NCCT REVIEW-COLLECTIONS

A patient with no previous balance presents for an encounter and wants to know what her bill will be. Calculate the patient's estimated balance if she will receive a service worth $127 and have a $15 copayment. The physician is a non-participating physician. A. $15 B. $112 C. $127 D. $142

$112 Rationale Since the provider is a non-participating provider, the patient is responsible for the full amount, $127. Since the patient will be paying her $15 copay, the balance will be $112 (127-15=112).

The payer provided the following information on a patient's account: Charge - $189.00 Discounted Amount - $74.59 Patient Responsibility - $30.00 Amount Paid to Provider - $84.41 Which of the following is the payer allowed amount for this claim? A. $84.41 B. $114.41 C. $74.59 D. $159.00

$114.41 —Rationale— The allowed amount in this scenario can be found using one of two methods. The first is to take the charge amount ($189) and subtract the discounted amount ($74.59), which would be $189- $74.59 = $114.41. The second is to take the patient's responsibility ($30) and add it to the amount paid to the provider ($84.41), which would be $30 + $84.41 = $114.41.

A patient received a bill from his doctor's office. His office visit charges were $195.00 and he paid his $20.00 copay. This left a balance of $175.00 which was billed to the insurance company. The insurance allowed amount was $155.00. Which of the following amount should be adjusted off his bill? A. $25.00 B. $40.00 C. $0.00 D. $20.00

$20.00 Rationale The adjusted amount is the difference between the billed amount and the allowed amount, which is $175 - $155 = $20.

The physician sees the patient for a physical exam. The amount billed to the insurance company is $150.00 and the EOB states the allowed amount is $105.00. The patient has 80/20 coverage. Which of the following is the patient's responsibility? A. $30.00 B. $21.00 C. $84.00 D. $45.00

$21.00 Rationale The patient is responsible for 20% of the allowable charge (105 x .20= 21). $21 is the patient's responsibility.

The insurance and coding specialist received an EOB and is posting the payments to the patient accounts. According to the following information below, how much does the patient still owe for this service? Non-participating provider Copay: $20, paid at time of service Deductible amount that patient paid: $100 Accepted fee for service: $250 Insurance payment: $75 A. $155 B. $175 C. $55 D. $75

$55 —Rationale— Total charges are $250.00 of which the patient has paid $20.00 and $100.00. This now leaves a balance of $130.00, of which the insurance company paid $75.00. This now leaves a balance due from the patient of $55.00.

A patient had a procedure which was billed at $200.00. The allowed amount was $150.00 and he has $50.00 left to meet of his deductible. His co-insurance is 20%. How much does the patient owe? A. $90.00 B. $80.00 C. $120.00 D. $100.00

$80.00 —Rationale— The insurance company's maximum allowed amount is the total amount allowed to be paid to the provider. In this case, it is $150.00. The deductible is a set amount that each patient must meet annually prior to their insurance benefits beginning. In this question the patient still has $50 remaining to their deductible. Coinsurance is cost sharing between the insurance company and the policyholder. After the deductible has been met, the policyholder pays a certain percentage of the bill and the insurance company pays the remaining percentage of allowable charges. The patient in this question is responsible for 20%. $150 allowed amount. 20% of $150 allowed is $30. Patient still owes $50 deductible. Patient would owe $80 total.

34. A patient's account is in collections for a past due balance. The patient calls stating that she has secondary insurance which she did not provide at the time of service. Upon validating the secondary insurance, which of the following should the insurance and coding specialist do in order to resolve the account? (Select the two (2) correct answers.) A. Contact the collection agency with this new insurance information so that they can send the balance to insurance company. B. Have the patient contact the collection agency with this new insurance information, so they can send the balance to the insurance company. C. Have the patient contact the insurance company so they can contact the collection agency. D. Send the patient an itemized bill so that she can submit her own claim to the insurance company. E. Inform the patient that secondary insurance must be provided at the time of service in order to file a claim.

-Contact the collection agency with this new insurance information so that they can send the balance to insurance company. -Have the patient contact the collection agency with this new insurance information, so they can send the balance to the insurance company. Rationale After a claim has been sold to an outside collection agency, it is no longer owned by the office that rendered the services. The claim is now owned by the outside collection agency. It is always the responsibility of the insurance and coding specialist to work on behalf of the patient, so it is the insurance and coding specialist's responsibility to contact the collection agency to give them the corrected information so that they can submit a claim to the secondary payer. The patient should also contact the collection agency to establish contact and let them know that the bill will be paid if the claim is sent to the secondary insurance.

Which of the following are likely reasons for a claim to be rejected? (Select the three (3) correct answers.) A. preauthorization not obtained B. incorrect patient address C. incorrect DOB D. incomplete registration form E. incorrect insurance information

-preauthorization not obtained, -incorrect DOB, -incorrect insurance information Rationale An insurance company may require a preauthorization. If preauthorization is not obtained, the claim will be rejected until one is supplied. The information about the patient must be accurate with the correct name and date of birth to be able to identify the correct patient. If the claim was submitted to the wrong insurance company for the patient, the claim will be denied as not in effect or cannot identify the patient.

Which of the following accounts should the insurance and coding specialist call on first on an aging report? A. 30 days out B. highest patient balance C. by last name alphabetically D. 120 days out

120 days out Rationale It is important to try to gain payment for the oldest delinquencies first. Ideally, only the delinquencies within the last thirty days would appear on the aging report, including cases on which payments might be made or those that might be paid by the insurance carrier. It is best to have any delinquencies be as close to the current date as possible. This can be done by working the oldest accounts first.

A patient has elected to have a procedure that is typically not covered by Medicare. Which of the following must be completed? A. EOB B. ABN C. disclosure form D. consent form

ABN Rationale In the event that the patient opts to have a procedure done that is not covered by their Medicare insurance, an ABN must be completed. An ABN, Advanced Beneficiary Notice, is a contract signed by the patient agreeing to pay the full amount for services. The patient is also acknowledging that Medicare will not pay for this service. An EOB is an Explanation of Benefits. An EOB is sent with payment from the insurance carrier and explains the payments and denials made. A consent form states that a patient gives consent for treatment and does not have anything to do with payment. A disclosure form gives the details of a policy.

Which of the following is a report used to track overdue accounts? A. Denials Management Report B. Financial Class Report C. Accounts Receivable Aging Report D. Unbilled Accounts Report

Accounts Receivable Aging Report Rationale An accounts receivable aging report is used to track overdue accounts. It breaks down accounts with money owing, based on the amount of time that they have been outstanding

Which of the following does a thorough understanding of the Explanation of Benefits (EOB) supplied by the payer allow the insurance and coding specialist to do? (Select three (3) correct answers.) A. Post CPT®. B. Apply write-offs. C. Correct the EOB. D. Bill patients correctly. E. Resolve payment issues.

Apply write-offs., Bill patients correctly., Resolve payment issues. —Rationale— An explanation of benefits is supplied by the payer and contains all of the payment information for a service. This document allows the insurance and coding specialist to apply write-offs, bill the patient correctly, and resolve payment issues.

51. The insurance and coding specialist is processing a credit card transaction for a patient copay and the card is denied. Which of the following options can the specialist offer the patient? (Select the two (2) correct answers.) A. Send the patient to an emergency room. B. Offer to write off the amount. C. Call the credit card company for the patient. D. Change the appointment to a later date. E. Ask if the patient can pay cash.

Change the appointment to a later date., Ask if the patient can pay cash. Rationale It would not be correct to direct the patient to the emergency room. It is not correct to write off the copay. Only the card holder can call and discuss the issue with CC company. Ask the patient if he/she would be able to pay cash or offer to reschedule the appointment

The patient makes a co-payment of $50. To which section of the patient's account should the payment be applied? A. Debit B. Credit C. Adjustment D. Deductible

Credit —Rationale— A co-payment made by the patient is a credit. It is credited off of the amount of money that is owed for services rendered. An adjustment is made by the physician in accordance with the payments, or lack of, made to an account. A deductible is an annual amount of money that a patient must pay before an insurance carrier will make any payments.

Which of the following is the first step in managing patient A/R? A. Obtain insurance information and verify it when the patient arrives. B. Accept credit and debit cards as a method of payment. C. Collect all copayments and deductibles when the patient checks in. D. Gather all patient information at the time the patient calls for an appointment .

Gather all patient information at the time the patient calls for an appointment . Rationale The first step in managing a patient's accounts receivable (A/R) is to gather all of the patient's information at the time the patient calls for an appointment. You will not be able to collect money from the patient if you do not first have all of their contact and insurance information.

Which of the following is the correct term for a doctor who enters into an agreement with a third party payer on charges, discounts, and services rendered to their policyholders within the network? A. MAC B. PAR C. LOA D. PPO

PAR —Rationale— A PAR (participating) provider is a physician who enters into an agreement with a payer to offer discounts on charges rendered to their policy holders.

Which of the following are legitimate reasons for a claim to be rejected? (Select the three (3) correct answers.) A. Total charges exceed the contractual agreement. B. Physician's credentials are not valid. C. Diagnostic pointers are missing. D. The billing location is missing. E. Tertiary insurance information is not provided.

Physician's credentials are not valid. Diagnostic pointers are missing. The billing location is missing. Rationale There are many items that MUST be on a claim when filed for payment. The physician must have valid credentials; ICD-10 codes must be complete to the highest specificity, and the location where the services were provided must be on the claim. If any of these items are missing or incorrect, the claim will be denied or returned.

A government payer performed a post payment audit and determined that the provider's documentation did not support the level of service that was billed and requested a refund. Which of the following should the insurance and coding specialist do? A. Promptly refund the overpayment. B. Appeal the refund request. C. Reallocate payment to another account due. D. Correct the documentation and submit a corrected claim.

Promptly refund the overpayment. Rationale An insurance and coding specialist should promptly refund the overpayment of a government agency that requests a refund. After that, the insurance and coding specialist should review the claim, make changes to the coding as necessary per the documentation, and resubmit the charges.

Which of the following must be done when an overpayment is received from a government agency? (Select the three (3) correct answers.) A. Report the reason for overpayment. B. Return the money within 60 days. C. Credit the account with the overpayment. D. Call to appeal the request of recoupment. E. Return the overpayment to the payer.

Report the reason for overpayment., Return the money within 60 days., Return the overpayment to the payer. Rationale An overpayment may occur due to administrative errors, medical necessity errors, or providing insufficient documentation. When receiving an overpayment from a government agency, a healthcare provider must report the reason for the overpayment, and return the money to the payer within sixty days. The healthcare provider may not call to appeal the request of recoupment. An appeal may be filed, but it must be in writing and will then follow the five levels of the appeals process. The account cannot be credited., A separate payment is mandatory.

Which of the following are the steps to posting a Medicare payment to the patient's account? (Select the three (3) correct answers.) A. Review the EOB. B. Adjust any contractual agreements. C. Check that the required copay was made. D. Send the billing statement if there is a balance. E. Review the encounter notes.

Review the EOB., Adjust any contractual agreements., Send the billing statement if there is a balance. —Rationale— First the EOB should be reviewed to make sure all the information is correct and the correct patient is credited. Any payments are posted and all the adjustments are made. Once these tasks are finished, the system will generate a statement of any balances due to send to the patient. There is no need to check the copay since the system will automatically have this information on the statement to the patient.

A Medicare patient received service on January 10th. The claim was rejected for reason: Patient not eligible for benefits for submitted dates. Which of the following should the insurance and coding specialist do first? A. Contact the patient for payment. B. Verify that the patient's employer did not change insurance January 1. C. Resubmit the claim with corrected dates. D. Review the claim against registration materials for accuracy.

Review the claim against registration materials for accuracy. Rationale When a Medicare beneficiary receives services that may not be payable, the Insurance Billing Specialist must always check to see if there is an Advance Beneficiary Notice (of Noncoverage) on file and signed by the patient for the services rendered. "Resubmit the claim with a different procedure code, resubmit the claim with a different diagnosis and resubmit claim using a HCPCS code are all incorrect actions.

40. Which of the following should the billing and coding specialist do when there is a credit balance on a patient's account after the carrier has paid? (You have already verified the credit is due to patient overpayment.) A. Send a check to the patient for the amount of the credit balance. B. Alert the carrier that an overpayment was made. C. Refund the amount of the credit balance to the carrier. D. Send a check to the carrier and allow the carrier to refund the patient.

Send a check to the patient for the amount of the credit balance. Rationale Since the overpayment is due to the patient paying more than necessary, the refund will be sent to the patient.The carrier would be sent the refund if they had issued the overpayment.

A patient has entered into a payment arrangement with the medical office. The patient has not been making any payments and the physician does not want to see this patient anymore. What should the billing and coding specialist do? A. Call the patient and demand payment. B. Fax a letter with the original terms of the agreement to the patient. C. Send a letter of termination to the patient. D. Cancel all future appointments for the patient.

Send a letter of termination to the patient. Rationale When a patient has not met their financial obligations, it is acceptable for the physician to terminate the patient/physician relationship, but the physician must do so in writing. The letter of termination must include the date of termination (at least thirty days in the future) and options for other physicians that the patient may wish to start seeing instead.

The rejected claim report identified two errors which require immediate attention. Which of the following errors should the billing and coding specialist expect to find on this report? (Select the two (2) correct answers.) A. The beneficiary's name is incomplete or missing. B. The patient's deductible has not been met. C. The patient has not been to the office in over three years. D. An incorrect patient copayment was received at the time of visit. E. The insurance identification number is invalid.

The beneficiary's name is incomplete or missing. The insurance identification number is invalid. Rationale A rejection report identifies claims that have not been processed. These claims require correction and resubmission. "The patient's deductible has not been met, the patient has not been to the office in over three years and an incorrect patient copayment was received at the time of visit would not affect the adjudication (processing) of a claim. whereas If the beneficiary's name is incomplete or missing and the insurance identification number is invalid, these errors would require correction.

The patient is questioning the balance due amount. She paid her co-pay prior to service. Which of the following is the most likely reason the patient owes an additional amount? A. The insurance refused to pay the bill. B. The patient has an un-met deductible. C. The insurance underestimated the co-pay. D. The patient is out-of-network.

The patient has an un-met deductible. Rationale There can be many different reasons why a patient owes money to a provider. A patient can become especially concerned when they believe that since they paid their copay, they should not owe any money. The most common reason that the patient owes additional money is because there is a deductible that has not yet been met.

The physician charges $100 for a visit. The insurer allowable amount is $80. The patient has a $200 deductible, which has not been met. Which of the following will happen? A. The insurer will send an $80 check. B. The patient will be billed $80. C. The insurer will send a $100 check. D. The patient will be billed $100.

The patient will be billed $80. —Rationale— In this scenario, the patient will be billed $80. The insurance company will not pay anything until the deductible is met. The allowed amount is now the cost of the service, so since the deductible is not met, the patient will be responsible for the entire $80.

Which of the following is the correct process for posting the electronic remittance advice and Explanation of Benefits to the patient's account? A. Upload from the patient's file and review adjustments, then save. B. Upload from the carrier file and scan to the patient's file. C. Upload information from the carrier file, adjust and save. D. Scan all information into the patient's record and save.

Upload information from the carrier file, adjust and save. -Rationale- All information will be uploaded from the insurance carrier, file. Any necessary adjustments should be made and saved to the file. Nothing is uploaded from the patient file you will just scan into a file and save since this will not allocate any funds or adjustments to the account.

Which of the following information will the insurance and coding specialist need to apply the payment correctly when in receipt of an insurance EOB and check for payment? (Select the three (3) correct answers.) A. account number B. phone number C. date of service D. patient name E. social security number

account number, date of service, patient name Rationale An insurance and coding specialist will need the account number, the date of service, the patient name, the CPT® codes billed, and the money received or denied when posting an EOB and check for payment. The phone number and the social security number are not necessary.

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. adjusted by the provider. D. adjusted by the insurance carrier.

adjusted by the provider. —Rationale— When a patient sees a participating provider, he receives a discount. This discounted amount is called the allowed amount. The difference between the billed amount and the allowed amount cannot be charged to the patient when seeing a participating provider. The provider must adjust, or write off, this amount in the billing system.

The patient is questioning charges, stating that a second x-ray was done because the first one could not be interpreted, due to cloudiness on the film. The patient wants one x-ray charge credited. The CEO tells the insurance and coding specialist to submit a write-off on the account balance. Which of the following is this type of action called? A. contractual allowance B. administrative adjustment C. case-level adjustment D. item charge credit

administrative adjustment Rationale When the CEO tells the insurance and coding specialist to write off a charge, it is called an administrative write off. This type of write off has nothing to do with the insurance carrier or the claim submitted. An administrative adjustment is made within the practice, and is done only in special circumstances.

Which of the following reports keeps track of how much money is owed to the practice and how long the account has been outstanding? A. balanced billing B. income analysis C. accounts payable D. aging report

aging report Rationale An aging report identifies how much is outstanding to the company usually by a date range and if it is patient or insurance responsibility. The ranges are 0-30, 31-60, 61-90, and 91+. Balance billing are statements that are sent to the patient after payment and adjustments are complete. Income analysis is the process of forecasting what will be paid and the amount that will be written off. Accounts payable are the fees collected by the end of the day.

In order to ensure that all monies owed to the practice are collected, the insurance and coding specialist should sort A. audit reports. B. service analyses. C. aging reports. D. day sheets.

aging reports. Rationale Aging reports are used to keep track of all money that is owed to the practice and the length of time it has been outstanding.

A patient comes into the office with a check from her insurance carrier for the full allowed amount of her last visit. Which of the following fields should the insurance and coding specialist edit in the electronic claim submission to allow the provider to receive the check directly from the patient's insurance carrier after the next visit? A. payer ID number B. coordination of benefits C. assignment of benefits D. explanation of benefits

assignment of benefits Rationale An assignment of benefits is a document that is signed by the patient, which allows payment from the insurance company to go directly to the provider. A payer ID number is a unique identifier for an insurance carrier. Coordination of benefits is the process that determines which insurance is primary, secondary, etc. An explanation of benefits is sent from the insurance carrier, to the provider, and explains payments and/or denials.

When entering into a payment arrangement with a patient, the medical practice must A. tell the patient that they will be calling their employer if they miss a payment. B. notify the insurance company of the arrangement, in writing. C. consult a financial advisor to see if the risk is too great. D. be honest about all of their fees.

be honest about all of their fees. Rationale When entering into a payment arrangement with a patient, the medical practice must be honest and upfront about all of the fees that could potentially be charged, which includes any interest and/or late fees.

Which of the following will an accounts receivable aging report do? A. determine how many co-pays have been unpaid B. breakdown claims by the number of days unpaid C. track the insurance checks received D. determine the amount of copays received

breakdown claims by the number of days unpaid Rationale An accounts receivable aging report will breakdown claims by the number of days unpaid. This report can be used to reconcile the oldest cases first.

The most effective way to collect patient balances sent to internal collections is to A. call the patient. B. mail a collection notice to the patient. C. email the patient. D. remind the patient of the balance at the next visit.

call the patient. Rationale Calling the patient is the best way to maintain contact with the patient for a balance due. Calling the patient gives the patient an opportunity to explain any extenuating circumstances. Payment arrangements can be made. Mailing a collection notice is usually put aside by the recipient. Email to a patient is not the best avenue since patient's email addresses tend to change often.

Which of the following is a method of payment in which the carrier pays the provider a fixed amount per patient, regardless of the number of visits or types of services? A. capitation B. fee-for-service C. sliding scale D. deduction

capitation Rationale Capitation is used with HMO insurance companies. The PCP is paid a flat fee per patient within the plan. It does not matter if the patient is seen several times per month or not at all. Claims will be processed for additional payments and the patient will pay the copay at the time of service

Based on the Fair Debt Collections Practices Act Guidelines, which of the following practices are acceptable? (Select the three (3) correct answers.) A. calling after 9 pm B. contacting and speaking to the debtor once per day C. leaving a message on the answering machine that the call is about a bill owed D. contacting the attorney if one is involved with the debt E. contacting the debtor at work if no other contact can be made

contacting and speaking to the debtor once per day, contacting the attorney if one is involved with the debt, contacting the debtor at work if no other contact can be made Rationale According to the Fair Debt Collections Practices Act Guidelines, there are certain rules that a debt collector must follow. A patient cannot be called after 9pm. A collector is also not allowed to leave a message describing the details of a debt. The collector is only allowed to call the patient once a day, any more would be considered harassment. The collector is allowed to contact the attorney if one is involved with the debt. In extenuating circumstances, a debt collector can contact the patient at work if no other contact has been able to be made.

Which of the following are types of insurance write offs? (Select the two (2) correct answers.) A. bad debt B. contractual adjustments C. non-participating provider D. participating provider E. administrative adjustments

contractual adjustments, participating provider Rationale Bad debt is when a patient has not paid the balance. Non-participating provider is when the patient sees a physician that is outside of his insurance network. Administrative adjustment is one that is approved by someone who has the authority to do so. Contractual and participating provider are the only choices that are considered insurance write off's.

After receiving the EOB, the patient calls the office asking for an explanation of charges. The statement appears as follows: Total Charge for Service $252.00 Insurance paid $140.00 Patient Co-pay $20.00 Balance Due $92.00 The patient states, "I have insurance and have paid the co-pay." Which of the following is the mostly likely reason the balance is the patient's responsibility? A. deductible not met B. premiums due C. the birthday rule applies D. physician write-off

deductible not met Rationale The only answer in this scenario is that the patient's deductible has not been met. If the premium was not paid, the patient would not have had insurance. The birthday rule is the way to coordinate benefits, not a reason for payment. A physician write-off would mean that the patient owes nothing.

Which of the following reasons should the insurance and coding specialist use to explain a bill that was not paid by a carrier to a patient? (Select the three (3) correct answers.) A. deductible B. premiums C. non-covered charges D. coinsurance E. in network provider

deductible, non-covered charges, coinsurance Rationale Deductible is the amount the patient has to pay prior to any payments from the insurance company for a claim. The coinsurance is the portion a patient pays for services provided. Non-covered/excluded services or procedures are what the insurance company will not pay for in their policy. These are specifically stated in the contract between the insurance company and the claimant.

Which of the following information can be found on an accounts receivable aging report? A. payment data received throughout the past month by procedure code B. complete comparison of the payment amount to the allowed amount throughout the last month C. detailed information of claims based on the number of days they have been unpaid D. breakdown of number of days to final reimbursement of the claim

detailed information of claims based on the number of days they have been unpaid Rationale An accounts receivable aging report gives detailed information of claims based on the number of days they have been unpaid. This is a helpful way to track all patient delinquencies.

Which of the following is the correct term for an insurance claim submitted with errors? A. pending B. dirty C. invalid D. incomplete

dirty Rationale A dirty claim is a claim that is submitted with errors, such as missing information or information entered into the wrong fields. A pending claim is a claim that is being checked by a carrier and is awaiting payment (or rejection). An invalid or incomplete claim is missing information.

Which of the following is required to process a credit card transaction over the phone? (Select the three (3) correct answers.) A. expiration date B. account number C. security code D. date of birth E. social security number

expiration date, account number, security code Rationale To process a credit card over the phone, the number on the card the expiration date and the 3 digit security code on the back will be needed. The CC machine will never ask for a DOB or a SS number.

When dealing with a Medicare denied claim, it is appropriate to write off the amount denied when the claim was submitted A. with the wrong date of birth. B. for experimental procedures. C. with no rendering provider listed. D. for non-covered procedures.

for experimental procedures. —Rationale— Experimental services are not covered by Medicare and would not be the patient responsibility unless the patient signed an ABN understanding to be financially responsible. Any denial with the wrong date of birth, no rendering provider listed, or non-covered procedures can be resubmitted with appropriate information or records.

Which of the following managed care payer denials indicates front end user error? A. a diagnosis inconsistent with the procedure B. incorrect insurance information C. a procedure deemed not medically necessary D. passed timely filing date

incorrect insurance information —Rationale— Front end user error refers to errors made in the claim process prior to transmitting the claim to the payer. "A diagnosis inconsistent with the procedure", "a procedure deemed not medically necessary" and "passed timely filing date" do not refer to incorrect information supplied that requires correcting so "incorrect insurance information" would be the only correct choice.

Which of the following are typical reasons for a claim to be rejected by a clearinghouse? (Select the two (2) correct answers.) A. invalid insurance policy B. invalid ICD code(s) C. invalid referral number D. invalid CLIA number E. invalid final date of treatment

invalid ICD code(s), invalid CLIA number Rationale A clearinghouse bundles claims together to send to the insurance carrier. They will also send claims back to the provider for basic, non-patient specific errors for which a claim can be denied. Claims with invalid ICD-10 codes and with invalid CLIA numbers, will be rejected by the clearinghouse. CLIA requires that clinical laboratories be certified throughout their state. Claims with invalid insurance policies, invalid referral numbers, and invalid final dates of service will not be rejected and will be sent to the insurance company. These situations are specific to treatment and would not be part of the clearinghouse's responsibility.

Which of the following is used to post patient payments in provider offices, electronically or manually? A. medical records B. encounter forms C. ledgers D. receipts

ledgers —Rationale— A ledger is used for each patient in an office. The ledger keeps track of all payments and outstanding balances for the patients

Which of the following are legitimate actions a medical office can take to manage accounts in a collection status? (Select the three (3) correct answers.) A. mail statement letters B. use collection agencies C. sue in small claims court D. call patient employers E. garnish patient wages

mail statement letters, use collection agencies, sue in small claims court Rationale The legal processes for collecting debts from patients include mailing statement letters to the patient, using collection agencies, and suing the patient in small claims court. Calling patient employers and garnishing patient wages are not legal because they can be considered harassment or can be violations of HIPAA

Which of the following reports allows the insurance and coding specialist to categorize a patient account's outstanding balance by the length of time the charges have been due? A. accounting control summary B. patient aging C. day sheet D. cumulative trial balance

patient aging Rationale A patient aging report keeps track of the patients who have outstanding balances and how many days the balance has been outstanding.

The physician charges $200 for an office visit. The allowed amount for the Medicare patient is $175 and the patient's deductible has been met. Which of the following are the amount the patient owes and the write-off amount? A. patient owes $35.00, write-off $0 B. patient owes $40.00, write-off $25 C. patient owes $35.00, write-off $25 D. patient owes $40.00, write-off $0

patient owes $35.00, write-off $25 Rationale The write off amount is the difference between the billed and the allowed amount, ($200.00 - $175.00= $25.00). The patient responsibility is 20% of the allowed amount, (20% of $175.00 = $35.00).

1. It is important to make the patient aware of the mailing address, interest rates, and length of agreement when setting up a A. fee schedule. B. payment arrangement. C. pre-payment plan. D. deductible fee.

payment arrangement. —-Rationale—- A payment arrangement is an agreement between the patient and medical office to make monthly payments on a balance that is the patient's responsibility. All the information will be on the agreement that the patient signs. A fee schedule is a list of the established charges for the physician office services. A pre-payment plan a way for a patient to pay for services in advance. The deductible is what is required by the insurance company and is the patient's responsibility to pay.

Which of the following are the patient responsibilities that must be met before payment from the insurer? (Select the two (2) correct answers.) A. balance B. billed amount C. premium D. deductible E. total charged

premium, deductible Rationale A premium is the fee for health insurance coverage. This money must be paid to the insurance carrier on the agreed schedule, for example, monthly or annually. A deductible is an amount of money that a patient must pay before the insurance carrier will pay any money. This is only applicable after a service has been rendered. A premium and a deductible both must be paid before an insurance carrier will issue any payments. A balance is what is owed for a service. A billed amount is the full amount that a physician charges for a service, before any insurance discounts. Another term for billed amount is total charged amount.

The physician submitted a claim on which he has accepted assignment to the third-party payer. The payer determined that the allowed amount for services provided to the patient was $500 and reimbursed the physician $400. The patient paid $200 at the time services were provided. The insurance specialist should A. write-off $200. B. refund the patient $100. C. refund the patient $200. D. write-off $100.

refund the patient $100. Rationale In this situation when a patient makes an overpayment, a refund must be issued to the patient in the amount of the overpayment. Since there was a $500 and the insurance paid $400 of that allowed amount, the patient is only responsible for $100. Since the patient paid $200, the patient is now entitled to a $100 refund.

A claim which has not been adjudicated due to errors is A. denied. B. rejected. C. pending. D. bypassed.

rejected. —Rationale— A rejected claim is one that has not been processed (adjudicated) because there are errors. Usually, the errors lie in errors in the patient information or demographics, or the physician or practice information. A rejected claim is not a denial per say. A denial is a claim that has been processed, but the insurance company has deemed it not payable based on the services rendered, whether the services are unbundled, the diagnosis does not match the service, or for many other reasons. A pending claim is one that has neither been rejected or denied, it is being processed.

Which of the following documents from the insurance carrier should the payment poster read and post the payments or contractual adjustments to the patient account? A. Medicare summary notice B. remittance advice C. advance beneficiary notice D. fee schedule

remittance advice —Rationale— A remittance advice is used to post payments from insurance carriers. It will explain the reasons for payments or denials, the allowable amounts, copayments, patient balances, etc. A Medicare summary notice is sent to Medicare patients and explains their responsibilities, if any. An advance beneficiary notice is a document that is signed by a patient prior to a service that is known to be ineligible for payment for an insurance carrier, the patient agrees to pay for the service in full. A fee schedule is used by a practice and states the charges for services.

A third party payer sent a report to the hospital explaining the payments of multiple claims submitted for ten patients in the month of November. Which of the following is the title of that document? A. encounter form B. charge master C. remittance advice D. superbill

remittance advice —Rationale— A remittance advice is used to post payments from insurance carriers. It will explain the reasons for payments or denials, the allowable amounts, copayments, patient balances, etc. A remittance advice is sent monthly and includes all of the patients seen by that practice, with that insurance. The physician uses an encounter form while seeing a patient. Information, such as diagnosis and procedures performed, are included on the encounter form. Another name for an encounter form is a superbill. A charge master is a list of all of the services that can be provided in a practice and is generated by the practice.

Which of the following occurs when the claim is being reviewed by a third party payer, but it is neither an approval nor a denial? A. adjustment B. suspension C. dirty claim D. write off

suspension Rationale While a claim is being reviewed by a third party payer, it is in suspension. An adjustment is made by the physician. A dirty claim has errors and has been rejected. A write off is an adjustment made by a physician in which they are not expecting the money to be paid.

Which of the following is sent by the card issuer and should be documented in the payment entry screen if the patient is paying by credit card? A. card verification value B. approval card slip C. transaction authorization number D. preauthorization number

transaction authorization number Rationale If the patient is paying by credit card, the transaction authorization number should be documented. The preauthorization number does not have to do with the credit card payment itself. The card verification value is for use between the credit card company and the card holder. The approval card slip will be kept on file by the insurance and coding specialist, but is not necessarily recorded by them.

Which of the following are the most common reasons for a claim to be rejected? (Select the three (3) correct answers.) A. missing social security number B. transposed numbers C. invalid POS D. incorrect DOB E. no employer name

transposed numbers, invalid POS, incorrect DOB Rationale A rejection is done before the claim is processed, paid, or denied. Rejections are due to missing or invalid information. Some of the most common reasons that a claim can be rejected are for typing errors, such as transposed numbers, invalid place of service, incorrect date of birth, or a missing name. A claim will not be rejected due to a missing employee name or missing social security number.

Which of the following steps will help prevent a denied claim? (Select the three (3) correct answers.) A. verifying frequency limitations B. determining the need for prior approval C. having the patient sign an ABN D. verifying coverage of a chosen diagnosis E. verifying patient marital status

verifying frequency limitations, determining the need for prior approval, verifying coverage of a chosen diagnosis —Rationale— There are some steps that can be followed to help prevent denials. One of them is to verify frequency limitations, which means to verify how many times a service can be performed. An example is EKGs. When charging for the interpretation and report (only) of EKGs, a maximum of 5 can be billed a day, according to Medically Unlikely Edits, MUE edits. If anymore more than that are billed, they will be denied. Another thing that can be done to help prevent a denied claim is to determine the need for prior approval. Written prior approval of a service from an insurance company will determine if the service is considered medically necessary. If the service is approved, then the claim shouldn't be denied. Verifying the diagnosis code against the payers' list of covered diagnoses for a service is also recommended to help prevent denials because a service will be denied for medical necessity if the diagnosis is not an "acceptable" reason to perform the service.

Which of the following should a practice's financial policy always explain? A. what is required from the patient and when payment is due B. what payment options the patient has available C. the practice's fee for service charge master D. the insurance carriers the practice is contracted with

what is required from the patient and when payment is due —Rationale— The practice's financial policies should always be explained to the patient. The patient should always be aware of what is required from them and when payments are due.