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.

Accepted Answer

The patient's financial accounting record will provide a detailed record of the services provided, the amount billed, and the amount paid by the insurance carrier. Comparing this with the payment amount on the EOB will ensure that the payment received is accurate and the remaining balance matches the patient's responsibility. The practice's daysheet and the copy of the CMS-1500 form will help in identifying the services provided and billed, but they do not provide the payment details. The patient's insurance contract will not provide payment details and is not directly relevant to verifying payment amounts.

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.

Accepted Answer

A

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.

Accepted Answer

Sending documents for a Medicare reconsideration by certified mail with return receipt requested ensures that the sender has proof of the mailing and the delivery of the documents. This is important for tracking the progress of the reconsideration request and for legal purposes if necessary.

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.

Accepted Answer

An insurance claims register provides a follow-up procedure for insurance claims. It is a log or database of all the insurance claims made by policyholders, and it helps to keep track of the status of each claim, ensuring that they are being reviewed and processed in a timely manner.

Question 5

The total number of levels of redetermination that exist in the Medicare program is
A) two.
B) three.
C) five.
D) six.

Accepted Answer

There are five levels of redetermination in the Medicare appeals process. These include: 1) Redetermination by a Medicare Administrative Contractor, 2) Reconsideration by a Qualified Independent Contractor, 3) Hearing by an Administrative Law Judge, 4) Review by the Medicare Appeals Council, and 5) Judicial Review in U.S. District Court.

Question 6

The first level of appeal in the Medicare program is
A) redetermination.
B) inquiry.
C) fair hearing.
D) appeals council review.

Accepted Answer

The first level of appeal in the Medicare program is redetermination. This involves a review of the initial claim by a different Medicare claims examiner. If the appeal is not successful at this level, the beneficiary may then request a reconsideration, followed by a hearing, and finally an appeals council review.

Question 7

When downcoding occurs, payment will
A) not be affected.
B) be denied.
C) be less.
D) be more.

Accepted Answer

When downcoding occurs, it means that the provider's billed service is being reimbursed at a lower level than what was requested. This results in the payment being less than what the provider expected to receive. Therefore, the correct answer is C - the payment will be less.

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.

Accepted Answer

The insured must begin the suit within three years from the date of loss, according to the statute of limitations. After this period, the insured will lose the right to pursue legal action against the insurer for the claim settlement.

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

Accepted Answer

The answer of A follow-up effort made to an insurance...

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.

Accepted Answer

The insurance company should honor the assignment of benefits and pay the physician within 2-3 weeks, even before recovering the money from the patient. The mistake made by the insurance company should not affect the physician's payment for services rendered.

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.

Accepted Answer

The answer of There are several ways to file pending...

Question 12

An insurance claim for which prior approval was not obtained would be
A) paid.
B) unauthorized.
C) suspended.
D) denied.

Accepted Answer

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

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.

Accepted Answer

The answer of An example of a technical error on...

Question 14

An insurance claim with an invalid procedure code would be
A) paid.
B) appealed.
C) suspended.
D) denied.

Accepted Answer

An insurance claim with an invalid procedure code would be denied because an invalid procedure code means that the procedure performed is not covered under the policy or the code is incorrect or not recognized by the insurance company. Hence, the claim is denied, and the healthcare provider needs to correct the error and resubmit the claim.

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.

Accepted Answer

State insurance commissioners are responsible for regulating insurance companies and handling consumer complaints within their respective states. They can investigate and intervene in cases where insurance companies are not fulfilling their obligations to policyholders, including not paying claims in a timely manner. The federal insurance commissioner does not exist as such; however, there is a federal agency called the National Association of Insurance Commissioners (NAIC) which provides guidance and support to state insurance commissioners, but they typically do not handle individual consumer complaints. The state insurance federation is not a recognized regulatory body, and the department of public service may not have jurisdiction over insurance matters.

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.

Accepted Answer

The document sent to a physician who has accepted assignment of benefits is called an Explanation of Benefits (EOB). It is usually accompanied by a payment voucher to reimburse the physician for their services. An EOMB (Explanation of Medicare Benefits) is a similar document but specifically refers to Medicare-covered services. MRA (Medical Record Audit) and MPS (Master Patient Schedule) are unrelated to this scenario.

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.

Accepted Answer

The best course of action would be to appeal the decision with a statement from the physician supporting the medical necessity of the service. This will provide an opportunity to provide additional documentation or explanation that may sway the insurance company's decision. Rebilling with a letter of explanation and sending a statement to the patient with a notation of the response from the insurance company could also be helpful steps to take, but they should not replace the initial appeal to the insurance company. Writing off the amount on the patient's account would not be appropriate unless all avenues of appeals have been exhausted and it has been determined that the patient is responsible for the cost of the service.

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.

Accepted Answer

Bundled services are typically billed together as a single charge, and if an insurance claim is submitted for a service that should be bundled, it may be denied because it is not billed separately.

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.

Accepted Answer

The answer of If an insurance claim has been lost...

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.

Accepted Answer

The answer of What should be done if an insurance...

Quiz 9: Receiving Payments and Insurance Problem Solving

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

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

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

An insurance claims register provides a

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

The first level of appeal in the Medicare program is

When downcoding occurs, payment will

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

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

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

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

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

An example of a technical error on an insurance claim is

An insurance claim with an invalid procedure code would be

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

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

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

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

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

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