CPB Study Chapter 3

From the information on this card, what copay should be collected for a patient seeing a cardiologist in his office? Your Health Insurance Company Policy Holder Name ID: Benefits Pharmacy-Rx Deductible: $2,500.00 $ 20/40/60 CoPays: Office: $35.00 Specialist: $60.00 Hospital Inpatient: $200.00 A. $20 B. $35 C $60 D. $200

C $60 The co-pay for a specialist (cardiologist) is $60.00.

A patient wants her results called to her home and states the physician is to talk to her husband. What form should be completed before this is done? A. Authorization to Disclose Health Information B. Consent for Payment C. Consent for Treatment D. Patient Information Form

A. Authorization to Disclose Health Information Section 164.508 of the HIPAA privacy rule states that covered entities may not use or disclose protected health information without a valid authorization. The Authorization to Disclose Health Information lists the names of the individuals to whom the PHI can be disclosed.

Which of the following lists are within the life cycle of a claim? A. Claims submission, claims processing, claims adjudication, Payment/Denial B. Claims submission, Claim denial, statement sent C. Claim submission, claims processing, patient payment D. Claims submission, claims processing, claims adjudication

A. Claims submission, claims processing, claims adjudication, Payment/Denial All 4 steps of the process include Claims submission, claims processing, claims adjudication, Payment/Denial.

A child is brought in by the mother to be seen. The mother (DOB 02/08/83) is the custodial parent and is remarried. She has an individual policy, the father (DOB 10/10/82) is covered by a policy from work. The step-father is also covered at work. Which of the following is correct? A. The mother's insurance is primary B. The step-parent is primary C. The father is always primary D. Either the mother or the father can be primary

A. The mother's insurance is primary

In what circumstance would the checkout process be unnecessary? A. The patient made a co-pay during the check-in process and no follow up appointment is necessary B. The patient needs to make a follow-up appointment C. The patient had a procedure performed in addition to the E/M D. The patient has services performed that are not covered by the insurance

A. The patient made a co-pay during the check-in process and no follow up appointment is necessary The discharge process is also called check-out. This is done after the patient has been seen by the provider. The receptionist should review the encounter form to make sure it has been completed. If the copayment was not collected at check-in, it should be collected at check-out. Any deductibles and payment for services that are not covered by insurance should also be collected. If the patient needs a follow-up appointment, it can be done so during the check-out process. Additional procedures or services not covered by the insurance carrier may require additional co-pay or deductibles to be collected. If a patient requires a follow-up appointment check-out would be necessary.

The group number on the insurance card is used to identify: A. The insured B. The covered employer group C. The insurance company D. The policy number

B. The covered employer group The group number identifies the employer group that covers the patient with health coverage. The verification information should be retained for future use.

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? A. $15.00 B. $61.40 C. $13.60 D. $10.00

C. $13.60 Policy pays 80% of $68 (contracted amount) with 20% of $68 being patient responsibility, $13.60

The parent with which the child resides is considered to be: A. Step-parent B. Non-custodial parent C. Custodial parent D. Natural parent

C. Custodial parent

Which of the following would represent a typical Blue Cross ID number? A. 123456789B B. 987654321A C. FEP555223113 D. M106325

C. FEP555223113 BCBS ID numbers are typically 3 letters followed by 9 numbers. Medicare ID numbers are 9 numbers followed by an A or B.

When insurance coverage if being verified, which of the following is not a method on which to rely? A. Phone B. Internet C. Patient D. Clearinghouse

C. Patient Verification of coverage should be done through the insurance company and many provide multiple options, such as phone, internet, and through the clearinghouse. Best practice would not be to rely on patient knowledge of their coverage.

Which of the following statements is TRUE regarding patient demographics? A. Demographic information can only be provided by the patient. B. Patient demographic information can be released to a third party without the patient's consent. C. Patient demographic information entered incorrectly can result in claim denials. D. Claim processing is not affected by patient demographic information.

C. Patient demographic information entered incorrectly can result in claims denials.

The back of the health insurance card typically includes what information? A. Primary Care Provider B. Co-pays C. Phone or contact information for eligibility D. Group number

C. Phone or contact information for eligibility Phone and contact information for eligibility are located on the back of the card.

What software system is used to store appointments, scheduling, registration, and billing and receivables? A. Electronic Health Record (EHR) B. Health Information Management System C. Practice Management System (PMS) D. Electronic Medical Record (EMR)

C. Practice Management System (PMS) Practice management system (PMS) - Is software used by physicians for scheduling, registration, billing and receivables management.

The processing of an insurance claim begins with what process? A. Patient information B. Charge entry C. Scheduling an appointment D. Submitting a claim

C. Scheduling an appointment

A claim that is sent for reimbursement that contains all the required data elements to process the claim is said to be: A. submitted B. adjudicated C. clean D. medically necessary

C. clean

A patient presents to the ER but is admitted for care. What co-pay is collected based on the insurance card for a participating facility? Insured name: Beth Jones Eff Date: 1/1/2013 In-network Ded Out-of-Network Ded ID# 123456789 Office visit $15.00 N/A Deductible $2500 ER $75.00 $75 Co-pay as listed Inpatient $100.00 N/A Preventive N/A N/A A.$15.00 B.$75.00 C.$100.00 D. Not Applicable

C.$100.00 Because the patient was admitted, the copay is $100.00.

Review the insurance card and patient registration form below: Your Health Insurance Company Policy Holder Name: Mary Jane Smith ID:G01489 Birthdate: 5/14/1962 Pharmacy-Rx Deductible: $2,500.00 $ 25.00 CoPays: Office: $20.00 InstaCare: $40.00 Hospital: $100.00 What information could cause a potential problem? A. The patient's name is not consistent B. Relationship to the patient is incorrect C. Date of Birth is incorrect D. Employer is not listed

A. The patient's name is not consistent Information on the insurance card should match the patient information sheet. Misspelling or inconsistent use of the patient's name can result in the insurance company being unable to identify the patient.

What is a deductible? A. A fixed amount the patient is responsible to pay at time of visit B. Amount of expenses that must be paid before any payment is made by the insurance company C. A percentage the patient is responsible to pay at the time of visit D. The amount paid by the insurance company

B. Amount of expenses that must be paid before any payment is made by the insurance company A deductible is an amount that is paid by the patient before any payment is made by the insurance company. This amount varies by each patient policy.

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? A. Policy holder, group number B. Claim number, CPT code, diagnosis C. Policy holder, copay, deductible D. Claims address, Group number

B. Claim number, CPT code, diagnosis

What authorizes information to be sent to the insurance payer so payment of medical benefits can be processed? A. MSP B. Consent for payment C. Encounter form D. Chargemaster List

B. Consent for payment The consent for payment authorizes information to be sent to the insurance payer so payment of medical benefits can be processed. It also demonstrates responsibility of the patient or responsible party for copayments, coinsurance, deductibles, and fees that exceed the payment made by insurance if the physician does not participate with the patient's insurance. This agreement must be in writing in order to collect any amount from the patient.

When entering patient data information into a practice management system? A. Assume the information is correct B. Enter the patient information accurately from the insurance card and patient registration form C. Review the information annually for correctness D. The format of the information is not important but must be entered

B. Enter the patient information accurately from the insurance card and patient registration form. Information gathered during the registration process is imperative to the success of a clean claim. If information is entered into the practice management system incorrectly, it can result in denied claims or delayed payment.

If your clinic has patients that do not show for their scheduled appointments it would be good clinical practice to: A. Not schedule them again B. Make reminder calls 1-2 days in advance C. Double book all appointments D. Charge for the visit

B. Make reminder calls 1-2 days in advance "No-show" appointments cannot be eliminated altogether; however is beneficial to make reminder calls 1-2 days in advance. Double booking is not recommended, and charging for the visit is not appropriate as a face-to-face encounter with the patient is required for this service.

Patient types help to classify the patients based on A. Age B. Payer C. Diagnosis D. Address

B. Payer Patient types are established to classify the type of insurance or the payer the patient has.

A charge ticket (encounter form) is not completed. What procedure would NOT be acceptable? A. Complete the form based on medical record documentation B. Query the provider for the charges and diagnosis C. Post the service as a no charge D. Return the form to the provider for completion

B. Query the provider for the charges and diagnosis The encounter form is used for the provider to relay to the charge entry staff what services or procedures were performed during that visit and why they were performed. If nothing is complete, the provider should be queried or the encounter coded from the medical record. Posting a no charge could result in the loss of revenue for the practice. Return the charge ticket to the provider or inquire what services should be billed. Completing the form based on documentation would also be an option.

A child present for care with the father. Both parents have coverage, date of birth for mother is 3/21 and date of birth for father is 6/20. The mother is covered by a COBRA. What is the primary coverage for the child? A. The mother's coverage is primary based on the birthday rule. B. The father's insurance is primary because the mother has COBRA C. The father is primary because he is older D. The father's is primary because he consented for care

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

A female patient is covered by her employer and also with her husband's insurance plan. His birthday is 3/21 and hers is 6/18. Which insurance is considered primary? A. The husband's insurance because of the birthday rule B. The patient's insurance because she is the primary subscriber C. The husband's insurance is primary because he is the head of the household D. Either can be filed as primary

B. The patient's insurance because she is the primary subscriber When a patient has insurance where they are the subscriber, this coverage is primary. The birthday rule applies only to children when both parents provide insurance coverage.

A 9-year-old is brought in by her father for a sore throat. The patient has insurance by both the mother and father. What coverage is considered to be primary? A. The father brought the patient for care making his coverage is primary. B. The primary is determined by the birthday rule C. Both are filed at the same time and the insurance companies sort it out D. The mother's because it was effective first

B. The primary is determined by the birthday rule

Information about deductibles, co-pays, eligibility dates, and benefit plans is what procedure? A. Patient registration B. Verification of Benefits C. Patient check-in D. Consent for payment

B. Verification of Benefits Verification of benefits provides information concerning the patient's coverage. This step verifies eligibility effective dates; patient coinsurance, copay and deductible amounts; and plan benefits as they pertain to specialty and place of service. Benefit information allows staff to be informed and ready to collect the appropriate copay, deductible, coinsurance or full balance due at the patient's visit.

Listed below are examples of patient reminders for appointments. Which one is HIPPA compliant? A. "This is the obstetrical office calling to remind you of your appointment Tuesday, April 12 at 9 AM for your annual exam." B. "This is Dr Smith's office calling to remind you of your appointment Tuesday April 12 at 9 AM for your annual exam." C. "This is to confirm your appointment for your first prenatal visit with Dr. Jones. Please notify us if you are not able to keep this appointment." D. "This is the doctor's office calling to remind you of your appointment Tuesday, April 12 at 9AM."

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

What information can be released based on this Disclosure form? AAPC Physician Practice are authorized to make the disclosure. The type of information to be used or disclosed is as follows: ____ Problem list ____ Medication list ____ List of allergies ____ Immunization records ____ Most recent history __X_ Most recent discharge summary __X__ Lab results (dates or types) ______________________ __X__ X-Ray and imagining reports (dates or types) _________________ ____ Consultation reports from ___________________________________ ___ Entire record A. The most recent visit B. Entire record C. Lab and X-ray D. Discharge summary, lab, X-ray

D. Discharge summary, lab, X-ray The discharge summary, lab, and X-ray can be disclosed to the individual(s) listed on the disclosure form. This would not pertain to release of information for treatment, payment, or operations.

Verification of insurance will allow the practice to know the amount to collect from the patient at the time of visit. Which of the following would NOT be true? A.If the insurance is unable to be verified the patient is offered the option for self-pay. B.Verify that patient information is correct and has been correctly conveyed to the insurance company. C. The patient should contact the insurance company if they believe the coverage is in effect. D. If the coverage is not in effect the patient should NOT be seen until the coverage can be verified.

D. If the coverage is not in effect the patient should NOT be seen until the coverage can be verified. The biller should not make a decision of turning a patient away for lack of insurance. The option of verifying information and making contact with the insurance company should be tried first, and the option should be provided to the patient to pay out-of-pocket.

Which of the following does not qualify a patient for coverage under Medicare? A. End stage renal disease B. Age 65 or older C. Under age 65 with disabilities D. Low-income individual

D. Low-income individual

What process would NOT be performed at the check-out process? A. Follow-up appointments B. Collection of co-pays or deductibles C. Review of charge ticket or encounter form D. Patient registration process

D. Patient registration process

Which statement regarding patient demographic information is correct? A.The patient does not need to provide all information on the registration form. B. The patient will always be the responsible party. C. There is no need for a copy of the insurance card if the patient demographic sheet is completed in its entirety. D. Patients can provide information by completing a paper form or by completing online registration.

D. Patients can provide information by completing a paper form or by completing online registration. An encounter form may also be referred to as a superbill or fee ticket. The encounter form usually has a list of common services the provider sees and a place for a diagnosis. When electronic medical records and practice management systems work together, the encounter form may be electronic. The encounter form is used for the provider to relay to the charge entry staff what services or procedures were performed during that visit and why they were performed.

HIPPA 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? A. Records sent to a physician asked to consult with the patient B. Payment of claims C. Records requested by the health department for communicable diseases. D. Records requested for life insurance

D. Records requested for life insurance