Exam 16: Explanation of Benefits and Payment Adjudication

In regard to the RBRVS system, the risk of harm posed to the patient by a particular service or procedure is considered to be part of the: A)provider's effort and stress level. B)practice expense. C)cost of liability insurance. D)risk factor for a given specialty.

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

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.

What is meant by verifying medical necessity when reviewing a claim?

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

When treatment is determined to be appropriate for the diagnosis, the care is considered: A)medically necessary. B)medically appropriate. C)medically reasonable. D)medically feasible.

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

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

State and federal regulations determine how long patient records must be kept and stored.

What types of costs are included in a patient's out-of-pocket expenses?

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 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.

If a carrier downcodes a claim and the provider maintains that the reported services were medically necessary, the medical office specialist should: A)send a bill to the patient for the remaining balance. B)write off the remaining balance. C)file an appeal with the insurance carrier. D)send a complaint to the state insurance commissioner.

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

The Medicare RBRVS system first implemented in 1992 is the: A)relative basis for resource-valued services. B)relative-based resource value scale. C)resource-based relative value scale. D)resource-based relative value services.

When third-party payers determine reimbursement, they consider UCR, which means: A)usual, customary, and reasonable charges. B)usual and common rates. C)uniform, customary reimbursement. D)usual and customary resources.

The amount of time it takes for the insurance carrier to process a claim is called the __________ time.

A provider's usual charge for a procedure or service can be: A)higher than the allowed charge. B)lower than the allowed charge. C)equal to the allowed charge. D)all of the above.

Under a capitation arrangement, a provider is paid a per-member-per-month (PMPM) fee for all enrolled members: A)who are seen that month. B)whether or not they are seen that month. C)who are not referred to specialty care that month. D)who are not hospitalized that month.

Explain how the explanation of benefits (EOB) is used in the coordination of benefits process.