1. If the doctor is a Participating Provider, what does this mean?* The payment goes to the patient and the doctor must bill the patient for any services rendered The physician is a certified HIPAA doctor Physician will accept the amount paid by the insurance company and will be responsible to write-off the non-allowed amount The physician can charge what they feel is reasonable and customary for their geographical location and will be paid 100% of their fee2. These services are performed by a non-physician practitioner and can be billed to Medicare under the physicians NPI number. The supervising physician must be present in the office and supervise the non-physician practitioner. Billing these type of services is called?* Batch Billing Incident-to services Free-for-service Capitation3. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. These guidelines describe what will or will not be covered and provides requirements that must be met in order to process payment.* Correct Coding Initiative Corporate Integrity Agreements Comprehensive Error Rate Testing National and Local Coverage Determinations4. What does Claim Adjudication mean?* Claim is reviewed by the insurance company to make sure it corrects for demographics, codes, payer rules have been followed and are covered benefit under the patient’s insurance contract This is the process a claim goes through for all appeals or denials that are refiled by the provider These are the claims that have been preauthorized for surgical procedures This is the credentialing process the physician must go through to become a provider with an insurance company5. The insurance companies will hire companies to review the appropriateness and medical necessity of procedures, surgeries and other services. This takes the burden off the insurance company off not authorizing a service due to cost. What are these types of services called?* Third Party Payers Utilization Review Organization Case Management Coordinators Managed Care Organizations6. Select the TRUE statement that defines per CPT why modifiers are reported?* Modifiers provides or indicates the procedure or service will be greatly increased in cost but not changed in its definition or code. Modifier provides or indicates Evaluation and Management codes only have been altered but not changed in its definition or code. Modifier provides or indicates procedure codes only have been altered but not changed in its definition or code Modifier provides or indicates the service or procedure has been altered but not changed in its definition or code.7. What is the type of insurance that provides health care by controlling cost through a network of physicians, hospitals and ancilliary services with plans such as PPOs, EPOs, POSs, etc.?* Managed Care Plans Indemnity Plans Blue Cross Blue Shield Workers Compensation8. A patient may choose to have Out-of-Network Services that is permitted within their insurance plan, what does this mean?* Choosing a provider for services that are not contracted with the insurance company and typically the patient will pay more out-of-pocket expenses When a patient is seen out-of-state for any medical services Choosing a contracted provider for services without a referral from their primary care physician Answers b and c9. Federal employees can have insurance benefits for enrollees and dependents called FEP and underwritten by which insurance company?* Principle Mutual Insurance State Workers Compensation United Healthcare Blue Cross Blue Shield10. What are Mutually Exclusive Edits?* Two procedure codes which cannot reasonably be performed together based on code definitions or anatomical sites A modifier that is included in the CCI edits to identify if a set of codes can be unbundled Surgical Package Guidelines that are mandated by Medicare ICD-9 and CPT guidelines for correct coding11. What is the name of the Medicare program that offers products such as HMO, PPO, MSA and other Medicare insurance policies?* Medicare Part D Medicare Part C Medigap Insurance QMB for patients that have Medicare and Medicaid12. The physician bills for a procedure in the amount of $100.00. Medicare allows $80.00 and the patient is responsible for 20% of the allowable. How much is paid to the physician by Medicare?* 84 16 64 2013. What are Medigap policies?* State Medicaid plans to fill in the “gaps” of healthcare costs that Medicare does not pay Health insurance sold by private insurance to help pay for some costs the Medicare plan doesn’t cover It is considered a Medigap policy when the beneficiary has Medicare Part A, B and Medicaid Medicare HMO plans14. What is the name of the form given to a Medicare patient before a service is performed that a particular service or procedure may not be paid by Medicare and could be the financial responsibility of the patient?* CERT ZPIC MIC ABN15. Some procedures in CPT say “separate procedure” after the code. According to the surgery guidelines some procedures are NOT to be reported in addition to another procedure. Which statement below is TRUE?* Would not be reported in additional to the code for total procedure or service of which it is considered an integral component. Would be reported in addition to the code for total procedure or service and is not an integral component of the main procedure Would not be reported in additional to the code for total procedure or service of which it is considered an integral component, however you could add a modifier 51 to unbundle You will always bill both procedures, attach modifiers when needs and list the most expensive procedure first on the billing form.Name* First Last Practice Name*Email* Phone*Location*United StatesOther Receive email updates with tips to increase revenueΔ
