Question 1

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 2

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 does take into account the provider's work, the practice expense, and the cost of professional liability insurance.

Question 3

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 fee schedule, not on the provider's charge-based fee schedule. The resource-based fee schedule takes into account the physician's time, skill, and intensity required to perform a specific service, as well as the cost of the equipment, supplies, and other expenses involved in providing that service. Therefore, the reimbursement rates under the MFS are not directly tied to the provider's charges, but rather to the relative value units (RVUs) assigned to each service in the fee schedule.

Question 4

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 5

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 6

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

Accepted Answer

A provider's usual charge for a service can indeed be higher, equal to, or lower than the insurance carrier's allowed charge. This can have an impact on the amount that the patient is responsible to pay, as well as on the reimbursement that the provider receives from the insurance company.

Question 7

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.

Accepted Answer

The answer of The section of the explanation of benefits...

Question 8

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

Accepted Answer

Both the front and back of the patient's insurance card should be copied to ensure all necessary information, including contact details and policy numbers, is captured.

Question 9

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.

Accepted Answer

The patient has not yet met their deductible, so they would be responsible for paying the full $50. The insurance carrier would not pay anything until the deductible is met.

Question 10

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. Instead, they must appeal the denial and/or work with the patient to determine alternative payment options.

Question 11

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

Accepted Answer

The geographic practice cost index (GPCI) adjusts only the practice expense and malpractice components of the RBRVS, not 75% of the physician's work value.

Question 12

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 13

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.

Accepted Answer

The answer of If a physician's office provides services that...

Question 14

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.

Accepted Answer

The answer of The types of payments that an insured...

Question 15

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

Accepted Answer

This statement is true. Physicians have the right to establish their fees at a level they believe is fair for the services they provide. However, there may be regulations or restrictions in place in certain locations or healthcare systems.

Question 16

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.

Accepted Answer

The term described in the question is a withhold.

Question 17

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 18

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

Accepted Answer

Insurance carriers often require preauthorization for certain procedures or medications. If the required preauthorization is not obtained, the claim can be denied upon manual review.

Question 19

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 20

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.

Accepted Answer

The answer of The section of the explanation of benefits...

Quiz 16: Explanation of Benefits and Payment Adjudication

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

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

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

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

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.

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 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.

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

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.

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.

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

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.

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.

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.

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

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.

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

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

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.

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.