Workers Compensation
Covered entities may disclose PHI when required by workers compensation laws or to obtain payment. The Privacy Rule doesn't apply to workers compensation insurers, administrative agencies, or employers. Is this statement True or False?
True
Which regulations require a health insurer offering group or individual coverage to implement an effective appeal process for appeals of coverage determinations and claims?
a. Health Insurance Portability and Accountability Act
b. False Claims Act
c. Prompt Payment Act
d. Patient Protection and Affordable Care Act
ANS: D
Rationale: The Patient Protection and Affordable Care Act provides provisions for the appeals process. Under Section 2719, a health insurer offering group or individual coverage has to implement an effective appeal process for appeals of coverage determinations and claims.
Which of the following are NCCI coding policies NOT based on?
A. Analysis of standard medical and surgical practice
B. Coding conventions included in CPT®
C. Review of current coding practices
D. Coding conventions included in ICD-10-CM
ANS: D
Rationale: NCCI coding policies are based on the analysis of standard medical and surgical practice; coding conventions included in CPT®; coding guidelines developed by national medical specialty societies (e.g., CPT® Advisory Committee that contains representatives of major medical societies); local and national coverage determinations; and a review of current coding practices.
What are two ways that non-covered service denials can be decreased in a practice?
I. Require payment up front for all services
II. Verify coverage before a major service
III. Understand policies of largest payer contracts
IV. Appeal all non-covered service denials
a. I, II
b. II, III
c. III, IV
d. II, IV
ANS: B
Rationale: A biller cannot be expected to know every exclusion that each plan carries but should be aware of the most common exclusions in the major plans that their office contracts with to ensure avoidance of this issue, when possible. Whenever a major service is going to be performed, it is advisable for staff to verify coverage. If the payer is correct that the service is non-covered under the contract, an appeal will be futile.
Albert has purchased a Medigap policy to supplement his Medicare benefits. To which entity will Albert pay his monthly premium?
a. Medicare
b. MAC
c. Medicaid
d. Medigap insurance company
ANS: D
Rationale: Premiums for Medigap policies are paid directly to the Medigap insurance company, not to CMS, MAC’s, or Medicaid.
Which entity governs workers’ compensation law?
a. Federal
b. State
c. Department of Labor
d. OSHA
b. State
A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every Medicare patient you send to them for radiology services. What does this offer violate?
a. Stark Laws
b. HIPAA
c. Anti-Kickback law
d. Qui Tam
ANS: C
Rationale: The Anti-Kickback law is a federal law that makes it a criminal offense to knowingly or willingly offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a federal healthcare program.
Which of the following modifiers are not used to bypass NCCI edits?
a. 76, 77
b. 24, 57
c. 59, 78
d. 27, 91
ANS: A
Rationale: Modifiers 76, Repeat procedure or service by same physician or other qualified healthcare professional, and 77, Repeat procedure or service by another physician or other qualified healthcare professional, are not NCCI-associated modifiers and cannot be used to bypass edits.
An initial denial is received in the office from Aetna. The denial is investigated and the office considers that the payment was not according to their contract. According to Aetna’s policy, what must the biller do?
a. Refile the claim
b. Submit a Level 1 appeal
c. Submit a Level 2 appeal
d. Submit a Reconsideration
ANS: D
Rationale: According to Aetna’s appeals process, a Reconsideration is a formal review of a claim’s reimbursements. If a provider believes that they were paid at an incorrect rate, paid not according to their contract, and/or invalid or incorrect coding decisions; they may ask for reconsideration on the claim. Claims that require reprocessing may require additional documentation, if necessary.
Beth has purchased a Medigap policy to supplement her Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the Medigap insurance company. This transfer of information is known as:
a. Cross-under
b. Shared billing
c. Cross-over
d. Data sharing
ANS: C
Rationale: The transfer of claims information from Medicare to Medigap is called cross-over.
Which of the following may be benefits included as part of workers’ compensation?
a. Wage-loss benefits
b. Medical rehabilitation
c. Career rehabilitation
d. All of the above
ANS: D
Rationale: Benefits may include cash or wage-loss benefits, medical and career rehabilitation benefits, and in the case of accidental death of an employee, benefits to dependents.
All the following are considered Fraud, EXCEPT:
a. Billing every new patient at the highest level E/M visit no matter what
b. Falsifying documentation to support a service that was billed to receive payment
c. Failure to maintain adequate medical records
d. Reporting a diagnosis code that the patient does not have, but is payable by Medicare
ANS: C
Rationale: CMS defines fraud as making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program. CMS defines abuse as an action that results in unnecessary costs to a federal healthcare program, either directly or indirectly. CMS lists examples of abuse as: Misusing codes on a claim, charging excessively for services or supplies, billing for services that were not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, and billing a Medicare patient a higher fee schedule than non-Medicare patients.
Which of the following is considered an anatomic modifier?
a. 77
b. LD
c. 59
d. G0
b. LD
Rationale: The following modifiers are identified as anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
A denial is received in the office indicating that a service was billed and denied due to bundling issues. The medical record is obtained and, upon review, it is documented that the second procedure is a staged procedure that was planned at the time of the initial procedure. When the claim is reviewed, no modifier was attached to the codes on the claim. What should be done to resolve the claim?
a. Write the claim off
b. Refile the claim
c. Balance bill the patient for the claim amount
d. Add modifier 58 to the procedure and follow the payer’s guidelines for appeals
ANS: D
Rationale: Modifier 58 is used to indicate a procedure is staged/related to another procedure during a postoperative period. Since the claim was denied, the payer’s guidelines on filing appeals must be followed after modifier 58 is added to the procedure.
Medigap policies must conform to minimum standards identified by federal and state laws and clearly be identified as:
a. Medicare Supplement Insurance
c. Medicare Selective Insurance
b. Medicare Subsequent Insurance
d. Medicare Secondary Insurance
ANS: A
Rationale: The Omnibus Budget Reconciliation Act of 1990 requires all Medigap insurance policies to conform to minimum standards including standardized benefits and consumer protection requirements. Every Medigap policy must follow federal and state laws and be clearly identified as Medicare Supplement Insurance.
OSHA is an agency of _______________?
a. Department of Health and Human Services
b. Department of Veterans Affairs
c. Department of Labor
d. Department of Inspector General
ANS: C
Rationale: With the Occupational Safety and Health Act of 1970, Congress created the Occupational Safety and Health Administration (OSHA), an agency of the U.S. Department of Labor.
A health plan sends a request for medical records to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information?
a. No, since the information is used for payment activities it is not necessary to notify or obtain authorization from the patient.
b. Yes, since PHI is being sent the patient must be notified and approve of the release.
c. No, because the office owns the medical record.
d. Yes, since it involves payment of a claim.
ANS: A
Rationale: According to the Privacy Rule, PHI may be used by a covered entity for treatment, payment, and healthcare operation activities. Payment includes a variety of activities for a provider to be reimbursed for his/her services and for a health plan to obtain premiums and provide benefits.
When applying an LCD to services, which of the following statements is TRUE regarding the CPT® and ICD-10-CM codes reported on a claim form?
a. The claim should contain an approved code to be reimbursed.
b. Documentation should provide medical necessity and support the CPT® and ICD-10-CM codes reported.
c. The LCD contains suggestions for CPT® and ICD-10-CM codes to be reported.
d. Documentation only needs to support the CPT® code, the ICD-10-CM code is automatically understood.
ANS: B
Rationale: The CPT® and ICD-10-CM codes listed are not suggestions but are the codes and conditions that have been approved for payment. Documentation must support both the procedure and the diagnosis reported.
What is one way to assist in lowering denials for non-covered services?
a. Keep every payer policy on file
b. Call insurance companies before any services are rendered
c. Be aware of the most common exclusions in the office’s major plans
d. Appeal all non-covered service denials
ANS: C
Rationale: A biller cannot be expected to know every exclusion that each plan carries, but should be aware of the most common exclusions in the major plans that their office contracts with to ensure avoidance of this issue, when possible. Appeals for non-covered services are futile.
Dr. Allen who is a non-PAR provider performs an appendectomy on a 67-year-old Medicare patient. The physician’s UCR for the surgery is $1500. Medicare’s approved fee for this procedure is $1100. What is the limiting charge that this non-PAR provider can charge to this Medicare patient?
a. $1265
c. $1500
b. $1100
d. $1201.75
ANS: D
Rationale: A non-PAR provider’s fee schedule is 95% of Medicare approved amounts for PAR providers, which sets the fee at $1045 ($1100 X .95). The provider’s limiting charge would be 115% of the Medicare approved amount for non-PAR ($1045 X 115% = $1201.75)
Workers’ compensation is a(n) ______________ insurance program.
a. Catastrophic
b. No fault
c. At fault
d. Personal injury
ANS: B
Rationale: Workers' compensation is a “no fault” insurance program that provides benefits to employees who suffer job-related injuries or illnesses.
A practice agrees to pay $250,000 to settle a lawsuit alleging that the practice used X-rays of one patient to justify services on multiple other patients’ claims. The manager of the office brought the civil suit. What type of case is this?
a. Qui Tam
c. Anti-Kickback
b. Stark case
d. HIPAA
ANS: A
Rationale: A Qui Tam case is also known as a whistleblower case. If an individual knows of a violation of the FCA, he or she may bring a civil action on behalf of him or herself and on behalf of the U.S. government (such an individual is called a relator).
Local Coverage Determinations (LCDs) are established by Medicare Administrative Contractors (MACs) for what purpose?
a. LCDs are established to override NCDs.
b. LCDs are developed when no NCD is available.
c. LCDs establish coding standards for certain services.
d. LCDs make coverage determinations universal throughout jurisdictions.
ANS: B
Rationale: LCDs are established by the MAC when there is not an NCD available, or when the NCD needs to be defined further. Each individual MAC can establish LCDs for their jurisdiction.
What rejections/denials are the easiest to prevent with good front office policy?
I. Incorrect patient information
II. Eligibility expiration
III. Medical necessity
IV. Liability denials
a. I, II
c. I, III, IV
b. I, II, IV
d. I, IV
ANS: B
Rationale: Incorrect patient information rejections can be avoided with accuracy of intake information taken from patients in the front office. Eligibility expiration denials can be avoided with insurance verification at the front desk at check in. Liability denials can be avoided with complete information gathering regarding injuries, including place of occurrence and whether the patient was working.
A Medicare patient receiving inpatient care in a critical access hospital would be covered under
a. Part C
c. Part A
b. Part B
d. Part D
ANS: C
Rationale: Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities for Medicare patients.