Cred./Denials
A claim is denied stating the provider is not credentialed with the commercial insurance. Which of the following would NOT be an option for the practice?
a.
Refile the claim under a credentialed provider in the group using the group number
b.
Bill the patient for the services
c.
Verify the status of the provider’s credentialing
d.
Write-off the balance of the encounter
ANS: A
Rationale: Billing the patient for services could be problematic if the patient was told the provider was in-network and writing-off the balance can create issues with providing free care but these could be done. It would be appropriate to verify the credentialing, as the claim could have been processed incorrectly. It is NOT appropriate to bill services to a provider that did not provide the care to the patient.
A new patient is seen for a visit with a participating commercial carrier. CPT® code 99204 is billed for $200. The contracted fee for this carrier is $153.35. The patient has a 20% co-pay after a $1000 deductible, of which $500 has been met. How much will the patient owe?
a.
$200
c.
$153.35
b.
$46.65
d.
$30.67
ANS: C
Rationale: This is a participating physician and the contracted amount for this visit is $153.35. Since the deductible has not been met, the contracted amount will be applied toward the deductible and will be paid by the patient.
What is an IPO in a health organization?
a.
A group of providers offering joint healthcare services
b.
A corporate umbrella for management of diversified healthcare delivery systems
c.
An organization that combines function of delivery of care with healthcare and administration
d.
A practice formed to share economic risk, expenses, and marketing efforts
ANS: B
Rationale: An IPO is a corporate umbrella for the management of diversified healthcare delivery systems. The system may include one or more hospitals, a large group practice and other healthcare operations. Physicians practice as employees of the organization or in a closely affiliated physician group.
Which option is not considered an MCO?
a.
Exclusive Provider Organizations (EPOs)
b.
Health Maintenance Organizations (HMOs)
c.
Preferred Provider Organizations (PPOs)
d.
Health Savings Account (HSA)
ANS: D
Rationale: MCOs include Exclusive Provider Organizations (EPOs); Health Maintenance Organizations (HMOs), which have already been discussed; Integrated Delivery Systems (IDSs), Preferred Provider Organizations (PPOs), and Triple Option Plans.
Who does Medicare provide hospital coverage and voluntary medical insurance to?
a.
Certain individuals of low-income
b.
All persons under the age of 26
c.
Certain disabled individuals under age 65
d.
Unemployed individuals
ANS: C
Rationale: Medicare is offered to those that are age 65 or older, and to certain individuals under age 65 that have disabilities.
Which of the following is NOT evaluated in the credentialing process?
a.
Physician’s education
c.
Physician’s request for privileges
b.
Physician’s residency
d.
Physician’s license(s)
ANS: C
Rationale: The credentialing process evaluates the licenses, residency, medical school education, and any adverse clinical information. Request for privileges is part of the privileging process for the hospital.
A patient presenting for care does not have an insurance card and is billed CPT® code 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed?
a.
Nothing needs to be done
b.
File a claim to Medicaid and refund the $100 to the patient
c.
File a claim with Medicaid, a refund will be completed when the EOB is received showing the patients responsibility
d.
Refund the $100 to Medicaid
ANS: C
Rationale: If the patient has coverage at the time of service the contracted provider is obligated to file a claim. The patient will be refunded the difference of $100 paid at the time of the visit and her liability.
A healthcare organization with 2 hospitals, 20 clinics, and 3 urgent care centers belongs to an ACO program. They have been in the shared savings program for two years and are now eligible to move large payments to a population-based model as they have been successful in keeping costs down and have met all the CMS benchmarks set for them. What type of ACO is this?
a.
Medicare Shared Savings Plan
c.
Advance Payment ACO Model
b.
Basic ACO
d.
Pioneer ACO Model
ANS: D
Rationale: The Pioneer ACO model is an ACO that allows for higher level of shared savings and risk. These ACOs will be in the shared savings payment model the first two years of the program and, in year three, if they have shown a specified level of savings, they will be eligible to move a large portion of their payments to a population-based model. The advance payment model ACO is for smaller ACOs that allows them the ability to participate by offering upfront fixed payments; upfront, variable payments based on the number of historically-assigned beneficiaries; or monthly payments of varying amounts depending on the size of the ACO based on its historically-assigned beneficiaries.
When a patient is enrolled in an HMO, which options below are the responsibilities of the primary care physician (PCP)?
I. Manage the member’s treatment
II. Be the only provider for all of the patient’s healthcare
III. Provide referrals to specialists
IV. Approve emergency department visits
V. Provide referrals for inpatient admissions
a.
I, II
c.
I, III, IV
b.
I, II, III
d.
I, III, V
ANS: D
Rationale: Upon joining an HMO, a member chooses a primary care provider, or PCP. This provider, sometimes called a gatekeeper, is responsible for providing a broad range of routine services. Their duty is to manage the member’s treatment, as they are responsible for the member’s healthcare decisions and referrals to other facilities (for example, inpatient admissions), in-network specialists, or out-of-network specialists when necessary. Most plans require the referral, or the member is responsible for the cost of treatment. Each covered member of a family may choose a different PCP. A PCP is usually a family or general medicine provider, an internal medicine provider, or a pediatrician.
Who does Medicare provide hospital coverage and voluntary medical insurance to?
a.
Certain individuals of low-income
b.
All persons under the age of 26
c.
Certain disabled individuals under age 65
d.
Unemployed individuals
ANS: C
Rationale: Medicare is offered to those that are age 65 or older, and to certain individuals under age 65 that have disabilities.
A new physician comes into the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans?
a.
Credentialing
c.
Contract negotiations
b.
Privileging
d.
Board certification
ANS: A
Rationale: Medical credentialing is used by various organizations and insurance companies to ensure that their healthcare providers meet all of the necessary requirements and are appropriately qualified. Physicians must have the necessary credentials and go through the process to participate with an insurance company. For Medicare, credentialing is required to receive reimbursement. Credentialing allows a physician to become affiliated with insurance companies to be able to accept third party reimbursement.
Dr. Williams is enrolled in a capitated plan. For his list of covered lives, he received a check for $100,000. During the year, the cost of treating the covered lives was $125,000. Which statement below is TRUE?
a.
Dr. Williams will receive payment for the overage cost of $25,000 from the insurance carrier.
b.
Dr. Williams has a loss of $25,000 on the capitated contract for the year.
c.
Dr. Williams can file claims for all services provided under the capitated plans and will be paid fee-for-service because his cost was more than the contracted payment.
d.
Dr. Williams will be reimbursed an additional $125,000 for his services.
ANS: B
Rationale: The disadvantage to capitation is that it involves total assumption of risk on the part of the physician. It is difficult to predict the costs of all healthcare to all patients in advance. It may incentivize physicians to take on too large a roster of members into its practice to increase its payment.
NPI numbers have two types of entities.What are the two types:
a.
Employee and Group
c.
Location and Group
b.
Sole proprietor and Group
d.
Sole proprietor and Individual
ANS: B
Rationale: There are two types of NPI entities: Entity Type 1 and Entity Type 2.
Entity Type 1: sole proprietor/sole proprietorship, which is an individual. The individual must apply using their own Social Security Number. They will need only one number, regardless of how many locations they provide services as they are not allowed to have subparts as a type 1 entity.
Entity Type 2: group healthcare providers. These are entities with EIN numbers, whether they have one employee (the physician him/herself) or thousands. These may include hospitals, home health agencies, clinics, and nursing homes.
What type of plan allows an insurer to administer straight indemnity insurance, an HMO, or a PPO insurance plans to its members?
a.
Triple option plan
c.
Integrated provider plan
b.
Full option plan
d.
Management service organization
ANS: A
Rationale: A triple option plan is usually operated by a single insurance plan or a joint venture among two or more insurance payers. A triple option plan allows an insurer to administer three different healthcare plans so that members may select the benefit options they want: straight indemnity insurance, an HMO, or a PPO.
Which of the following statements is TRUE regarding Medicare?
a.
A patient can participate in Part A, B, C, and D for Medicare
b.
Medicare beneficiaries must be age 65 to qualify for coverage
c.
No premiums are charged for Part A if the beneficiary contributed through the work force
d.
Beneficiaries are required to participate in Part B Medicare
ANS: C
Rationale: No premiums are charged for those that contributed through the work force. Part C is for Medicare Advantage plans that substitute for Part A and Part B traditional Medicare. Part B Medicare is optional and requires a monthly premium. Medicare coverage is extended for some individuals with disabilities, even if they are not 65 years of age.
The Protecting Patients and Affordable Care Act (PPACA) is a federal mandate which establishes that coverage can no longer be denied for what reason?
a.
Being unemployed
c.
Having other coverage
b.
Pre-existing conditions
d.
Having high medical costs
ANS: B
Rationale: PPACA stipulates that coverage cannot be denied for pre-existing conditions, maternity care, newborn care, mental health services, and preventive care.
The following is a capitation schedule for a pediatric practice.
Member's Age
Capitation per Member, per Month
0-1
$25.00
2-4
$10.00
5-20
$5.00
The practice has 300 members age 0-1, 500 members age 2-4, and 2000 members age 5-20 that stay with the practice for an entire year. If the practice also performs “carve-out” services worth $20,000, how much money will they earn over the course of a year?
a.
270,000
c.
290,000
b.
250,000
d.
300,000
ANS: C
Rationale: Adding up the monthly amounts and multiplying by 12, the fees received would total $270,000. Carve-out services are additional services paid on a fee-for-service basis, so that adds to the total received. In this case, the total the practice would receive over the year is $290,000.
NPI is an abbreviation for a unique number that is required by HIPAA. What does NPI stand for?
a.
National Physician Identifier
c.
National Provider Identifier
b.
National Provider Insurance
d.
National Participating Identifier
ANS: C
Rationale: A National Provider Identifier, or NPI, is a unique 10-digit identification number required by HIPAA.
Which type of HMO contracts with multiple specialty groups, individual practice groups, and individual physicians?
a.
Group Model HMO
c.
Network Model HMO
b.
Mixed Model HMO
d.
Hybrid Model HMO
ANS: C
Rationale: A Network Model HMO is an HMO that contracts with more than one multi-specialty group, individual practice groups and individual physicians so a variety of services may be offered to its members.
What Medicaid services are eligible for reimbursement for an individual that is not a citizen or does not have eligible immigration status?
a.
No services are covered
c.
Emergency services
b.
All services are covered
d.
Outpatient services only
ANS: C
Rationale: To be eligible for Medicaid an applicant must be a US citizen or provide proof of immigration status unless applying for Emergency services.
Which of the following statements is true regarding the key provisions of coverage under the Affordable Care Act (ACA)?
a.
Children under the age of 21 may be eligible to be covered under their parent’s health plan if they are in college.
b.
There are 30 covered preventive services for women.
c.
Patients have the right to appeal a health plan’s decision to deny payment for a claim or termination of health coverage.
d.
Lifetime limits are not banned on any health plans issued.
ANS: C
Rationale: Key provisions of coverage for patients under the ACA include: Patients have the right the right to appeal a health plan’s decision to deny payment for a claim or termination of health coverage, children under the age of 26 may be eligible to be covered under their parent’s health plan, lifetime limits on most benefits are banned, and there are 22 covered preventive services for women.
The patient's coinsurance percentage stated as 75-25 in the insurance policy. The deductible for the year has been met. If the visit charges are $1,000, what payment should the medical insurance specialist expect from the payer?
A. $750
B. $250
C. $800
D. $500
ANS: A.
What is the benefit of using NPI numbers for payers?
I. It is a single identifier for all payers
II. It contains the providers’ birthdates to allow certain identification
III. Each payer can make their own number
IV. It has no personal identifying information in the number
a.
I, II
c.
I, II, IV
b.
III, IV
d.
I, IV
ANS: D
Rationale: A National Provider Identifier, or NPI, is a unique 10-digit identification number required by HIPAA. In the past, providers had different identification numbers for each payer, but the introduction of the NPI is a single identifier for all payers to improve efficiency of the healthcare system. It will also help reduce fraud and abuse. It is an “intelligence-free” number, meaning that there is no personal identifying information (birthdate or social security number) other than a name and business address.
Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient. How are they reimbursed?
a.
Capitation
c.
Reimbursement account
b.
Fee-for-service
d.
Patient payments
ANS: A
Rationale: The physician is paid on per-patient per month method rather than a fee-for-service method.
Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct?
a.
CMS reviews all state plans to make sure they offer federal regulations.
b.
Individual states establish their own rates based on the multiple criteria.
c.
All Medicaid plans offer HMO options.
d.
States have the option to charge co-pays and deductibles.
ANS: C
Rationale: Although Medicaid plans are overseen by CMS, the individual states have the option to decide rates, co-pays for certain populations, and if co-pays and deductibles will be required. Not all states offer HMO plans.