Deck 9: Receiving Payments and Insurance Problem Solving

Question 1

When receiving payment from a private insurance carrier, check the amount of payment on the EOB with the

A) patient's financial accounting record.
B) practice's daysheet.
C) copy of the CMS-1500 form.
D) patient's insurance contract.

Answer 1

patient's financial accounting record.

Question 2

What should you do if an insurance carrier requests information about another insurance carrier?

A) Provide the information.
B) Call the patient and advise him or her to contact the insurance carrier with the requested information.
C) The carrier should contact the other carrier and coordinate benefits.
D) None of the above.

Answer 2

Provide the information.

Question 3

The correct method to send documents for a Medicare reconsideration (Level 2) is by

A) certified mail with return receipt requested.
B) certified mail.
C) standard mail.
D) overnight mail.

Answer 3

certified mail with return receipt requested.

Question 4

An insurance claims register provides a

A) file containing the name and address of all insurance companies.
B) follow-up report that is sent to the insurance commissioner.
C) follow-up procedure for insurance claims.
D) practice analysis.

Question 5

The total number of levels of redetermination that exist in the Medicare program is

A) two.
B) three.
C) five.
D) six.

Question 6

The first level of appeal in the Medicare program is

A) redetermination.
B) inquiry.
C) fair hearing.
D) appeals council review.

Question 7

When downcoding occurs, payment will

A) not be affected.
B) be denied.
C) be less.
D) be more.

Question 8

If an insured is in disagreement with the insurer for settlement of a claim, a suit must begin within

A) 1 year.
B) 2 years.
C) 3 years.
D) 5 years.

Question 9

A follow-up effort made to an insurance company to locate the status of an insurance claim is called a/an

A) inquiry.
B) tracer.
C) rebill.
D) both a and b

Question 10

If an insurance company admits that a patient signed an assignment of benefits document and that it inadvertently paid the patient instead of the physician, the insurance company should

A) advise the physician to write-off the amount as a bad debt.
B) pay the physician within 2-3 weeks and honor the assignment even before the company recovers its money from the patient.
C) pay the physician within 2-3 weeks after recovering the money from the patient.
D) notify the physician of the error and indicate in a letter that it will never happen again.

Question 11

There are several ways to file pending insurance claims. What is the best way to file so that timely follow-up can be made?

A) File by patient's last name.
B) File by type of insurance.
C) File by patient's account number.
D) File by month of service.

Question 12

An insurance claim for which prior approval was not obtained would be

A) paid.
B) unauthorized.
C) suspended.
D) denied.

Question 13

An example of a technical error on an insurance claim is

A) duplicate dates of service.
B) transposed numbers.
C) missing place of service code.
D) all of the above.

Question 14

An insurance claim with an invalid procedure code would be

A) paid.
B) appealed.
C) suspended.
D) denied.

Question 15

If a payment problem develops with an insurance company and the company ignores claims and exceeds time limits to pay a claim, it is prudent to contact the

A) federal insurance commissioner.
B) state insurance commissioner.
C) state insurance federation.
D) department of public service.

Question 16

The document together with the payment voucher that is sent to a physician who has accepted assignment of benefits is referred to as an

A) EOB.
B) EOMB.
C) MRA.
D) MPS.

Question 17

What should be done if an insurance company denies a service stating it was not medically necessary and the physician believes it was?

A) Rebill with a letter of explanation from the physician.
B) Write-off the amount on the patient's account.
C) Send the patient a statement with a notation of the response from the insurance company.
D) Appeal the decision with a statement from the physician.

Question 18

An insurance claim for a service that has been bundled with other services would be

A) paid.
B) rejected.
C) suspended.
D) denied.

Question 19

If an insurance claim has been lost by the insurance carrier, the procedure(s) to follow is to

A) ask if there is a backlog of claims at the insurance office.
B) submit a copy of the original claim.
C) verify the correct mailing address.
D) all of the above.

Question 20

What should be done if an insurance claim denial is received because a billed service was not a program benefit?

A) Rebill with a letter of explanation from the physician.
B) Write-off the amount on the patient's ledger.
C) Send the patient a statement with a notation of the response from the insurance company.
D) Appeal the decision with a statement from the physician.

Question 21

All of the following are responsibilities of the insurance payment poster EXCEPT:

A) posting insurance reimbursements for every code submitted in the insurance claim.
B) adjusting the amount charged to match the allowable charge.
C) filing the appeal for denial.
D) sending statements for patient deductibles and coinsurance balances.

Question 22

Generally, if a bill has not been paid, the physician rebills the patient every ____________________ days.

Question 23

A delinquent insurance claim may be easily located by reviewing the _________________________.

Question 24

An insurance claim that is pending because of the need for additional information is also referred to as being in ____________________.

Question 25

In a TRICARE case, a request for an independent hearing may be pursued if the amount in question is

A) $100 or more.
B) $300 or more.
C) $500 or more.
D) $1000 or more.

Question 26

The following are examples of problem claim filing EXCEPT:

A) payment paid to patient.
B) payment lost in the mail.
C) denied for no preauthorization.
D) all are examples of problem claim filing.

Question 27

All requests of the insurance commissioner must be submitted in writing and include the ____________________ signature.

Question 28

FTC stands for _________________________.

Question 29

An insurance claim that is processed without following specific insurance carrier instructions is considered a/an ____________________ claim.

Question 30

Monitoring the activities of insurance companies and making sure that the interests of the policyholders are protected are the jobs of the insurance ____________________.

Question 31

A request for a Medicare administrative law judge hearing can be made if the amount in controversy is at least

A) $130.
B) $250.
C) $350.
D) $500.

Question 32

Documentation from private insurance carriers sent to participating providers that accompanies payment and describes the response to a claim is referred to by the acronym ____________________.

Question 33

Which of the following is a benefit to using the online health insurance provider web portal?

A) Saves time by eliminating the need to telephone insurance company for every patient
B) Supports HIPAA standards of patient privacy and security
C) Interacts with EHR systems in downloading directly into patient medical record
D) All of the above

Question 34

If the medical practice receives payment from an insurance company that is more than the contract rate, it is called a/an ____________________.

Question 35

An insured person cannot bring legal action against an insurance company until ____________________ days after a claim is submitted to the insurance company.

Question 36

Overdue payment on an insurance claim is referred to as ____________________.

Question 37

How many levels of review exist for TRICARE appeal procedures?

A) One
B) Two
C) Three
D) Five

Question 38

Which statement is true of the insurance commission of the state?

A) To maintain all complaints confidential every year.
B) To make sure that all organizations authorized to transact insurance including agents and brokers are in compliance with the insurance laws of that state.
C) To bring insurance claim submissions to court when there are disputes about payments.
D) To monitor activities of policyholders and to ensure the interests of insurance companies.

Question 39

For Medicare patients whose secondary insurance is Medicaid:

A) Medicaid is billed separately.
B) Medicare reimburses both the primary and secondary payments.
C) The balance is adjusted because the Medicaid fee schedule is less than Medicare.
D) The patient is sent a statement for the secondary insurance balance.

Question 40

TRICARE appeals are normally resolved within

A) 2 weeks.
B) 30 days.
C) 60 days.
D) 90 days.

Question 41

Approximately 50% of individuals pursue appeals on a denied insurance claim.

Question 42

Requests to the insurance commissioner must be submitted _______________.

Question 43

Appeal decisions on Medicare unassigned insurance claims are sent to the patient.

Question 44

The highest level of a Medicare redetermination is with an administrative law judge hearing.

Question 45

The insurance industry is protected by a special exemption from the Federal Trade Commission (FTC).

Question 46

A rejected insurance claim should be corrected and sent for review or appeal.

Question 47

Time limits stated in individual health insurance policies about an insurance company's obligation to pay benefits are the same for all insurance companies.

Question 48

A request for a hearing before an administrative law judge (in a Medicare case) may be made if the amount still in question is ____________________ or more.

Question 49

In the case of a Medicare Part B redetermination, carriers have been instructed to pay an appealed insurance claim if the cost of the hearing process is more than the amount of the claim.

Question 50

If the provider is notified by a commercial insurance carrier that an overpayment has been made, investigate the refund request.

Question 51

If inadequate payment was received from an insurance company for a complicated procedure, the insurance billing specialist should file a/an ____________________ on behalf of the physician.

Question 52

Routine use of too many nonspecific diagnostic codes may result in downcoding.

Question 53

A Level 1 Medicare redetermination (appeal) may be made by telephone, in writing, or by submitting a CMS-20027 form.

Question 54

If you have a denied insurance claim, you should change the information and resubmit the claim.

Question 55

The status of electronic insurance claims may be accessed quickly through online health insurance physician web portals.

Question 56

There is standardization of format for the explanation of benefits document for all private insurance carriers.

Question 57

Insurance companies are rated according to the number of complaints received about them.

Question 58

The ______________________ manages complaints about delays in settling insurance claims, illegal cancellations or terminations of an insurance policy, and problems about insurance premium rates.

Question 59

A peer review is usually done before the appeal process.

Question 60

In any type of overpayment situation, always cash the third-party payers check and write a refund check payable to the originator of the overpayment.

Question 61

The explanation of benefits (EOB), which details the amount allowable, the amount that needs to be adjusted, and the reason why, is issued by the health insurance company.

Question 62

The patient's health insurance card specifies all benefits and coverages.

Question 63

The management of health insurance claims by paper and electronically are the same.

Question 64

The insurance payment poster is responsible for submitting appeals for denied claims.

Question 65

If the insurance company inadvertently paid the patient even though there was an assignment of benefits on file, the physician must file a complaint with the state commissioner.