Chapter 5 CPMA Exam: Contract-based
Commercial Insurance Plans Questions And
Answers
Is the provider offered a chance at implementing corrective action?
How these questions are answered will significantly affect the audit result, in terms of whether
an auditor can declare error or can simply declare potential risk.
Where the provider is not contracted with a particular payer, consider the provider has no
legal duty to conform his or her reporting or documentation to the mandates of the payer's
medical policies.
Although this might prevent an auditor from declaring an error, it does not prevent an auditor
from identifying potential risk and suggesting change that would assist the provider in avoiding
an issue with that carrier.
Insurance contracts are not always available to the auditor (I have yet to see one)
, Chapter 5 CPMA Exam: Contract-based
Commercial Insurance Plans Questions And
Answers
State regulated Commercial insurance plans are mostly associated with first party medical
claims in an auto insurance case (where the state law requires or provides for such coverage)
or workers' compensation claims
Every Medicaid plan is subject to state-specific requirements
Regardless of the nature of the state regulated plan, identify any regulatory provision
or administrative agency guidance that provides a standard for how services are to be reported.
It is not uncommon, especially because auto and worker's compensation are exempt from the
HIPPA mandated code set rules, to identify non-standard coding and reimbursement rules.
Rules applicable to federally regulated health plans are found primarily in a federal statute (these
federally regulated health plans include: Federal Employee Benefit plans,
Commercial Insurance Plans Questions And
Answers
Is the provider offered a chance at implementing corrective action?
How these questions are answered will significantly affect the audit result, in terms of whether
an auditor can declare error or can simply declare potential risk.
Where the provider is not contracted with a particular payer, consider the provider has no
legal duty to conform his or her reporting or documentation to the mandates of the payer's
medical policies.
Although this might prevent an auditor from declaring an error, it does not prevent an auditor
from identifying potential risk and suggesting change that would assist the provider in avoiding
an issue with that carrier.
Insurance contracts are not always available to the auditor (I have yet to see one)
, Chapter 5 CPMA Exam: Contract-based
Commercial Insurance Plans Questions And
Answers
State regulated Commercial insurance plans are mostly associated with first party medical
claims in an auto insurance case (where the state law requires or provides for such coverage)
or workers' compensation claims
Every Medicaid plan is subject to state-specific requirements
Regardless of the nature of the state regulated plan, identify any regulatory provision
or administrative agency guidance that provides a standard for how services are to be reported.
It is not uncommon, especially because auto and worker's compensation are exempt from the
HIPPA mandated code set rules, to identify non-standard coding and reimbursement rules.
Rules applicable to federally regulated health plans are found primarily in a federal statute (these
federally regulated health plans include: Federal Employee Benefit plans,
