Medical Insurance & Billing Ch.9

As a result of Medicare issuing about _____ in payments per year with significant amounts of improper payments, the Medicare Integrity Program was enacted.

$500 Billion

Providers located in HPSAs are eligible for _____ percent bonus payments from Medicare.

10

Under the Medicare limiting charges clause, nonPAR providers may not charge a Medicare patient more than _____ percent of the fee listed in the nonPAR MFS.

115

How much is the coinsurance for physicians' services covered under Medicare Part B?

20 percent

What percentage of Medicare beneficiaries are under the Original Medicare Plan?

30

How much are providers paid by Medicare who elect not to participate in the Medicare program but who accept assignment on a claim?

5 percent less than PAR providers

What percentage of all Medicare beneficiaries are enrolled in group managed care plans called Medicare Advantage and Medicare Part C?

70

The Medicare assignment code _____ indicates the provider accepts Medicare assignment.

A

Which of the following statements are true about the ABN? (Select all that apply.)

A copy of the form is given to the beneficiary, and the provider must retain the original notice on file. It is used to help the beneficiary make an informed decision about services that might have to be paid out-of-pocket. The form must be completely filled in, explained to the patient, and signed by the patient.

What is an HPSA?

A geographic area in which physicians who participate in Medicare receive bonuses

What is "step therapy"?

A plan that requires patients to try a generic or less expensive drug rather than the prescribed medication

Which of the following individuals would be eligible to receive Medicare benefits? (Select all that apply.)

A thirty-year-old person who receives dialysis A person who is sixty-five and has paid FICA taxes for at least forty calendar quarters A person who is receiving Social Security disability benefits

If a provider thinks that a procedure will not be covered by Medicare, the patient is notified by means of a(n) _____.

ABN

What is issued when the MAC conducts a medical review and requests additional documentation?

ADR

Which modifier does the principal physician of record use with the E/M code when billed?

AI

Which insurance type code is used to identify an auto insurance policy as the primary payer?

AP

Which federal legislation changed the timely filing period for Medicare Part B claims?

Affordable Care Act

Which of the following statements are true about roster billing? (Select all that apply.)

Annual Part B deductibles do not apply to these services. The claims do not have to be sent electronically. Vaccinations for influenza and pneumococcal are covered by Medicare.

What information must be submitted to Medicare when a provider shares postoperative care?

Assumed care date

Which of the following are elements on the MSN? (Select all that apply.)

Beneficiary dashboard Claims information detailing the services provided and charges Helpful tips on how to receive an MSN and resources for information

Which of the following elements are found on a Medicare card? (Select all that apply.)

Beneficiary's name Effective dates for Part A and B Medicare number

What type of benefits do supplemental insurance plans provide?

Benefits similar to those offered in the employer's standard group health plan

In which of the following areas were changes made to Medicare as a result of the Medicare Modernization Act? (Select all that apply.)

Better benefits and lower costs for Part C enrollees Medicare + Choice plans

Blanks D-F on the ABN form are part of the _____ section.

Body

A participating provider may locate the Medicare Internet-Only Manuals for day-to-day operating instructions, policies, and procedures at the _____ website.

CMS

The National Medicaid EDI HIPAA Workgroup advises which of the following organizations about HIPAA compliance issues related to Medicaid?

CMS

Who issues the Medicare card to Medicare enrollees?

CMS

Providers who do not wish to renew or participate in Medicare by using the online system can do so by completing the paper form _____.

CMS 855

Which of the following are advantages in having a Medicaid managed care plan? (Select all that apply.)

Choice of a PCP Increased access to preventive care Access to specialists.

Which of the following are considered cost sharing by the beneficiary? (Select all that apply.)

Coinsurances Deductibles

Which of the following are gaps paid by Medigap plans? (Select all that apply.)

Coinsurances Deductibles

According to Medicare guidelines, what should a provider do if a claim has not been paid after thirty days?

Contact the payer using the telephone or electronic claim status inquiry.

Medicaid claims are submitted to which of the following agencies, depending on the particular state? (Select all that apply.)

County welfare agencies Fiscal intermediaries State Department of Health and Human Services

What are claims billed to Medicare that are automatically sent to Medicaid called?

Crossover claims

Which of the following are included in the LCDs? (Select all that apply.)

Description of the service Appropriate CPT and ICD codes List of indications

Which of the following types of information are used in the NTE segment? (Select all that apply.)

Description of unlisted surgery codes Reason for a reduced service Description of why a service is unusual

To determine eligibility for TANF assistance at the county level, which of the following questions are asked? (Select all that apply.)

Does the household include at least one child under eighteen? Does the individual receive adoptive or foster care assistance?

In 2010, Medicare stopped paying for all consultation CPT codes from the _____ section except for G-codes.

E/M

Which former form does the MSN replace?

EOMB

Which of the following data elements are found on PECOS and the CMS 855 form? (Select all that apply.)

Education Credentials

What is included in a typical MBI?

Eleven characters using only numbers and uppercase letters

Which of the following types of descriptors may be used in Blank D on the ABN form? (Select all that apply.)

Equipment Item Procedure

What does the Medical Savings Account pay for under the Medicare Advantage plan?

Expenses for covered services

Which of the following services are excluded under Medicare? (Select all that apply.)

Eye refraction Self-administered medications Acupuncture

What determines the services that are covered under Medicare?

Federal legislation

Which of the following plans are offered by Medicaid in most states? (Select all that apply.)

Fee-for-service Managed care

The provider may use Blank _____ to provided additional clarification that the provider believes will be of use to the patient.

H

Medicare requires the use of the _____ for coding services.

HCPCS

Which mandates electronic billing for physician practices with the exception of offices with fewer than ten full-time employees?

HIPAA

Because Medicaid is a state-based program, coordination of the requirements for completion of the _____ is handled by a national committee called the National Medicaid EDI HIPAA Workgroup (NMEH).

HIPAA 837P

What are the most restrictive plans of the Medicare CCP plans?

HMOs

Which of the following are Medicare coordinated care plans? (Select all that apply.)

HMOs POSs PPOs

On the ABN form, blanks A-C comprise the _____.

Header

Which of the following are sections of the ABN? (Select all that apply.)

Header Body Options Box

According to Spousal Impoverishment legislation, which of the following resources held by both spouses are not considered to be available to the spouse in the medical facility? (Select all that apply.)

Home Household goods Automobile Burial funds

Which of the following services are a covered benefit under Medicare Part B? (Select all that apply.)

Kidney dialysis Emergency care Ambulance services

What are nonPAR physicians subjected to under the Medicare payment guidelines?

Limiting charges

A(n) _____ is responsible for providing all Medicare-covered services except hospice care in return for predetermined capitated payment.

MAO

_____ created a new plan for Medicare called a Medical Savings Account.

MMA

Who runs many of the Medicare CCPs?

Major payers that offer commercial coverage

By what means are services denied when they do not not meet medically necessary parameters?

Medicare code edits

Under a Medicare private fee-for service plan, patients receive services from _____.

Medicare-approved providers

_____ are private insurance plans that beneficiaries may purchase to cover the unpaid amounts in Medicare coverage.

Medigap plans

What should be appended to CPT/HCPCS codes on Medicare claims when an ABN has been signed?

Modifiers

Which of the following are true about Medicare Part D? (Select all that apply.)

Most participants pay monthly premiums. There are two types of plans. All drug plans are private insurance plans.

_____ outline the conditions under which a service is paid by CMS.

NCDs

Which form did the voluntary ABN replace?

NEMB

What does the Medicare assignment code C indicate?

Not assigned

Which of the following services are covered under Medicaid?

Nurse midwife services EPSDT services for people under age twenty-one, including physical examinations, immunizations, and certain age-relevant services Laboratory and X-ray services Inpatient and outpatient hospital services

Which of the following would be denied if a Medicaid patient is on restricted status? (Select all that apply.)

Obtaining prescriptions from any pharmacy Seeing a physician whose name is not listed on the patient's ID card

According to Medicare regulations, lab work may be performed at which of the following locations? (Select all that apply.)

Off-site labs Physician's offices

How many blanks are part of the Additional Information section of the ABN?

One

The Medicare fee-for-service plan is referred to by Medicare as the ___________.

Original Medicare Plan

What are payment arrangements for Medicare PAR providers?

PAR providers must accept the charge amounts listed in the MPFS as the total payment amounts.

Providers who wish to participate in Medicare or to renew contracts may apply online using a system called _____.

PECOS

Which of the following are true about paper claims? (Select all that apply.)

Paper claims cannot be paid before the twenty-ninth day after receipt of the claim. The use of paper claims slows cash flow. By law, paper claims must be held longer than HIPAA-compliant electronic claims before payment can be released.

What does the Medicare Shared Savings Program use to assess PAR providers?

Performance

Which of the following medical staff members perform incident-to services? (Select all that apply.)

Physician assistants Nurse-practitioners

When are audits performed for the Medicare recovery auditor program?

Postpayment

Who operates the Medicare private fee-for service plan?

Private contracted insurance companies

Which of the following are the processes involved in analyzing data to identify services that are being billed correctly? (Select all that apply.)

Probe reviews Postpayment reviews Prepayment reviews

Who completes the Header section of the ABN?

Provider

Which of the following are conditions for Medicare participating providers? (Select all that apply.)

Providers agree to submit claims on behalf of the patient at no charge and receive payment directly from Medicare on the patient's behalf. PAR providers accept assignment and Medicare's allowed charge as payment in full for services. Providers are responsible for knowing the rules and regulations of the program as they affect their patients.

Which of the following are incentives offered to PAR providers? (Select all that apply.)

Providers may participate in PQRS and are eligible for additional payments. PAR providers receive 5 percent higher payments than nonPAR providers. PAR providers do not have to forward claims for beneficiaries who also have supplemental insurance coverage.

When are CCI updates issued?

Quarterly

MPFS was developed from the _____ system.

RBRVS

Which of the following are considered waived tests? (Select all that apply.)

Rapid strep tests Urine dipstick Blood glucose

Medicaid beneficiaries are often referred to as which of the following? (Select all that apply.)

Recipients Subscribers

Which of the following are true about the Medicare recovery auditor program? (Select all that apply.)

Recovery auditors are paid a percentage of the incorrect payments they recover. CMS instructs recovery auditors to use the same payment policies to review claims as Medicare did to initially pay them. Regional recovery auditors analyze paid claim data.

If the patient has coverage through any other insurance plan, the other plan is billed first and then what is forwarded from the primary payer to Medicaid?

Remittance advice

What is the term for services that are performed for a patient who does not have symptoms, abnormal findings, or any past history of the disease?

Screening services

Which of the following are identified on the ABN form? (Select all that apply.)

Service or item for which Medicare is unlikely to pay Estimate of how much the service or item will cost the beneficiary if Medicare does not pay Reason Medicare is unlikely to pay

Once the beneficiary reviews and understands the information contained in the ABN, the beneficiary can complete the _____.

Signature Box

What section of the ABN includes Boxes I-J?

Signature Box

To help fight identify theft, the Medicare Beneficiary Identifier (MBI) has replaced the Medicare health insurance claim number (HICN) because the HICN was based on the beneficiary's ______.

Social Security Number

What should practices do if covered and noncovered services are performed for a patient on the same date?

Split the bill.

A general income and asset guideline states that information provided on the Medicaid application is checked and verified using other sources of information, including which of the following?

State Motor Vehicle Agency Social Security Administration State Department of Labor Internal Revenue Service

Physicians who contract with Medicaid to provide services may not engage in which of the following unacceptable billing practices? (Select all that apply.)

Submitting claims using an individual provider NPI when a physician working for or on behalf of a group practice or clinic performs the services Submitting claims for individual procedures that are part of a global procedure Billing for services not provided or billing more than once for the same procedure

When providers agree to accept payment from Medicaid as payment in full for services, which of the following are true? (Select all that apply.)

They may not bill patients for additional amounts. The difference must be entered into the billing system as a write-off.

Which of the following are true about ZPIC? (Select all that apply.)

They send requests for information to healthcare providers. They are responsible for identifying fraudulent providers and making referrals to CMS. They conduct site visits of healthcare providers.

How many choices are listed in Blank G?

Three

What is the purpose of screening services?

To detect an undiagnosed disease so early medical intervention can begin to prevent harm

What is the purpose of the Medicare Integrity Program?

To identify and address fraud, waste, and abuse

What is the maximum number of diagnosis codes that can be reported on the HIPAA 837P?

Twelve

How often do some states issue Medicaid cards to their subscribers? (Select all that apply.)

Twice a month Every six months Once a month Every two months

The federal government provides Medicaid patients with matching funds for which of these more common optional services?

Vision care Diagnostic services Prescription drugs

When is an insurance type code required?

When a claim is sent to Medicare when Medicare is not the primary payer

Under what conditions should practices split the bill when preparing claims?

When covered and noncovered services are both performed for a patient on the same day

What do ABN modifiers indicate? (Select all that apply.)

Whether services are considered medically necessary Whether an ABN is on file

What is the timely filing period for claims for Part B providers under the Affordable Care Act?

Within one calendar year after the date of service

When providers share postoperative care, the date the provider _____ or gave up care is reported to Medicare.

assumed

If a patient is covered by Medicare and Medigap plan, Medicare will _________ send claim to Medigap for secondary payment.

automatically

NonPAR providers decide whether to accept assignment on a ________ basis.

claim-by-claim

Certain preventive services for qualified individuals are covered under Medicare without requiring a _____ and a _____ payment.

deductible; coinsurance

The EHR Incentive Programs provide _____ for Medicare-eligible professionals, eligible hospitals, and critical care hospitals that do not successfully demonstrate meaningful use.

disincentives

Medicare defines _____ as those sent to one or more Medicare contractors from the same provider for the same beneficiary, the same service, and the same date of service.

duplicate claims

The ABN has _____ sections and _____ blanks.

five; ten

With Medicaid managed care plans, claims are sent to the _____ instead of to the state Medicaid department.

managed care organization

The Zone Program Integrity Contractors conduct both prepayment and postpayment audits based upon the rules for _____.

medical necessity

Services that do not meet certain conditions for coverage are classified as _____.

not medically necessary

If a patient is covered by Medicare and a Medigap plan, how many claims are sent to Medicare?

one

The Options Box section on the ABN form must be filled in by the _____.

patient

Upon enrollment in the Medicare program, providers are issued a(n) _____.

provider transaction access number

Claims that have invalid or missing diagnosis codes will be _____.

returned

A(n) _____ plan is a plan an individual may receive when retiring from a company.

supplemental insurance

Billing for services that are not medically necessary by physicians who contract with Medicaid to provide services is an _____ billing practice.

unacceptable

One of the general Medicaid income and asset guidelines states that only a portion of _____ income from Social Security benefits, Supplemental Security Income (SSI), and veterans' benefits and pensions is counted toward income limits.

unearned

Participating providers may bill patients for services that are excluded from the Medicare program with a written notification called a(n) _____.

voluntary ABN