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