Exam 16: Explanation of Benefits and Payment Adjudication

Under Medicare Part B, reimbursement to a participating provider is based on: A)80% payment by Medicare and 20% by the patient after a deductible. B)20% payment by Medicare and 80% by the patient after a deductible. C)80% payment by Medicare and 20% by the patient without a deductible. D)20% payment by Medicare and 80% by the patient without a deductible.

Under an 80/20 plan, if a participating provider's usual charge is $200 for a procedure and the allowed amount is $150, the provider can collect: A)$150 from the insurance carrier and $50 from the patient. B)$120 from the insurance carrier and $30 from the patient. C)$120 from the insurance carrier and $80 from the patient. D)$160 from the insurance carrier and $40 from the patient.

After a claim is processed, an explanation of benefits (EOB) is sent to the: A)provider only. B)patient only. C)provider and the patient. D)carrier's headquarters.

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

Using the RBRVS system, how does the geographic practice cost index (GPCI) affect provider payments?

The RBRVS system establishes the nationally uniform relative value of a service based on which three cost elements? A)The cost of payroll, the cost of supplies, and the cost of liability insurance B)The physician's specialty, the physician's work, and the location of the practice C)The location of the practice, the overhead, and the cost of liability insurance D)The physician's work, the practice expense, and the cost of liability insurance

Electronic funds transfer (EFT) is more costly to the practice than depositing checks.

The steps that result in an insurance carrier's decision to either pay or deny a claim are known as: A)allocation. B)adjudication. C)determination. D)justification.

The two main methods used by providers to determine their fees are: A)capitation-based and resource-based fee structures. B)profit-based and charge-based fee structures. C)charge-based and resource-based fee structures. D)resource-based and usual-and-customary fee structures.

When a claim has been downcoded or denied by the insurance carrier, the medical office specialist can ask for reconsideration by filing: A)an appeal. B)an adjudication. C)a complaint. D)a request.

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

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.

If the reported services are deemed NOT medically necessary at the level reported, the claim will be: A)denied. B)downcoded. C)upcoded. D)pended.

The state official who has regulatory control over insurance carriers and can assist with disputes is the: A)state attorney general. B)state economic development director. C)senior state senator. D)state insurance commissioner.

Where can a medical office specialist find the annually established Medicare conversion factor (MCF)?

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.

The nationally uniform relative values are adjusted by: A)physician training and specialty. B)geographic practice cost differences. C)liability insurance cost differences. D)the number of employees of the practice.

When providers determine what fee to charge by considering what other providers charge for similar services, this method is: A)charge based. B)research based. C)resource based. D)comparison based.

If a claim is denied, what process can be followed to request that the carrier reconsider the decision?

The first step that the medical office specialist is responsible for before submitting a medical claim is: A)verifying patient insurance benefits. B)obtaining correct and complete patient information. C)entering patient information data into the computer. D)posting charges.