CPB Term D Final

Listed below are examples of patient reminders for appointments. Which one is HIPAA compliant?

"This is the doctor's office calling to remind you of your appointment Tuesday, April 12th at 9 am."

A family practitioner sees a Medicare patient and bills a 99213. This provider has opted-out of Medicare. His fee for the service is $125.00. Medicare's approved amount is $73.08 and the patient has met $0 of his deductible. The provider and patient have a contract in place. What can the provider bill the patient?

$125.00

Patient is seen and billed for a 99213 for $75.00. She has a policy that pays 80% of the contracted amount which is $68.00. What is the patient responsibility and amount to collect for the visit?

$13.60

A Medicare patient is seen in an office that accepts Medicare assignment. Code 99213 is billed to Medicare and the patient has no secondary insurance. The EOMB is received and Medicare approved $73.08 and pays $58.46. What amount does the patient owe?

$14.62

A patient is seen for a visit with a participating commercial carrier. Code 99204 is billed for $200.00. The contracted fee for this carrier is $153.35. The patient had a 20% co-insurance after $1,000 deductible, of which $500 is met. How much will the patient owe?

$153.35

The following is a capitation schedule for a pediatric practice. Age 0-1 yr Capitation per member, per month $25.00 2-4 $10.00 5-20 $5.00 The practice has 300 members age 0-1, 500 members age 2-4, and 2000 members age 5-20 that stay with the practice for an entire year. If the practice also preforms "carve-out" services worth $20,000, how much money will they earn over the course of a year?

290,000

Medicare overpayments should be returned within ____ days after the overpayment has been identified.

60

Medicare has 4 parts - which part is responsible for paying hospital claims?

A

A private practice hires a consultant to come in and audit some medical records. Under the privacy rule, what is this consultant considered?

A business associate

What is a clean claim?

A claim with no errors that will clear the claim scrubber, clearinghouse, and payer with no issues resulting in payment.

According to the Privacy Rule, what must a business associate and a covered entity have in order to do business?

A contract with specific safeguards on the individually identifiable health information used or disclosed by the business associate

Which of the following is not a covered entity in the Privacy Rule?

A healthcare consulting firm

When a practice sends an electronic claim to a commercial health plan for payment, what is this considered?

A transaction

Why must a provider obtain an NPI number? a. To submit claims b. To prove that he is licensed c. To be HIPAA compliant d. To guarantee payment by a health plan

A, C

When a patient is enrolled in an HMO, which options below are the responsibility of the primary care provider? a. Manage the member's treatment b. Be the only provider for all of the patient's healthcare c. Provide referrals to specialists d. Approve emergency department visits e. Provide referrals for inpatient admissions

A, C, E

Fraud and abuse penalties do NOT include:

Ability to refile claims in question

A claim submitted for a patient on Medicare with a higher fee than a patient on insurance ABC. What is this considered by CMS?

Abuse

In which of the following circumstances may PHI NOT be disclosed without the patient's authorization or permission?

An office receives a call from a patient's husband asking for information about his wife's recent office visit

A new laboratory company opens in town. The manager calls your practice and offered to pay $20.00 for every Medicare patient you send to them for radiology services. What does this offer violate?

Anti-kickback law

Insurance coverage provided by an organization that is not an employer (membership organization, credit card company offering benefits to its member) is what kind of group insurance?

Association group

Which of the following is NOT considered a part of the authorized process when the patient signs the "consent for payment???"

Authorization for treatment

A patient wants her results called to her home and states the physician is to talk with her husband. What form should be completed before this is done?

Authorization to Disclose Health Information

What makes a DVT different from a PE?

Blood clots DVT (deep vein thrombosis) is in lower leg, PE (pulmonary embolism) is in the lungs

A patient presents to be seen in the office. They do not pay at the time that the services are rendered as the provider is their primary care provider, or gatekeeper. The large group practice has 800 covered members under this plan and is paid on a monthly basis with a set amount that is based on the number of members covered and their ages. What type of plan is this?

Capitation

MCO's place the physician at financial risk for the care of the patient and are reimbursed by:

Capitation

What process is done after the patient has seen the provider?

Check out

A patient's insurance card will contain vital information that will allow a claim to be processed. Which of the following is NOT provided on the insurance card?

Claim number, CPT code, diagnosis

Which type of insurance is a health insurance that is not offered and managed by a government program?

Commercial

Which is a fixed amount that the patient receives health services?

Copayment

A records request is received from a health plan for three dates of service in a chart months apart. What should the biller do?

Copy each date of service individually and send to the health plan

What information could cause a potential problem?

Could be any of the following answers although not an option... The patients name is not consistent Relationship to the patient is incorrect Date of birth is incorrect

Health plan, clearinghouses, and any entity transmitting health information is considered by the Privacy Rule to be a:

Covered entity

A physician wants to join a new health plan. They require him to go through a process to evaluate his qualifications, education, and licensure. What is this process?

Credentialing

The parent with which child resides is considered to be

Custodial parent

Medicare beneficiary needing to fill a prescription would utilize what Part of their Medicare benefits?

D

Dr. Williams is enrolled in a capitated plan. For his list of covered lives, he receives a check for $100,000. During the year, the cost of treating the covered lives was $125,000. Which statement below is true?

Dr. Williams has a loss of $25,000 from the insurance carrier.

What Medicaid services are eligible for reimbursement for an individual that is not a citizen or does not have eligible immigration status?

Emergency services are covered

Which form is used to indicate the services performed and the diagnosis for a visit?

Encounter form

An employee has money deducted from her paycheck every week and put into an account. She uses this to pay for her deductibles, copayments, glasses, and dental care. Her employer allows no options, so if she does not use all of the money she puts in, she loses it. What type of account does she have?

FSA

A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are a Urology office they bill every patient for a urinalysis. What standard could this violate?

False Claims Act

A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statute?

False Claims Act

OIG, CMS, and DOJ are the governing agencies enforcing?

Federal Fraud and Abuse Laws

A patient presents for care and does not have an insurance card. They are billed a 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed?

File a claim with Medicaid, a refund will be completed when the RA is received showing the patients responsibility

CMS defines _____ as billing for a lower level of care than is supported in documentation, making false statements to obtain underserved benefits or payment from a federal healthcare program, for services that were not performed.

Fraud

This type of health insurance is paid for by employers for employees and takes advantage of purchasing power of having large member numbers.

Group Health Plan

HIPAA mandated what entity to adopt national standards for electronic transactions and code sets?

HHS

A patient is seen in your practice. Her husband calls later in the day to ask for information about the visit. The practice pulls the patient's privacy authorization to see if they can speak to the husband. What act does this action fall under?

HIPAA

A patient presents to be seen by his primary care physician. The physician belongs to a multispecialty group that provides care to the members of the patient's insurance. The group is paid on a quarterly on a per member basis with a flat fee. The group also contracts with other health plans. What type of insurance plan does this patient have?

HMO

An insurance plan that provides a "gatekeeper" to manage the patient's health care is known as a/an:

HMO

An employee at a company has money withheld from his or her paycheck that is moved in to an account, to which his or her employer also contributes. He or she has a high-deductible family insurance plan with a $5000 deductible. This account is used to pay for their deductibles. What type of account does he or she have?

HSA (on the test it was incorrectly labeled HAS)

There are benefits and disadvantages to providing care to a patient in a capitated managed care situation. Which of these listed is a disadvantage?

Having a large population of high-risk patients

Which of the following statements is true regarding the key provisions of coverage under the ACA?

Health plans may no longer limit or deny benefits to children under the age of 19 for pre-existing conditions.

What organ is a CABG performed on?

Heart

A patient goes by Kathy Smith. The insurance card states Katherine Smith. Which name is entered into the practice management system for claims filing?

Katherine Smith

Under the Patient Protection and Affordable Care Act what is banned?

Lifetime limits

Which of the following does not qualify a patient for coverage under Medicare?

Low-income individual

This type of healthcare organization combines the functions of health insurance, delivery of care, and administration.

MCO

Which form should be completed to determine if Medicare is primary or secondary insurance?

MSP

What is the largest health program in the United States?

Medicare

Medical records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are sent in reply to the request. What standard does this violate?

Minimum Necessary

A child is covered by insurance plans for both parents. The mother's birthday is 10/15/86 and the father's birthday is 12/15/85. Based on the birthday rule, which insurance is primary?

Mother

A new provider wants to bill insurance for his services. He has his biller apply for a number to be HIPAA compliant with his claims submission. The number is unique to him. What type of number is this?

NPI number

Which of the following statements are TRUE regarding Medicare?

No premiums are charged for Part A if the beneficiary contributed through the work force.

An internist sees a 20 year old patient for an office visit. The patient needs to see an Endocrinologist for a consultation regarding her diabetes. The internist is a participating provider in her plan. She can choose any provider she wished for her consultation, but will save money if she sees a specialist that is in her network. She does not require a referral for her consultation. What type of plan does the patient carry?

PPO

Which is a true statement regarding patient demographics?

Patient demographic information entered incorrectly can result in claims denials.

What process would NOT be preformed at the check-out process?

Patient registration process

The back of the health insurance card typically includes what information?

Phone or contact information for eligibility

A charge ticket (encounter form) is not completed. What procedure would NOT be acceptable?

Post the service as a no charge

Which of the following processes could result in lost charges?

Posting charges and payment in different batches with no balancing

The ACA is a federal mandate which establishes that coverage can no longer be denied for ____?

Pre-existing conditions

What are the options for a provider with regards to participation with Medicare?

Providers may participate, may choose not to participate, or may opt-out of Medicare.

Individuals have the right to review and obtain copies of their PHI. What is excluded from the right of access?

Psychotherapy notes

A practice agrees to pay $550,000 to settle a lawsuit alleging that the practice used imaging from one patient to justify services on multiple other patients' claims. The manager of the office brought the civil suit. What type of case is this?

Qui Tam

HIPAA section 164.508 states that covered entities may not use or disclose protected information without a valid authorization. In what circumstances can a practice NOT release protected information without a ROI?

Records request for life insurance

A claim is denied stating the provider is not credentialed with the commercial insurance. Which of the following would NOT be an option for the practice?

Refile the claim under a credentialed provider in the group using the group number.

Which list best represents information that is important to copy or scan and file in the patient's chart?

Registration form, insurance card, and photo ID

A request for medical records is received for a specific date of service from a patient's insurance company with regards to a submitted claim. No authorization from the patient is provided. What action should be taken?

Release the requested records to the insurance company

Which of the following is NOT a component of the PPO payer model?

Require the enrollee to maintain a PCP

Processing of an insurance claim begins with what process?

Scheduling an appointment

Where do you find Basal Cell carcinoma?

Skin

NPI numbers have two types of entities - identify the two types

Sole Proprietor and Group

A physician office (covered entity) discovers that the billing company (business associate) is in breach of their contract. What is the first step to be taken?

Take steps to correct the problem and end the violation

A patient has questions regarding the Privacy Practices in the clinic. Who should address these?

The Privacy Official

A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate?

The Truth in Lending Act

What is a deductible?

The amount the patient pays before co-insurance kicks in.

A child presents for care with the father. Both parents have coverage, date of birth for the mother is March 21st, the date of birth for the father is June 20th. The mother is covered by COBRA. What is the primary coverage for the child?

The father's insurance is primary because the mother has COBRA

In what circumstance would the checkout process be unnecessary?

The patient made a co-pay during the check-in process and no follow-up appointment is necessary

If a provider decides not to participate with Medicare what is one of the disadvantages?

The patient receives the reimbursement

A female patient is covered by her employer and also with her husband's insurance plan. His birthday is March 21st and hers is June 18th. Which insurance is considered primary?

The patient's insurance because she is the primary subscriber

What is the standard time frame established for records retention?

There is no single standard record retention, it varies by state and federal regulation.

HMO plans require the enrollee to:

To have referrals to see a specialist that is generated by the patient's PCP

What is the purpose of the privacy rule?

To protect patient privacy

A patient is seen that is an active duty military soldier. He has a primary care manager that sees him for his healthcare needs. At this visit, he is given a referral for some services that are not available at the military treatment facility. What type of plan does this man have?

Tricare Prime

A practice sets up a payment plan with a patient. If more than 4 installments are offered to the patient, what regulation is the practice subject to that makes the practice a creditor?

Truth in Lending Act

In addition to the standardization of the codes (ICD-10, CPT, HCPCS, and NDC) what other identifier is used on all claims?

Unique identifier for employers and providers

Which of the following actions is considered under the False Claims Act?

Up-coding or unbundling services

Which of the following situations allows release of PHI without authorization from the patient?

Worker's Compensation

What penalties can be imposed for Fraud and/or Abuse related to the US code?

a. Monetary penalties ranging from $10,000 to $50,000 for each item or service b. Imprisonment c. Exclusion from Federal Healthcare programs *d. All of the above*

Medicare coverage provides hospital coverage and voluntary medical insurance to

b. Person age 65 or older c. Certain disabled individuals under age 65 *d. Both b and c are correct*

All of the following are considered fraud, except: a. Billing every new patient at the highest level E/M visit no matter what b. Falsifying documentation to support a service that was billed to receive payment c. Failure to maintain adequate medical records d. Reporting a diagnosis code that the patient does not have, but is payable by Medicare

c