Question 1

The section of the 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.

Accepted Answer

The answer of The section of the EOB that summarizes...

Question 2

A percentage of a provider's 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.

Accepted Answer

The term described in the question is a withhold.

Question 3

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

Accepted Answer

Physicians are entitled to set their fees according to their perceived cost of service.

Question 4

The Medicare conversion factor to be used for physician payments as of January 1, 2015, is $35.8043.

Accepted Answer

This information is accurate as of January 2021. However, it is possible that the Medicare conversion factor may change in the future.

Question 5

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.

Accepted Answer

If a claim is denied due to lack of medical necessity, the provider cannot bill the patient for the balance. They can appeal the decision or work with the patient to find alternative treatment options.

Question 6

When the practice receives the EOBs and documentation of deposit from the lockbox, the office insurance specialist should: (Select all that apply)
A) add up the EOBs to ensure that the total equals the company's check.
B) consider "batching" the EOBs if there are a lot of them.
C) call the bank to ensure all EOBs are accounted for in the case of a discrepancy.
D) all of the above.

Accepted Answer

The answer of When the practice receives the EOBs and...

Question 7

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

Accepted Answer

Insurance carriers may require preauthorization for certain medical services or procedures. If preauthorization was not obtained prior to the service being performed, the claim may be denied upon manual review by the carrier.

Question 8

The set amount a patient must pay at the time of service is the:
A) coinsurance.
B) copayment.
C) deductible.
D) premium.

Accepted Answer

The set amount a patient must pay at the time of service is the copayment. Coinsurance is a percentage of the cost of a covered healthcare service that you pay out-of-pocket after you've met your deductible. A deductible is the amount you pay for covered healthcare services before your insurance plan starts to pay. The premium is the amount you pay monthly, quarterly or yearly to buy an insurance policy.

Question 9

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

Accepted Answer

It is possible for a provider's usual charge for a service to be higher or lower than the insurance carrier's allowed charge.

Question 10

The section of the 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.

Accepted Answer

The section of the EOB that indicates who was paid, how much, and when is the benefit payment information.

Question 11

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.

Accepted Answer

When services are received from a participating provider, the provider has agreed to accept the carrier's allowed charge as payment in full, and the patient is not responsible for any additional charges.

Question 12

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

Accepted Answer

An Explanation of Benefits (EOB) is a statement sent by the insurance company to the patient explaining what medical treatments and/or services were paid for on their behalf, not a notification sent by the provider.

Question 13

What is the benefit specified in an insurance policy that is different from out-of-pocket expenses because once the stated maximum has been met for a lifetime, no more benefits will be paid?
A) lifetime maximum
B) lifelong maximum
C) maximum benefits
D) existence benefits

Accepted Answer

The phrase "once the stated maximum has been met for a lifetime, no more benefits will be paid" refers to the concept of lifetime maximum benefit. This represents a cap on the total amount of benefits that can be received over the course of an individual's lifetime.

Question 14

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.

Accepted Answer

Coinsurance refers to a percentage of allowable charges that the patient must pay. For example, if the coinsurance is 20%, the patient would be responsible for paying 20% of the cost of the service, while the insurance company would pay the remaining 80%. This is different from a deductible, which is a set amount the patient must pay before insurance benefits kick in.

Question 15

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

Accepted Answer

The resource-based fee structure, also known as the resource-based relative value scale (RBRVS), takes into account the provider's work, the practice expense, and the cost of professional liability insurance.

Question 16

The deductible under most insurance plans applies to each covered individual each:
A) date of service.
B) month.
C) calendar year.
D) contract.

Accepted Answer

The deductible under most insurance plans applies to each covered individual each calendar year. This means that the deductible amount needs to be met individually by each covered person within the same calendar year, regardless of when their specific medical services were incurred during that year.

Question 17

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

Accepted Answer

The Medicare Fee Schedule (MFS) is based on a resource-based relative value scale (RBRVS), which takes into account factors such as the complexity of the service, the time and skill required by the provider, and the resources used in providing the service. It is not based on the provider's charge-based fee schedule.

Question 18

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.

Accepted Answer

The difference between the billed amount and the allowed amount for services is referred to as a "provider write-off." This means that the participating provider agrees to accept the allowed amount as payment in full and does not bill the patient for the difference.

Question 19

Seventy-five percent of the physician's work value under the RBRVS is adjusted by geographic cost differences.

Accepted Answer

Under the Resource-Based Relative Value Scale (RBRVS), it is the practice expense and malpractice components, not the physician's work value, that are adjusted for geographic cost differences. The physician's work value is considered to be constant across geographic areas.

Question 20

The Medicare Shared Savings Program is the most well-known and standardized example of value-based reimbursement.

Accepted Answer

The Medicare Shared Savings Program is a well-known and standardized example of value-based reimbursement.

Quiz 15: Explanation of Benefits and Payment Adjudication

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

A percentage of a provider's 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:

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

The Medicare conversion factor to be used for physician payments as of January 1, 2015, is $35.8043.

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.

When the practice receives the EOBs and documentation of deposit from the lockbox, the office insurance specialist should: (Select all that apply)

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

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

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

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

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.

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

What is the benefit specified in an insurance policy that is different from out-of-pocket expenses because once the stated maximum has been met for a lifetime, no more benefits will be paid?

Coinsurance refers to:

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

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

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

The difference between the billed amount and the allowed amount for services from a participating provider is:

Seventy-five percent of the physician's work value under the RBRVS is adjusted by geographic cost differences.

The Medicare Shared Savings Program is the most well-known and standardized example of value-based reimbursement.