CPB Exam B Top Questions and answers. 100% Accurate, graded A+

CPB Exam B Top Questions and answers. 100% Accurate, graded A+ What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? - -Deductible Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? - -Medical malpractice Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. V. Employee can make changes to the policy. VI. The employee's spouse and children are not eligible for coverage. - -I, IV, V, VI Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan.He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? - -Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. What is the deadline for filing a Medicare claim? - -One year from the date of service A provider sees a patient who has TRICARE Standard. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for? - -$60.00 What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures? - -Utilization Review Organization Medicaid providers are forbidden by law to: - -Balance bill patients Which statement is FALSE about Local Coverage Determinations (LCDs)? - -CMS develops LCDs when there is no National Coverage Determination When a minor procedure is performed on a Medicare patient, what is the global period and what timeframe is covered? - -10-day global period - the day of the procedure and 10 days following the procedure If add-on procedure code 11101 is performed twice during an office visit, how is it indicated on the CMS-1500 claim form? - -Code 11101 is reported once with the number 2 in box 24G Which set of documentation guidelines can be used for E/M services submitted to Medicare for a physician assistant (PA)? - -Either 1995 or 1997 CMS documentation guidelines Select the scenario that meets the incident-to requirements - -Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. Medicare beneficiary is having a screening colonoscopy performed. How is the service reported to Medicare? - -G0121 Which providers submit the CMS-1500 claim form? I. Independent diagnostic testing facilities (IDTFs) II. Emergency department physicians III. Hospice organizations IV. Ambulance companies submitting under their own Medicare number V. Physicians in a group practice VI. Ambulatory surgery centers - -I, II, IV, V and VI According to CPT® Radiology Guidelines if a patient is given oral contrast for a CT scan of the abdomen which code is reported? - -74150 Computed tomography, abdomen; without contrast material Which of the following is NOT in the HIPAA Privacy Rule? - -Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI). When a physician intentionally bills procedures to Medicaid that he did not perform he is in violation of which Act? - -False Claims Act Cardiologist Dr. W has been consistently reporting a higher E/M level than what is documented to cover the revenue being lost in his practice. Is this considered fraud or abuse and why? - -Fraud; the provider intentionally over-coded to gain financially What is a Qui tam relator? - -A person who brings civil action for violation under the False Claims Act (FCA) for themselves and the US government Dr. Wilson assigns all established Medicare patients E/M level 99215 regardless of the work performed during the visit. He considers all Medicare patients to be complicated patients and therefore, he should be paid at the highest rate possible. Is Dr. Wilson's actions considered fraud or abuse? - -Fraud; he is knowingly billing patients incorrectly to obtain higher payment Dr. Jay is a gynecologist and has been reporting two codes for a total abdominal hysterectomy with removal of the ovaries and fallopian tubes (salpingo-oophorectomy), codes 58150 and 58720. - -58150 JR had surgery on January 15, 20XX by Dr. Waters (a Medicare participating provider). The Medicare fee schedule for the surgery is $500. Four months later, JR and Dr. Waters each received a check from Medicare in the amount of $400. JR signed over his $400 to Dr. Waters. JR had previously paid the doctor $100 for the co-insurance. In total Dr. Waters has received $900 for the surgery provided on January 15, an overpayment of $400. What should Dr. Waters do? - -Contact the MAC of the overpayment and provide a refund. Which one is NOT a Nonphysician Practitioner (aka mid-level