Deck 16: Explanation of Benefits and Payment Adjudication

Question 1

An appeal for reconsideration of a carrier's decision on a claim must be made:

A)online.
B)in writing.
C)by phone and in writing.
D)with the help of an attorney.

Answer 1

in writing.

Question 2

If a carrier downcodes a claim and the provider maintains that the reported services were medically necessary, the medical office specialist should:

A)send a bill to the patient for the remaining balance.
B)write off the remaining balance.
C)file an appeal with the insurance carrier.
D)send a complaint to the state insurance commissioner.

Answer 2

file an appeal with the insurance carrier.

Question 3

During the patient's care, all procedures and tests are documented on the:

A)encounter form.
B)explanation of benefits.
C)claim form.
D)registration form.

Answer 3

encounter form.

Question 4

The two main methods used by providers to determine their fees are:

A)capitation-based and resource-based fee structures.
B)profit-based and charge-based fee structures.
C)charge-based and resource-based fee structures.
D)resource-based and usual-and-customary fee structures.

Question 5

The steps that result in an insurance carrier's decision to either pay or deny a claim are known as:

A)allocation.
B)adjudication.
C)determination.
D)justification.

Question 6

After a claim is processed, an explanation of benefits (EOB) is sent to the:

A)provider only.
B)patient only.
C)provider and the patient.
D)carrier's headquarters.

Question 7

No matter what amount a provider charges for a given service, each third-party payer will establish the amount they will pay based on what is considered:

A)medically appropriate.
B)usual and ordinary.
C)usual, customary, and reasonable.
D)average.

Question 8

Claims processing involves the verification of medical necessity for the reported procedures; this task is performed by:

A)medical office specialists.
B)medical directors.
C)medical review examiners.
D)automated claims processors.

Question 9

The state official who has regulatory control over insurance carriers and can assist with disputes is the:

A)state attorney general.
B)state economic development director.
C)senior state senator.
D)state insurance commissioner.

Question 10

Resource-based fee structures consider all of the following factors EXCEPT the:

A)provider's location.
B)work involved.
C)overhead (expense) involved.
D)malpractice risk.

Question 11

When providers determine what fee to charge by considering what other providers charge for similar services, this method is:

A)charge based.
B)research based.
C)resource based.
D)comparison based.

Question 12

If no payment is made on a claim by the carrier because the patient has NOT yet satisfied the deductible:

A)an EOB is sent to the patient only.
B)an EOB is sent to the provider only.
C)an EOB is sent to both the patient and the provider.
D)no EOB is sent.

Question 13

When treatment is determined to be appropriate for the diagnosis, the care is considered:

A)medically necessary.
B)medically appropriate.
C)medically reasonable.
D)medically feasible.

Question 14

When a claim has been downcoded or denied by the insurance carrier, the medical office specialist can ask for reconsideration by filing:

A)an appeal.
B)an adjudication.
C)a complaint.
D)a request.

Question 15

When third-party payers determine reimbursement, they consider UCR, which means:

A)usual, customary, and reasonable charges.
B)usual and common rates.
C)uniform, customary reimbursement.
D)usual and customary resources.

Question 16

The first step that the medical office specialist is responsible for before submitting a medical claim is:

A)verifying patient insurance benefits.
B)obtaining correct and complete patient information.
C)entering patient information data into the computer.
D)posting charges.

Question 17

If the reported services are deemed NOT medically necessary at the level reported, the claim will be:

A)denied.
B)downcoded.
C)upcoded.
D)pended.

Question 18

The notification sent by the insurance carrier to the patient and provider after a claim has been processed is known as a(n):

A)patient registration form.
B)encounter form.
C)charge slip.
D)explanation of benefits.

Question 19

If an insurance carrier does NOT reconsider a downcoded claim that has been appealed, the medical office specialist can:

A)request assistance from the state insurance commissioner.
B)file a complaint with the Department of Health and Human Services (DHHS).
C)file a complaint with the Centers for Medicare and Medicaid Services (CMS).
D)bill the patient for the remaining balance.

Question 20

A claim that is removed from a payer's automated processing system for additional review is subject to:

A)preauthorization.
B)manual review.
C)medical-necessity examination.
D)claims edit.

Question 21

Under Medicare Part B, reimbursement to a participating provider is based on:

A)80% payment by Medicare and 20% by the patient after a deductible.
B)20% payment by Medicare and 80% by the patient after a deductible.
C)80% payment by Medicare and 20% by the patient without a deductible.
D)20% payment by Medicare and 80% by the patient without a deductible.

Question 22

What percentage of a physician's work value is adjusted based on geographic cost differences?

A)25%
B)45%
C)55%
D)75%

Question 23

The Medicare RBRVS system first implemented in 1992 is the:

A)relative basis for resource-valued services.
B)relative-based resource value scale.
C)resource-based relative value scale.
D)resource-based relative value services.

Question 24

A provider's usual charge for a procedure or service can be:

A)higher than the allowed charge.
B)lower than the allowed charge.
C)equal to the allowed charge.
D)all of the above.

Question 25

In regard to the RBRVS system, the risk of harm posed to the patient by a particular service or procedure is considered to be part of the:

A)provider's effort and stress level.
B)practice expense.
C)cost of liability insurance.
D)risk factor for a given specialty.

Question 26

Under an 80/20 plan, if a nonparticipating provider's usual charge is $200 for a procedure and the allowed amount is $150, the provider can collect:

A)$150 from the insurance carrier and $50 from the patient.
B)$120 from the insurance carrier and $30 from the patient.
C)$120 from the insurance carrier and $80 from the patient.
D)$160 from the insurance carrier and $40 from the patient.

Question 27

The allowed charge includes the amount that will be paid by:

A)the insurance carrier only.
B)the patient only.
C)the insurance carrier and the patient.
D)none of the above.

Question 28

The cost of malpractice insurance is highest for physicians in which of the following specialties?

A)Obstetrics and gynecology
B)Cardiology
C)Dermatology
D)Neurosurgery

Question 29

A provider who is able to balance-bill a patient for the amount over the carrier's allowed charge is a(n):

A)contracted provider.
B)independent provider.
C)nonparticipating provider.
D)participating provider.

Question 30

The physician's work element accounts for what percentage of the total relative value for each service?

A)25%
B)32%
C)52%
D)75%

Question 31

The Medicare conversion factor is updated annually by:

A)independent insurance carriers.
B)the Centers for Medicare and Medicaid Services (CMS).
C)the legislature.
D)the Federal Register.

Question 32

In regard to the RBRVS system, the time it takes to perform a service is considered to be part of the:

A)provider's work.
B)practice expense.
C)time factor.
D)staff expense.

Question 33

Under a capitation arrangement, a provider is paid a per-member-per-month (PMPM) fee for all enrolled members:

A)who are seen that month.
B)whether or not they are seen that month.
C)who are not referred to specialty care that month.
D)who are not hospitalized that month.

Question 34

The RBRVS system establishes the nationally uniform relative value of a service based on which three cost elements?

A)The cost of payroll, the cost of supplies, and the cost of liability insurance
B)The physician's specialty, the physician's work, and the location of the practice
C)The location of the practice, the overhead, and the cost of liability insurance
D)The physician's work, the practice expense, and the cost of liability insurance

Question 35

In regard to the RBRVS system, the overhead of a physician's office is referred to as the:

A)provider's work.
B)practice expense.
C)professional liability insurance.
D)payroll expense.

Question 36

Prior to the Omnibus Budget Reconciliation Act (OBRA) of 1989, Medicare payments to providers were based on:

A)the resources used to perform the procedure or services.
B)a Medicare-developed reasonable fee schedule.
C)physicians' charge-based fees.
D)a capitation arrangement.

Question 37

The nationally uniform relative values are adjusted by:

A)physician training and specialty.
B)geographic practice cost differences.
C)liability insurance cost differences.
D)the number of employees of the practice.

Question 38

The largest cost element in determining the nationally uniform relative value of a service is the:

A)provider's work.
B)practice expense.
C)cost of professional liability insurance.
D)location of the practice.

Question 39

In regard to the RBRVS system, the technical skill of the provider is considered to be part of the:

A)provider's work.
B)practice expense.
C)provider's training.
D)malpractice risk.

Question 40

Under an 80/20 plan, if a participating provider's usual charge is $200 for a procedure and the allowed amount is $150, the provider can collect:

A)$150 from the insurance carrier and $50 from the patient.
B)$120 from the insurance carrier and $30 from the patient.
C)$120 from the insurance carrier and $80 from the patient.
D)$160 from the insurance carrier and $40 from the patient.

Question 41

An explanation of benefits (EOB) is notification the provider sends to the patient detailing what the insurance carrier has paid.

Question 42

The resource-based fee structure takes into account the provider's work, the practice expense, and the cost of professional liability insurance.

Question 43

The Medicare Fee Schedule (MFS) is based on the provider's charge-based fee schedule.

Question 44

The set amount a patient must pay at the time of service is the:

A)coinsurance.
B)copayment.
C)deductible.
D)premium.

Question 45

Coinsurance refers to:

A)the amount a patient must pay each year before benefits begin.
B)a set amount a patient must pay at the time of service.
C)a percentage of allowable charges the patient must pay.
D)the amount of out-of-pocket expenses a patient must pay.

Question 46

A provider's usual charge for a service can be higher, equal to, or lower than the insurance carrier's allowed charge.

Question 47

The section of the explanation of benefits (EOB) that indicates who was paid, how much, and when is the:

A)service information.
B)coverage determination.
C)benefit payment information.
D)summary information.

Question 48

The medical office specialist must make a copy of only the front of the patient's insurance card.

Question 49

If a patient has a $200 deductible and receives $50 of services on January 1, the insurance carrier will pay 80% of the billed amount.

Question 50

If a claim is denied due to lack of medical necessity, the provider must refund any payment made by the carrier and can bill the patient for the balance.

Question 51

Seventy-five percent of the physician's work value under the resource-based relative value scale (RBRVS) is adjusted by geographic cost differences.

Question 52

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)written off by the provider.
D)written off by the insurance carrier.

Question 53

If a physician's office provides services that are excluded from an insurance policy, the:

A)patient must pay 100% of the cost.
B)insurance carrier will pay 100% of the cost.
C)physician must write off the charges.
D)patient must pay 80% of the cost after a deductible.

Question 54

The types of payments that an insured person is responsible for paying include all of the following EXCEPT:

A)deductibles.
B)charges over the allowed amount for a participating provider.
C)charges over the allowed amount for a nonparticipating provider.
D)charges for excluded services.

Question 55

Physicians have the right to establish their fees at a level that they believe fairly reflects the costs of providing a service.

Question 56

A percentage of a providers' payment that is NOT paid during a contract year but is kept by the health plan to offset additional costs incurred for referrals, hospital admissions, or other covered services is called a:

A)disincentive.
B)per-member-per-month (PMPM) fee.
C)withdrawal.
D)withhold.

Question 57

The deductible under most insurance plans applies to each covered individual each:

A)date of service.
B)month.
C)calendar year.
D)contract.

Question 58

A claim that is manually reviewed by an insurance carrier can be denied for lack of required preauthorization.

Question 59

The patient is responsible for the difference between the provider's usual charge and the carrier's allowed charge when services are received from a participating provider.

Question 60

The section of the explanation of benefits (EOB) that summarizes the total deductions, charges NOT covered by the plan, and the amount the patient may owe the provider is the:

A)service information.
B)coverage determination.
C)benefit payment information.
D)summary information.

Question 61

Medical necessity reduction by an insurance carrier is also known as __________ .

Question 62

What information is found on the explanation of benefits (EOB)?

Question 63

A(n) __________ claim is one that has been received by the carrier but cannot be processed due to an error or because additional information is needed.

Question 64

A lockbox service provided by a bank helps control receivables by collecting and depositing carrier and patient payments faster than if the process were performed by office staff.

Question 65

refers to the steps involved in processing a claim that result in payment or denial of the claim.

Question 66

The RBRVS system unit of measurement assigned to a service based on the relative skill and time required to perform it is the __________ unit.

Question 67

State and federal regulations determine how long patient records must be kept and stored.

Question 68

What forms of identification should be requested to verify a patient's identity?

Question 69

A patient is expected to pay for services excluded from his or her insurance policy at the time the service is rendered.

Question 70

Under a managed care contract with a capitation reimbursement method, the provider is paid a per-member-per-month (PMPM) fee for each enrolled member regardless of services provided.

Question 71

Monies owed to a provider by insurance carriers or patients makes up the __________ .

Question 72

Electronic funds transfer (EFT) is more costly to the practice than depositing checks.

Question 73

The benefit payment information on an explanation of benefits (EOB) indicates who was paid, how much, and when.

Question 74

A provider is paid a per-member-per-month (PMPM) fee for each enrolled member in a health plan that uses the __________ method of reimbursement.

Question 75

A positive or negative change to a patient's account balance is a(n) __________ .

Question 76

The amount of time it takes for the insurance carrier to process a claim is called the __________ time.

Question 77

The amount of covered expenses that a policyholder must pay before insurance benefits begin is the __________ .

Question 78

A patient's out-of-pocket expenses include deductibles, coinsurance, and copayments.

Question 79

Participating providers can demand payment in full from the patient rather than waiting for the insurance carrier to process the claim.

Question 80

Match the following:

A) Code shown on an explanation of benefits (EOB) to explain the coverage determination or a denial
B) A set amount that the patient must pay at the time of service
C) The steps involved in the processing and payment or denial of a claim
D) Unit of measurement assigned to a service based on the skill and time required to perform it
E) A number used to multiply or divide a quantity when converting from one system of units to another
F) The maximum amount an insurance carrier will pay for a covered service
G) Percentage of the provider's payment held back to offset any additional costs under a capitation agreement
H) The amount that a policyholder must pay for covered services before insurance benefits begin to pay
I) Percentage of the cost of covered services that the policyholder must pay
J) Version of the explanation of benefits (EOB) sent to the provider by the insurance carrier after the processing of electronic claims


reason code
copayment
adjudication
relative value unit
conversion factor
allowed charge
withhold
deductible
coinsurance
electronic remittance advice (ERA)