Exam 16: Explanation of Benefits and Payment Adjudication

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

The benefit payment information on an explanation of benefits (EOB) indicates who was paid, how much, and when.

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 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 amount of covered expenses that a policyholder must pay before insurance benefits begin is the __________ .

Resource-based fee structures consider all of the following factors EXCEPT the: A)provider's location. B)work involved. C)overhead (expense) involved. D)malpractice risk.

Explanation of benefits (EOB) notifications are issued in the same format by all insurance carriers.

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

A patient's out-of-pocket expenses include deductibles, coinsurance, and copayments.

The allowed charge includes the amount that will be paid by: A)the insurance carrier only. B)the patient only. C)the insurance carrier and the patient. D)none of the above.

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

refers to the steps involved in processing a claim that result in payment or denial of the claim.

If an insurance carrier does NOT reconsider a downcoded claim that has been appealed, the medical office specialist can: A)request assistance from the state insurance commissioner. B)file a complaint with the Department of Health and Human Services (DHHS). C)file a complaint with the Centers for Medicare and Medicaid Services (CMS). D)bill the patient for the remaining balance.

The cost of malpractice insurance is highest for physicians in which of the following specialties? A)Obstetrics and gynecology B)Cardiology C)Dermatology D)Neurosurgery

The RBRVS system unit of measurement assigned to a service based on the relative skill and time required to perform it is the __________ unit.

An appeal for reconsideration of a carrier's decision on a claim must be made: A)online. B)in writing. C)by phone and in writing. D)with the help of an attorney.

The largest cost element in determining the nationally uniform relative value of a service is the: A)provider's work. B)practice expense. C)cost of professional liability insurance. D)location of the practice.

In regard to the RBRVS system, the overhead of a physician's office is referred to as the: A)provider's work. B)practice expense. C)professional liability insurance. D)payroll expense.

Under a managed care contract with a capitation reimbursement method, the provider is paid a per-member-per-month (PMPM) fee for each enrolled member regardless of services provided.