CHAPTER 17

Mr. Johnson came to the office today complaining of headache and upset stomach. He has the traditional Medicare fee-for-service plan. Your office's usual fee for an established patient visit is $125. Medicare's allowable charge is $100. If Mr. Johnson does not have Medigap insurance, how much will he have to pay for this visit?

$20

Which of the following must be verbally discussed with a Medicare beneficiary to enable the beneficiary to consider options and make informed choices?

ABN

Which of the following is correct regarding electronic claim submissions?

Claims are prepared for transmission after all required data elements have been entered.

Mrs. Lawrence is an elderly diabetic patient who is on Medicare. She recently injured her lower left leg, and since then has had trouble with open sores or ulcers on that leg. She came to the office last week to have the physician examine and treat the ulcers. At that time, you checked, and she qualified for Medicaid as well as Medicare. She has come to the office today for follow-up care and treatment. Which of the following should you do first?

Contact Medicaid to verify her eligibility

How should data in medical billing programs be entered?

Enter information using capital letters

Which of the following is not part of the process for verifying workers' compensation coverage?

Getting the name and policy number of the patient's personal health insurance policy

Greg Owen is in the office today for treatment of a small but deep cut he received while playing football. He is listed as a dependent on both of his parents insurance plans. Greg's mothers DOB is 5/23/1978 and his fathers DOB is 7/19/1973. Who is the primary payer in this case?

Greg's mothers insurance, because her birthday occurs earlier in the calendar year

Which of the following is a characteristic of Medicaid?

It is a health cost assistance program.

Which of the following types of insurance covers injuries that are caused by the insured or that occurred on the insured's property?

Liability

Of the federal programs providing healthcare, the largest is ____, which provides health insurance for citizens aged 65 and older.

Medicare

Which insurance covers a patient who has been hospitalized up to 90 days for each benefit period?

Medicare Part A

Which of the following is not part of Medicare's resource-based relative value scale?

Medigap, to reduce the gap in coverage

In which program can enrollees who are aged 65 and older continue to obtain medical services at military hospitals and clinics as they did before they turned 65?

TRICARE for Life

A husband and wife are both employed and have work-sponsored insurance plans that cover each other and their three children. Which insurance plan is the primary payer?

The insurance plan of the person whose birthday comes first in the calendar year

Which of the following guidelines is applicable when filing a Medicaid claim and interacting with Medicaid patients?

Treat the patient as if he or she has private insurance

Eligibility for Medicaid is ____.

based on the patient's reported income and assets from the previuous month

Under a contracted or fixed prepayment called ____, physicians are paid a fixed amount of money to provide needed care.

capitation

An appropriate approach to maintaining patient confidentiality on the computer is to ____.

change your password every 90 days

The usual fees that are listed on the medical office's fee schedule are fees ____.

charged to most of their patients most of the time under typical conditions

The fixed dollar amount a subscriber must pay or "meet" each year before the insurer begins to cover expenses is the ____.

deductible

The most likely outcome of an insurance claim submitted with a diagnosis code of a sore throat and a treatment code indicating a cast for a broken leg would be ____.

denied because the treatment was not medically necessary based on the diagnosis

One advantage of submitting claims electronically is ____.

electronic submissions are cost-efficient

To be covered under Medicare Part B, patients must ____.

enroll, because coverage is not automatic

An organization that provides pain relief to terminally ill patients and supports these patients and their families is a ____.

hospice

Using a clearinghouse to transmit electronic media claims ____.

includes data elements that are transmitted in a computer file.

The process of deciding the amount of money that will be paid by a third-party payer for a procedure is ____.

predetermination

When the insured person pays an annual cost for healthcare insurance, it is called a ________.

premium

The payment system used by Medicare is based on ____.

resources

An insurance claims department compares the fee the doctor charges with the benefits provided by the patient's health plan. This is called the ____.

review for allowable benefits

If providers submit a claim for a simple procedure when in fact a more complicated procedure was documented in the medical record, ____ may occur.

underpaymentOne advantage of submitting claims electronically is ____.

When a physician agrees to accept assignment for a Medicare patient, this means the physician ____.

will accept the amount of money Medicare pays as payment in full.