D) who are not hospitalized that month.

Question 40

In regard to the RBRVS system, the technical skill of the provider is considered to be part of the:

A) provider's work.
B) practice expense.
C) provider's training.
D) malpractice risk.

Question 41

The section of the EOB that summarizes the total deductions, charges NOT covered by the plan, and the amount the patient may owe the provider is the:

A) service information.
B) coverage determination.
C) benefit payment information.
D) summary information.

Question 42

A percentage of a provider's payment that is NOT paid during a contract year but is kept by the health plan to offset additional costs incurred for referrals, hospital admissions, or other covered services is called a:

A) disincentive.
B) per-member-per-month (PMPM) fee.
C) withdrawal.
D) withhold.

Question 43

Physicians have the right to establish their fees at a level that they believe fairly reflects the costs of providing a service.

Question 44

The Medicare conversion factor to be used for physician payments as of January 1, 2015, is $35.8043.

Question 45

If a claim is denied due to lack of medical necessity, the provider must refund any payment made by the carrier and can bill the patient for the balance.

Question 46

When the practice receives the EOBs and documentation of deposit from the lockbox, the office insurance specialist should: (Select all that apply)

A) add up the EOBs to ensure that the total equals the company's check.
B) consider "batching" the EOBs if there are a lot of them.
C) call the bank to ensure all EOBs are accounted for in the case of a discrepancy.
D) all of the above.

Question 47

A claim that is manually reviewed by an insurance carrier can be denied for lack of required preauthorization.

Question 48

The set amount a patient must pay at the time of service is the:

A) coinsurance.
B) copayment.
C) deductible.
D) premium.

Question 49

A provider's usual charge for a service can be higher, equal to, or lower than the insurance carrier's allowed charge.

Question 50

The section of the EOB that indicates who was paid, how much, and when is the:

A) service information.
B) coverage determination.
C) benefit payment information.
D) summary information.

Question 51

The patient is responsible for the difference between the provider's usual charge and the carrier's allowed charge when services are received from a participating provider.

Question 52

An explanation of benefits (EOB) is notification the provider sends to the patient detailing what the insurance carrier has paid.

Question 53

What is the benefit specified in an insurance policy that is different from out-of-pocket expenses because once the stated maximum has been met for a lifetime, no more benefits will be paid?

A) lifetime maximum
B) lifelong maximum
C) maximum benefits
D) existence benefits

Question 54

Coinsurance refers to:

A) the amount a patient must pay each year before benefits begin.
B) a set amount a patient must pay at the time of service.
C) a percentage of allowable charges the patient must pay.
D) the amount of out-of-pocket expenses a patient must pay.

Question 55

The resource-based fee structure takes into account the provider's work, the practice expense, and the cost of professional liability insurance.

Question 56

The deductible under most insurance plans applies to each covered individual each:

A) date of service.
B) month.
C) calendar year.
D) contract.

Question 57

The Medicare Fee Schedule (MFS) is based on the provider's charge-based fee schedule.

Question 58

The difference between the billed amount and the allowed amount for services from a participating provider is:

A) billed to the insurance carrier.
B) billed to the patient.
C) written off by the provider.
D) written off by the insurance carrier.

Question 59

Seventy-five percent of the physician's work value under the RBRVS is adjusted by geographic cost differences.

Question 60

The Medicare Shared Savings Program is the most well-known and standardized example of value-based reimbursement.

Question 61

EOB notifications are issued in the same format by all insurance carriers.

Question 62

A patient's out-of-pocket expenses include deductibles, coinsurance, and copayments.

Question 63

________ is the act of processing a claim that consists of edits, review, and determination.

Question 64

A(n) ________ claim is one that has been received by the carrier but cannot be processed due to an error or because additional information is needed.

Question 65

Medical necessity reduction by an insurance carrier is also known as ________.

Question 66

Under a managed care contract with a capitation reimbursement method, the provider is paid a PMPM fee for each enrolled member regardless of services provided.

Question 67

The benefit payment information on an EOB indicates who was paid, how much, and when.

Question 68

Match the following

Code shown on an explanation of benefits (EOB) to explain the coverage determination or a denial

A) deductible
B) electronic remittance advice (ERA)
C) conversion factor
D) coinsurance
E) relative value unit
F) reason code
G) adjudication
H) copayment
I) withhold
J) allowed charge

Question 69

A provider is paid a per-member-per-month (PMPM) fee for each enrolled member in a health plan that uses the ________ method of reimbursement.

Question 70

The amount of time it takes for the insurance carrier to process a claim is called the ________ time.

Question 71

Monies owed to a provider by insurance carriers or patients make up the ________.

Question 72

A positive or negative change to a patient's account balance is a(n) ________.

Question 73

Reason and remark codes are explained on the face or back of the EOB/ERA.

Question 74

A lockbox service provided by a bank helps control receivables by collecting and depositing carrier and patient payments faster than if the process were performed by office staff.

Question 75

The RBRVS system unit of measurement assigned to a service based on the relative skill and time required to perform it is the ________ unit.

Question 76

A patient is expected to pay for services excluded from his or her insurance policy at the time the service is rendered.

Question 77

The amount of covered expenses that a policyholder must pay before insurance benefits begin is the ________.

Question 78

State and federal regulations determine how long patient records must be kept and stored.

Question 79

Electronic funds transfer (EFT) is more costly to the practice than depositing checks.

Question 80

Participating providers can demand payment in full from the patient rather than waiting for the insurance carrier to process the claim.