MIB Final Exam Study Guide
A plan pays 75 percent of the provider's usual charge and requires the copayment of $15 to be applied toward the provider's payment. Calculate what the plan pays the provider when the usual charge is $380?
$270 --The provider is paid $270 ((380 x .75) - 15 = $270) by the plan--
The Medicare allowed charge is $240 and the PAR provider's usual charge is $600. What amount does the patient pay, if the deductible has already been paid?
$48 -The patient pays $48, or 20 percent of the allowed charge-
Calculate the amount of money a patient would owe for a noncovered service costing $900 if their indemnity policy has a coinsurance rate of 80-20, and they have already met their deductible.
$900 --The patient would owe the entire cost of $900, as insurance policies do not pay for noncovered services--
A plan pays 50 percent of the provider's usual charge and requires the copayment of $5 to be applied toward the provider's payment. Calculate what the plan pays the provider when the usual charge is $200?
$95 --The provider is paid $95 ((200 x .50) - 5 = $95) by the plan--
Which of the following modifiers is important for compliant billing?
-91 -59 -25 ***all of these are important***
Which of the following is another common term for encounter forms?
-charge slips -superbills -routing slips **all of these are correct**
The federal government requires states to offer Medicaid benefits to children whose family income is under ____ percent of the poverty level.
133
The coinsurance for Medicare Part B is:
20%
Global periods for a major procedure have which of the following postoperative periods?
90 days
Medicare Part A is administered by:
CMS
The federal agency that runs Medicare and Medicaid is:
CMS
You need to send a claim to a payer who does not accept electronic claims. Identify the claim form you would use to send a paper claim.
CMS-1500 claim
CMS stands for
Centers for Medicare & Medicaid Services
A(n) ______________ can be used by providers to transmit claims in the proper format for carriers.
Clearinghouse
CE is the abbreviation for:
Covered entity
Which of the following three factors are built into the resource-based fee structure?
Difficulty of procedure, office overhead, risk of procedure
EPSDT is the abbreviation for
Early and Periodic Screening, Diagnosis, and Treatment
________ is the process of encoding information in such a way that only the person (or computer) with the key can decode it.
Encryption
What provides workers' compensation benefits for civilian employees of the federal government?
FECA
_____________ is deception with intent to benefit from the behavior.
Fraud
Durable medical equipment (DME) such as wheelchairs covered by the Medicare program are reported using?
HCPCS codes
__________ is referred to as the payer of last resort.
Medicaid
Restricted status refers to a category of:
Medicaid beneficiary
Under the payer-of-last-resort regulation:
Medicaid pays last on a claim when a patient has other effective insurance coverage
Hospital benefits are provided under:
Medicare Part A
Outpatient hospital benefits are provided under:
Medicare Part B
Which Medicare Part provides coverage for durable medical equipment?
Medicare Part B
Which of the following is also called Supplemental Medical Insurance?
Medicare Part B
Roster billing is used to file simplified claims for certain:
Medicare immunization programs
For release of PHI for treatment, payment, and operations:
No authorization is required from the patient
Releasing protected health information for other than treatment, payment, or healthcare operations requires
Patient's signed authorization
PHI is the abbreviation for
Protected Health Information
Each Medicare enrollee receives a Medicare card issued by:
Social Security Administration
SOAP is the abbreviation for which of the following?
Subjective/Objective/Assessment/Plan
What does the abbreviation SSI stand for?
Supplemental Security Income
The abbreviation for treatment, payment, and healthcare operations is:
TPO
TANF is the abbreviation for
Temporary Assistance for Needy Families
Patients with end-stage renal disease are entitled to Medicare benefits until:
They can be any age as long as they receive dialysis
After discharging a workers' compensation for a patient to go back to work, the provider must file
a final report
Physicians who participate in the Medicare program must:
accept assignment and file claims for beneficiaries
Patients have the right to _____ and inspect their complete health record.
access
For unassigned claims, the payment for services rendered is expected:
at the time of service
Anyone over age 65 who receives Social Security benefits is automatically
both enrolled in Medicare Part A and eligible for Medicare Part B
A ____________ is an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI and also that could pose a significant risk of financial, reputational, or other harm to the affected person.
breach
What type of provider is required to have patients sign an acknowledgment?
direct provider
The medical insurance specialist should check patients' Medicaid eligibility:
each time an appointment is made
EDI is the abbreviation for
electronic data interchange
The Medicare program:
employs MACs to pay the claims submitted by providers
Which of the following steps comes second in the standard medical billing cycle?
establish financial responsibility for a visit
Stop-loss provisions protect providers against
extreme financial loss
If a patient authorizes a provider to accept assignment, what can the provider now do on their behalf?
file claims for the patient and receive payments directly from the payer
When a provider initially examines a workers' compensation patient, what document must be filed with the state?
first report of injury
Among the following, who do most states require public and private companies to provide workers' compensation coverage for?
full time, part time and minors
If a patient has coverage under two insurance plans, the primary plan is the one that?
has been in effect for the patient the longest
HIPAA identifies three types of covered entities:
health plans, clearinghouses, and providers
The Medicare limiting charge is the ____________ fee that can be charged for a procedure by a nonparticipating provider.
highest
An employee suffers a bad fall in a factory and has to be trained to work in the administrative office for the company as a result of the injury. Which category describes this type of injury?
injury requiring vocational rehabilitation
Which of these categories applies to a worker who is injured on the job, requires treatment, and is unable to return to work without vocational rehabilitation?
injury requiring vocational rehabilitation
Which of these categories applies to a worker who is injured on the job, requires treatment, is unable to return to work, and is not expected to be able to return to his or her regular job in the future?
injury with permanent disability
Which of these categories applies to a worker who is injured on the job, requires treatment, and is unable to return to work within several days?
injury with temporary disability
Which of these categories applies to a worker who is injured on the job, and requires treatment, but is able to return to work within several days?
injury without disability -The injury without disability category applies to a worker who is injured on the job, and requires treatment, but is able to resume working within several days-
The terms "subscriber" and "guarantor" have the same meaning as:
insured
A "self-pay" patient is one who:
is uninsured
Name the function of the carrier block.
it allows for a four-line address for the payer
What type of disabilities are due to lower extremity injuries?
limitation to sedentary and semisedentary work
Determine which of the following types of services a health plan will not pay for.
noncovered services
NonPAR stands for:
nonparticipating
The limiting charge under the Medicare program can be billed by:
nonparticipating providers only
Medicare may classify conditions that are not covered as:
not medically necessary
A person eligible for Medicaid in a given state is
not necessarily eligible in all other states
Which term is used to describe the physician who first treats the injured or ill employee?
physician of record
What classification of disability describes an individual who has lost 50 percent of heavy lifting ability?
precluding heavy lifting
Which of the following steps comes after checking billing compliance in the standard medical billing cycle?
prepare and transmit claims
What kind of medical services are annual physical examinations and routine screening procedures?
preventive
What does the physician of record file with the insurance carrier every time there is a substantial change in the patient's condition that affects disability status or when required by state rules and regulations?
progress report
If a patient was sent by another physician, that physician is known as the
referring physician
A ____________ is a person who makes an accusation of fraud or abuse.
relator
Spending on healthcare is
rising
What type of pain will force an employee to avoid any activities that will lead to the pain?
severe pain
What type of pain may limit an employee on some work assignments but is generally tolerable?
slight pain
What step is used when patient payments are later than permitted under the financial policy?
step 10, follow up patient payments and collections
Verifying insurance is part of which medical billing cycle step?
step 2, establish financial responsibility for the visit
Another term for the insured is:
subscriber
Which of the following is NOT part of usual evaluation and management services?
surgical procedure --A surgical procedure is not included in the E/M service--
An RTCA generates
the actual amount the patient will owe
What information does RTCA allow the practice to view?
the amount the health plan will pay and amount patient will owe
If an employed patient has coverage under two insurance plans, one from a current employer and one from a previous employer, the primary plan is:
the current employer's plan
For how many days of disability are cash benefits generally not paid?
the first seven days
How is coinsurance defined?
the percentage of each claim that the insured pays
Assignment of benefits authorizes:
the physician to file claims for a patient and receive direct payments from the payer
If a retired patient with Medicare also has coverage under a working spouse's plan, the primary plan is:
the spouse's plan
FMAP is the basis for federal government Medicaid allocations to
the states
What is the most common method states use to determine wage-loss benefits?
they compensate employees based on a percentage of their salary before the injury
An established patient is defined as one who has seen the provider within the last
three years
A crossover claim is automatically:
transmitted by the primary payer to the secondary payer.
How many diagnosis codes may be reported on the HIPAA 837?
twelve
The three parts of an RBRVS fee are:
uniform value, GPCI, and conversion factor
_______ is a normal fee charged by a provider.
usual fee
The amount of time that must pass before an employee can enroll in a health plan is called a(n)
waiting period
How current must the signature on file have been obtained for the release of information to be permissible?
within twelve months