Deck 17: Refunds and Appeals

Question 1

If a patient is upset about a claim denial, the medical office specialist should do all of the following EXCEPT:

A)explain in simple language why the insurance carrier denied payment.
B)ask the patient to call the insurance carrier to try to get them to reconsider.
C)use respect and care when explaining policy benefits.
D)if the denial was due to a need for additional information, submit the additional documentation immediately and let the patient know it has been done.

Answer 1

ask the patient to call the insurance carrier to try to get them to reconsider.

Question 2

An examination and verification of claims and supporting documentation submitted by a physician is known as a(n):

A)appeal.
B)audit.
C)reconsideration.
D)review.

Answer 2

audit.

Question 3

The patient is responsible for payment when a claim is denied in all of the following cases EXCEPT when:

A)services were for treatment of an excluded preexisting condition.
B)services were provided after coverage was canceled.
C)services were provided that were not preauthorized.
D)services were provided before coverage was in effect.

Answer 3

services were provided that were not preauthorized.

Question 4

Using the SOAP format, the physician's recommended treatment, testing, or therapy is:

A)a subjective finding.
B)an objective finding.
C)part of the assessment.
D)part of the plan.

Question 5

In medical record documentation, a commonly used format is SOAP, which stands for:

A)subjective, objective, audit, process.
B)subjective, objective, action, plan.
C)subjective, objective, assessment, plan.
D)subjective, objective, assessment, payment.

Question 6

Using the SOAP format, the diagnosis made by the doctor is:

A)subjective information.
B)objective information.
C)part of the assessment.
D)part of the plan.

Question 7

If a claim is denied because additional information is needed to prove medical necessity, the medical office specialist should:

A)bill the patient.
B)write off the entire amount.
C)ask the patient to write a letter explaining the situation.
D)submit the required information and follow up with the carrier.

Question 8

Of the following, who may ask the state insurance commissioner for help in resolving a payment dispute?

A)Patients and physicians only
B)Patients and insurance carriers only
C)Physicians and insurance carriers only
D)Patients, physicians, and insurance carriers

Question 9

Using the SOAP format, the patient's chief complaint and reason for the encounter as the patient told it to the doctor are:

A)subjective information.
B)objective information.
C)assessment information.
D)the plan.

Question 10

If a physician requests a peer review that results in confirmation that services were NOT medically necessary:

A)the patient should be billed for the review.
B)the insurance carrier will pay for the review.
C)there is no charge for the review.
D)the physician must pay for the review.

Question 11

From the insurance carrier's perspective, if a service is NOT documented in the medical record, the:

A)patient should be contacted to confirm the service was rendered.
B)medical office specialist should be contacted to modify the record.
C)physician should verbally verify that the service was provided.
D)service was not performed and cannot be billed.

Question 12

Providing additional clinical information to an insurance company as part of an attempt to overturn a claim denial is known as submitting a(n):

A)appeal.
B)audit.
C)adjudication.
D)reconsideration.

Question 13

Reasons to rebill an insurance claim include all of the following EXCEPT:

A)the medical office specialist made a mistake on the claim.
B)charges on the original claim were not detailed.
C)the patient was not eligible when the initial claim was filed.
D)some of the services provided to a patient were not billed on prior claims.

Question 14

An objective, unbiased group of physicians that determines what payment is adequate for services provided is a(n):

A)appeal committee review.
B)routine examination of claims.
C)peer review.
D)utilization review.

Question 15

Some insurance carriers perceive automatic rebilling after 30 days to be aggressive and a:

A)requirement.
B)fraudulent practice.
C)sign of error on the part of the physician's office.
D)recommended practice.

Question 16

The chronological recording of pertinent facts and observations regarding a patient's health status is known as:

A)medical transcription.
B)documentation.
C)claims processing.
D)encounter form completion.

Question 17

If a claim is denied because services were provided before insurance coverage was in effect, the medical office specialist should:

A)bill the patient.
B)write off the entire amount.
C)wait until the effective date of the coverage, then bill the insurance carrier.
D)change the date of service and resubmit the claim.

Question 18

Using the SOAP format, documentation of the physical examination performed by the physician is:

A)subjective information.
B)objective information.
C)assessment information.
D)the plan.

Question 19

Using the SOAP format, the evaluation and management (E/M) history that the physician takes is:

A)subjective information.
B)objective information.
C)assessment information.
D)the plan.

Question 20

If a claim is denied as a noncovered service, the medical office specialist should:

A)bill the patient.
B)write off the entire amount.
C)negotiate with the patient for partial payment.
D)file an appeal with the insurance carrier.

Question 21

When appealing a denial made because the carrier doesn't believe the services were medically necessary, the medical office assistant should include information:

A)from the patient's medical record.
B)about payment from other carriers in similar cases.
C)about the physician's time spent with the patient.
D)about the patient's benefit plan.

Question 22

The third level of a Medicare appeal is a request for:

A)review by a qualified independent contractor.
B)redetermination by the carrier.
C)review by an administrative law judge.
D)review by the state insurance commissioner.

Question 23

Using the SOAP format, medication ordered for the patient is:

A)subjective information.
B)objective information.
C)part of the assessment.
D)part of the plan.

Question 24

Using the SOAP format, documentation of the physician's medical decision making is:

A)subjective information.
B)objective information.
C)part of the assessment.
D)part of the plan.

Question 25

According to ERISA, a carrier must provide a decision on an appeal within:

A)60 days.
B)90 days.
C)120 days.
D)180 days.

Question 26

The first level of Medicare appeals is a request for:

A)review by a qualified independent contractor.
B)redetermination by the carrier.
C)review by an administrative law judge.
D)review by the state insurance commissioner.

Question 27

An appeal must be made in writing if:

A)a billing error was made by the medical office assistant.
B)the carrier requested information from the patient that was not received.
C)the patient had a routine service covered by the policy.
D)the claim was for services related to an accident.

Question 28

Using the SOAP format, the documentation of vital signs, height, weight, and blood pressure is:

A)subjective information.
B)objective information.
C)part of the assessment.
D)part of the plan.

Question 29

The law that protects the interests of beneficiaries enrolled in private employee benefit plans is known as:

A)Title XXI of the Social Security Act.
B)HIPAA.
C)ERISA.
D)FECA.

Question 30

When appealing disallowances resulting from low maximum allowable fees, the medical office assistant should include information:

A)from the patient medical record.
B)about payment from other carriers for the reported service.
C)about the physician's financial situation
D)about why the patient cannot afford to pay more.

Question 31

Benefit plans NOT covered by the Employee Retirement Income Security Act (ERISA) include:

A)private employee benefit plans.
B)church plans.
C)self-funded plans.
D)insurance plans offered by employers.

Question 32

The medical office specialist can learn about an insurance carrier's appeals process through:

A)an administrative manual.
B)newsletters from the carrier.
C)phone calls to the carrier.
D)all of the above.

Question 33

Simple appeals may be accepted by:

A)telephone or fax.
B)sending a form letter.
C)rebilling the claim.
D)sending a copy of pertinent court decisions.

Question 34

The second level of Medicare appeals is a request for:

A)review by a qualified independent contractor.
B)redetermination by the carrier.
C)review by an administrative law judge.
D)review by the state insurance commissioner.

Question 35

Qualified independent contractors must process a reconsideration within:

A)30 days.
B)60 days.
C)90 days.
D)180 days.

Question 36

ERISA stands for the:

A)Employer Resources Income Security Act.
B)Employer Retirement Incentive Savings Act.
C)Employee Retirement Incentive Savings Act.
D)Employee Retirement Income Security Act.

Question 37

According to ERISA, a plan must pay a claim or respond regarding its status within:

A)30 days.
B)60 days.
C)90 days.
D)1 year.

Question 38

According to ERISA, a provider must file an appeal within:

A)30 days after denial.
B)60 days after denial.
C)90 days after denial.
D)180 days after denial.

Question 39

All of the following claims can be appealed by telephone EXCEPT those in which:

A)a modifier was used to indicate multiple procedures that the carrier bundled.
B)the claim was considered not medically necessary.
C)the carrier requested information from the patient that was not received.
D)the patient had a routine service covered by the policy.

Question 40

Medicare carriers must process a redetermination within:

A)30 days.
B)60 days.
C)90 days.
D)180 days.

Question 41

If the services provided are NOT appropriate in light of the diagnosis and the claim is denied, a telephone appeal can resolve the situation.

Question 42

When answering a patient's questions about claims, the medical office specialist should use technical terms in order to sound more professional and accurate.

Question 43

If a denial by a self-funded plan is upheld, the medical office assistant should appeal to the:

A)carrier legal department.
B)carrier president.
C)Department of Labor.
D)Department of Insurance.

Question 44

A medical office specialist can appeal a claim in writing or over the telephone.

Question 45

When a provider receives a partial payment on a claim because the amount billed was in excess of the maximum allowed charge, this is a:

A)denial.
B)downcode.
C)determination.
D)disallowance.

Question 46

If a procedure is NOT documented in the medical record, it cannot be reported or billed.

Question 47

When payment is denied, the insurance carrier only notifies the patient.

Question 48

The statute of limitations for refunds in cases in which no contract language covers refunds is:

A)2 years.
B)4 years.
C)5 years.
D)7 years.

Question 49

To take a Medicare appeal to the level of a decision by an administrative law judge, the claim must be for a minimum of:

A)$130.
B)$150.
C)$360.
D)$500.

Question 50

In general, Medicaid can request refunds for overpayments to providers for up to:

A)180 days.
B)1 year.
C)3 years.
D)5 years.

Question 51

The number one reason that appeals of Medicare Part B claims are returned is for not:

A)filing within the specified time limit.
B)including a valid signature.
C)including necessary documentation.
D)having patient consent.

Question 52

If a claim is denied due to services NOT being covered under the insurance policy, the patient cannot be billed for the services.

Question 53

Statistics show that the percentage of claims typically overturned on the first appeal is:

A)15%.
B)20%.
C)25%.
D)30%.

Question 54

A patient's vital signs, height, and weight would be documented as subjective information in the medical record.

Question 55

The plan section of the medical record includes the diagnosis made at the time of the encounter or shortly thereafter.

Question 56

Wrongfully keeping an overpayment is illegal and is called:

A)conversion.
B)retention.
C)fraud.
D)embezzlement.

Question 57

Subjective information in the medical record includes the history of the present illness (HPI).

Question 58

If a denial is upheld when regulatory information was included in the original appeal, the medical office assistant should appeal to the:

A)carrier legal department.
B)carrier president.
C)Department of Labor.
D)Department of Insurance.

Question 59

Physicians must file a Medicare appeal with an administrative law judge within:

A)30 days.
B)60 days.
C)90 days.
D)120 days.

Question 60

Most practices learn about the appeals policies of the insurance carriers they work with by referring to administrative manuals, contracts, and newsletters.

Question 61

If a claim is denied because the carrier does NOT have details about an accident, the appeal can be handled through a telephone call.

Question 62

Negative adjustments will __________ the balance, while positive adjustments will __________ the balance on a patient account.

Question 63

A copy of an appeal letter sent to a carrier should also be sent to the patient.

Question 64

An appeal letter is more effective when the medical office specialist includes information about the federal and state laws that affect the claim submission.

Question 65

Credit balances and refunds are a result of an overpayment by the __________ or the insurance carrier.

Question 66

When a carrier denies a claim because it determines that another carrier should be the primary payer, __________ of benefits is needed to determine the responsibility of each payer.

Question 67

Church and government health benefit plans are NOT regulated by the Employee Retirement Income Security Act (ERISA).

Question 68

A(n) __________ is an examination and verification of claims and supporting documentation submitted by a physician or medical facility to a carrier.

Question 69

To ensure timely payment, claim status must be __________ and follow-up done with the insurance carrier.

Question 70

When an objective, unbiased group of physicians reviews claims to determine what payment is adequate for the services provided, the process is called __________ .

Question 71

When rebilling using paper claims, the second submission should be clearly identified as a(n) __________ billing.

Question 72

Approximately 50% of all claims are overturned on the first or second appeal.

Question 73

A stamped provider signature or that of an authorized employee is acceptable on Medicare appeals.

Question 74

A negative adjustment to a patient account will decrease the balance owed.

Question 75

The government official whose office regulates the insurance industry and who serves as a liaison between patients and carriers, and physicians and carriers, is the state __________ .

Question 76

Under the Employee Retirement Income Security Act (ERISA), a carrier must respond to a claim that has been filed within 120 days.

Question 77

The second level of appeal for a Medicare claim is handled by __________ who process reconsiderations.

Question 78

Credit balances and refunds result from __________ by patients and third-party payers.

Question 79

A provider has 120 days to file a request with the Medicare carrier for a redetermination on a denied claim.

Question 80

To be reconsidered for payment by qualified independent contractors (QICs), a claim must be for an amount greater than $100.