Exam 17: Refunds and Appeals

The third level of a Medicare appeal is a request for: A)review by a qualified independent contractor. B)redetermination by the carrier. C)review by an administrative law judge. D)review by the state insurance commissioner.

If a denial by a self-funded plan is upheld, the medical office assistant should appeal to the: A)carrier legal department. B)carrier president. C)Department of Labor. D)Department of Insurance.

When a provider receives a partial payment on a claim because the amount billed was in excess of the maximum allowed charge, this is a: A)denial. B)downcode. C)determination. D)disallowance.

In medical record documentation, a commonly used format is SOAP, which stands for: A)subjective, objective, audit, process. B)subjective, objective, action, plan. C)subjective, objective, assessment, plan. D)subjective, objective, assessment, payment.

The government official whose office regulates the insurance industry and who serves as a liaison between patients and carriers, and physicians and carriers, is the state __________ .

A medical office specialist can appeal a claim in writing or over the telephone.

Most practices learn about the appeals policies of the insurance carriers they work with by referring to administrative manuals, contracts, and newsletters.

An objective, unbiased group of physicians that determines what payment is adequate for services provided is a(n): A)appeal committee review. B)routine examination of claims. C)peer review. D)utilization review.

A stamped provider signature or that of an authorized employee is acceptable on Medicare appeals.

When answering a patient's questions about claims, the medical office specialist should use technical terms in order to sound more professional and accurate.

Using the SOAP format, documentation of the physician's medical decision making is: A)subjective information. B)objective information. C)part of the assessment. D)part of the plan.

From the insurance carrier's perspective, if a service is NOT documented in the medical record, the: A)patient should be contacted to confirm the service was rendered. B)medical office specialist should be contacted to modify the record. C)physician should verbally verify that the service was provided. D)service was not performed and cannot be billed.

Of the following, who may ask the state insurance commissioner for help in resolving a payment dispute? A)Patients and physicians only B)Patients and insurance carriers only C)Physicians and insurance carriers only D)Patients, physicians, and insurance carriers

If a physician requests a peer review that results in confirmation that services were NOT medically necessary: A)the patient should be billed for the review. B)the insurance carrier will pay for the review. C)there is no charge for the review. D)the physician must pay for the review.

An appeal must be made in writing if: A)a billing error was made by the medical office assistant. B)the carrier requested information from the patient that was not received. C)the patient had a routine service covered by the policy. D)the claim was for services related to an accident.

Statistics show that the percentage of claims typically overturned on the first appeal is: A)15%. B)20%. C)25%. D)30%.

What is peer review?

If a claim is denied because services were provided before insurance coverage was in effect, the medical office specialist should: A)bill the patient. B)write off the entire amount. C)wait until the effective date of the coverage, then bill the insurance carrier. D)change the date of service and resubmit the claim.

Using the SOAP format, the evaluation and management (E/M) history that the physician takes is: A)subjective information. B)objective information. C)assessment information. D)the plan.