Deck 13: Medicare Medical Billing

Question 1

The Medicare program that provides expanded benefits through private managed care health plans is:

A)Medicare Part A.
B)Medicare Part B.
C)Medicare Part D.
D)Medicare Advantage (MA).

Answer 1

Medicare Advantage (MA).

Question 2

The role of the Centers for Medicare and Medicaid Services (CMS) includes all of the following EXCEPT:

A)paying claims for Medicare beneficiaries.
B)establishing policy for provider reimbursement.
C)conducting research of healthcare management and treatment.
D)assessing the quality of healthcare facilities and services.

Answer 2

paying claims for Medicare beneficiaries.

Question 3

For each benefit period, a Medicare Part A beneficiary will receive coverage for how many days of skilled nursing care?

A)30 days
B)60 days
C)90 days
D)100 days

Answer 3

100 days

Question 4

The abbreviation ESRD stands for:

A)ending symptoms of renal disease.
B)early status of respiratory distress.
C)end-stage respiratory distress.
D)end-stage renal disease.

Question 5

Under Medicare Part A, what time limit applies to coverage for home healthcare services?

A)60 days per benefit period
B)90 days per benefit period
C)120 days per benefit period
D)There is no time limit as long as medical necessity has been proven.

Question 6

For each benefit period, a Medicare Part A beneficiary will receive coverage for:

A)30 days of hospital care.
B)60 days of hospital care.
C)90 days of hospital care.
D)unlimited days of hospital care if medically necessary.

Question 7

Medicare prescription drug coverage is offered through:

A)Medicare Part A.
B)Medicare Part B.
C)Medicare Part D.
D)Medicare Advantage (MA).

Question 8

For Medicare Part A, a deductible applies:

A)to each benefit period.
B)to each household.
C)to each hospital admission.
D)only if skilled nursing care is provided.

Question 9

Individuals eligible for Medicare may be classified into one or more of the following categories EXCEPT:

A)age 65 or older.
B)disabled.
C)low income.
D)end-stage renal disease (ESRD).

Question 10

Hospice services covered under Medicare Part A may be provided as:

A)short-term hospital care.
B)inpatient respite care.
C)in-home care.
D)all of the above.

Question 11

When receiving inpatient hospital care, a Medicare Part A beneficiary has a lifetime reserve of:

A)30 days.
B)60 days.
C)90 days.
D)unlimited days if medically necessary.

Question 12

Coverage for hospice care is provided by:

A)Medicare Part A.
B)Medicare Part B.
C)Medicare Part D.
D)Medicare Advantage (MA).

Question 13

Organizations that are hired by the CMS to carry out day-to-day Medicare program operations are known as:

A)administrators.
B)contractors.
C)intermediaries.
D)carriers.

Question 14

Medicare Part A provides coverage for all of the following services EXCEPT:

A)inpatient hospital care.
B)inpatient physician services.
C)home health care.
D)hospice care.

Question 15

To qualify for Medicare, disabled adults must have been receiving Social Security disability benefits for:

A)1 year.
B)more than 1 year.
C)more than 2 years.
D)more than 3 years.

Question 16

Individuals age 65 and older qualify for Medicare if they have paid FICA taxes for at least:

A)10 calendar quarters.
B)25 calendar quarters.
C)40 calendar quarters.
D)50 calendar quarters.

Question 17

The organization that enrolls new Medicare beneficiaries into the program is the:

A)Centers for Medicare and Medicaid Services (CMS).
B)Department of Health and Human Services (DHHS).
C)Internal Revenue Service (IRS).
D)Social Security Administration (SSA).

Question 18

The Medicare coverage that pays for physician services is:

A)Medicare Part A.
B)Medicare Part B.
C)Medicare Part D.
D)Medicare Advantage (MA).

Question 19

The Medicare coverage that consists of hospital insurance is:

A)Medicare Part A.
B)Medicare Part B.
C)Medicare Part D.
D)Medicare Advantage (MA).

Question 20

A spouse of a deceased, retired, or disabled individual who was or is eligible for Medicare benefits:

A)is not eligible for Medicare coverage.
B)is also eligible for Medicare coverage.
C)must apply for Medicaid benefits.
D)is eligible for Supplemental Security Income benefits.

Question 21

Medicare Part D consists of:

A)home healthcare coverage.
B)wellness coverage.
C)prescription drug coverage.
D)long-term-care coverage.

Question 22

The Physician Quality Reporting Initiative (PQRI) is a:

A)mandatory quality reporting program.
B)voluntary quality reporting program that requires enrollment by physicians.
C)voluntary quality reporting program that requires registration by physicians.
D)voluntary quality reporting program that includes financial incentives.

Question 23

The Program of All-Inclusive Care for the Elderly (PACE) is a program for low-income elderly individuals that is:

A)a Medicaid program.
B)a joint Medicare-Medicaid program.
C)a program funded by private insurers.
D)a state-run program.

Question 24

To obtain Medicare Part B coverage, individuals must qualify by meeting eligibility requirements for Part A or:

A)qualifying as a disabled individual.
B)purchasing Part D coverage.
C)purchasing Part A coverage.
D)qualifying based on income status.

Question 25

When a provider has agreed to accept the allowed charge for a service as payment in full, it is known as:

A)discounted billing.
B)accepting assignment.
C)accepting contract terms.
D)fraud.

Question 26

Items that are NOT covered by Medicare Part A or Part B include:

A)long-term care, such as custodial care in a nursing home.
B)care in a skilled nursing facility (SNF) after a 3-day hospital stay.
C)care provided by a rural health clinic.
D)home healthcare.

Question 27

Medicare Part B insurance helps pay for all of the following services EXCEPT:

A)hospital inpatient care provided by a physician.
B)hospital outpatient care provided by a physician.
C)inpatient laboratory and diagnostic services.
D)ambulance transportation.

Question 28

All of the following are considered physicians by Medicare EXCEPT a(n):

A)doctor of osteopathy.
B)optometrist.
C)doctor of dental medicine.
D)physical therapist.

Question 29

Which of the following services is covered by Medicare Part A or Part B?

A)Acupuncture
B)Dental care
C)Routine eye care
D)Physical therapy

Question 30

Medicare Part B providers agree to accept as payment in full the amount paid by:

A)Medicare only.
B)Medicare plus the patient's share.
C)Medicare and Medicaid.
D)the patient only.

Question 31

Private-duty nursing care is:

A)covered by Medicare Part A.
B)covered by Medicare Part B.
C)covered by Medicare Part C.
D)not covered by Medicare.

Question 32

Medicare Part C plans are offered through:

A)HMO plans.
B)PPO plans.
C)fee-for-service plans.
D)all of the above.

Question 33

For a service to be considered medically necessary by Medicare, which of the following criteria must be met?

A)It is delivered at the most appropriate level.
B)It is an elective procedure.
C)It is an investigational procedure.
D)It is performed for the patient's convenience.

Question 34

A physician who chooses NOT to participate in a Medicare health plan is known as a:

A)noncontracting provider.
B)nonpracticing provider.
C)nonproviding provider.
D)nonparticipating provider.

Question 35

The types of Medicare Advantage managed care plans include:

A)PPO plans.
B)HMO plans.
C)PPO and HMO plans.
D)traditional fee-for-service plans.

Question 36

Certain organ transplants are covered under Part A as long as:

A)a second opinion has been obtained prior to the surgery.
B)services are performed in a hospital that is an approved Medicare provider.
C)the patient has not exceeded his or her Part A benefit limit.
D)an in-home caregiver will be available to care for the patient after surgery.

Question 37

Medicare patients with Part B fee-for-service benefits are responsible for what percentage of the Medicare Fee Schedule (MFS) after the deductible has been met and services are rendered by a provider who accepts assignment?

A)15%
B)20%
C)25%
D)30%

Question 38

Medicare Part B covers:

A)annual physical examinations.
B)prescription drugs.
C)acupuncture.
D)custodial care.

Question 39

Medicare Part B premiums are determined by the beneficiary's:

A)health status.
B)annual income.
C)geographic location.
D)age.

Question 40

The original Medicare plan is based on which type of payment method?

A)Per diem
B)Capitation
C)Fee-for-service
D)Sliding scale

Question 41

Information
included on a Medicare identification card includes the

A)name of the beneficiary.
B)Medicare claim number.
C)type of coverage.
D)effective dates.

Question 42

Hearing aids are NOT routinely covered by Medicare.

Question 43

Medicare beneficiaries include individuals age 65 and older and low-income individuals.

Question 44

Which of the following is true of nonparticipating providers who accept assignment?

A)They receive 10% lower fees for services than participating providers.
B)They have access to beneficiary eligibility information.
C)They are required to file Medicare claims on behalf of Medicare patients.
D)They receive 15% lower fees for services than participating providers.

Question 45

When referring to Medicare, MSP refers to:

A)Medical specialty providers.
B)Medicare supplement plans.
C)Medicare secondary payer.
D)Medicare services and plans.

Question 46

In which of the following cases involving a patient who is age 65 or older is Medicare considered the primary payer?

A)The patient's condition is the result of an automobile accident.
B)The patient works for an employer with 20 or fewer employees.
C)The patient has group health insurance through a working spouse.
D)The patient's injury or condition is covered by workers' compensation.

Question 47

A Medicare beneficiary has a lifetime reserve of 90 days of coverage that can be used to cover inpatient hospital services.

Question 48

Which of the following information is NOT included on a Medicare beneficiary's identification card?

A)Effective date of coverage
B)Primary care physician's name
C)Claim number
D)Type of coverage

Question 49

Medicare is considered the primary payer when an individual age 65 or older:

A)is eligible for coverage through the Veteran's Administration.
B)receives treatment for an accident-related claim.
C)fails to apply for end-stage renal disease (ESRD)-based coverage.
D)is covered by another policy that is NOT a group policy.

Question 50

All Medicare beneficiaries are automatically enrolled in Medicare Part D.

Question 51

Part A provider certification is obtained through formal inspections by state agencies.

Question 52

The Medicare program is administered by the Centers for Medicare and Medicaid Services (CMS), a division of the United States Department of Health and Human Services.

Question 53

Physicians who are NOT participating and NOT accepting assignment from Medicare can charge:

A)the usual, customary, and reasonable fee for services.
B)no more than 115% of the nonparticipating provider Medicare Fee Schedule (MFS).
C)the rate as shown on the nonparticipating provider Medicare Fee Schedule (MFS).
D)no more than 110% of the nonparticipating provider Medicare Fee Schedule (MFS).

Question 54

The types of Medicare Advantage plans include health maintenance organizations (HMOs).

Question 55

Medicare Part A contractors were formerly referred to as intermediaries.

Question 56

Part C is the Medicare option that allows beneficiaries to enroll in their choice of managed care plan, known as a Medicare Advantage plan.

Question 57

Individuals with end-stage renal disease (ESRD) are Medicare eligible.

Question 58

An additional health insurance policy sold by a private carrier that provides limited coverage for services that Medicare does NOT cover is known as a:

A)Medicare Part C plan.
B)Medicare secondary plan.
C)Medicaid plan.
D)Medigap plan.

Question 59

The Medicare Part B premium is determined by the patient's annual income.

Question 60

Only Medicare participating providers are required to file claims on behalf of Medicare patients.

Question 61

The coding system used to report procedures and services for Medicare patients is the __________ Coding System.

Question 62

If a patient is more than 65 years old and works for a company with more than 100 employees, Medicare is the primary payer.

Question 63

If a veteran is entitled to Medicare benefits, he or she may choose whether to receive coverage through Medicare or through the Veterans Administration.

Question 64

Nonparticipating providers who accept assignment receive 100% of the applicable Medicare Fee Schedule (MFS).

Question 65

When a Medicare patient is covered by more than one plan and Medicare is clearly NOT the primary payer, the type of claim submitted to Medicare is a Medicare __________ payer claim.

Question 66

A Medicare __________ is sent to a provider when a Medicare claim has been filed but needs additional information or documentation before the claim can be processed and paid.

Question 67

If the patient's name is misspelled on the Medicare ID card, the correct spelling should be used on the claim form.

Question 68

When Medicare is the secondary payer, a copy of the primary insurance remittance notice must be submitted with the claim.

Question 69

The __________ notice is a notification to a Medicare patient that the services to be provided may NOT be covered by Medicare because they are NOT medically necessary, and the patient is responsible for the charges.

Question 70

The Medicare document that patients sign to authorize the release of information for claims processing and payment is the __________ Claim Authorization and Information Release form.

Question 71

Knowingly and willfully executing a scheme to defraud any healthcare benefit program is considered __________ .

Question 72

Notices sent to physicians on a regular basis that contain detailed and updated information about the coding and medical necessity of a specific service are __________ Determinations.

Question 73

The form sent to patients by the Medicare contractor (carrier) that itemizes services billed to Medicare, the amount paid, and the amount the beneficiary is responsible for (if any) is a(n) __________ Notice.

Question 74

Briefly describe the four types of Medicare coverage.

Question 75

When an individual has Medicare and a Medigap policy, the reassignment of the gaps in coverage is known as __________ .

Question 76

What role does the Social Security Administration (SSA) play in the Medicare program?

Question 77

Once a Medicare patient has been hospitalized for 60 consecutive days, during the next 30 days of hospitalization the patient is responsible for paying __________ .

Question 78

Offering, accepting, or soliciting bribes, rebates, or kickbacks is considered fraud.

Question 79

Routinely waiving coinsurance and/or deductibles for Medicare patients when the patient has the ability to pay is considered abuse.

Question 80

Match the following:

A) A company hired to process and pay Medicare claims on behalf of the federal government
B) A notice provided to inform beneficiaries that services may NOT be covered by Medicare due to lack of medical necessity
C) The portion of Medicare that provides for coverage of physician services
D) The use of Medicare funds to pay for items or services when the provider is NOT legally entitled to this payment but has NOT deliberately committed fraud
E) The type of claim submitted to Medicare when Medicare is NOT the primary payer
F) Organization hired by Medicare to provide information on eligibility and benefits entitlement for situations in which beneficiaries are covered by Medicare and other coverage
G) Notice sent to a provider when a claim is filed that needs additional documentation
H) Supplementary health insurance policy that covers portions of the costs NOT paid for by Medicare
I) The portion of Medicare that provides for inpatient hospital coverage
J) The portion of Medicare that provides prescription drug coverage


Medicare contractor
Advance Beneficiary Notice (ABN)
Medicare Part B
Medicare abuse
Medicare secondary payer
coordination of benefits contractor
Medicare Development Letter
Medigap
Medicare Part A
Medicare Part D