CPB Final Exam Top Questions and answers. 100% Accurate. Graded A+

CPB Final Exam Top Questions and answers. 100% Accurate. Graded A+ A practice agrees to pay $250,000.00 to settle a lawsuit alleging that the practice used x-rays of one patient to justify services on multiple other patients' claims. The office manager brought the civil suit. What type of case is this? - -Qui Tam In which of the following circumstances may PHI not be disclosed without the patient's authorization or permission? - -An office receives a call from the patient's husband asking for information about his wife's recent office visit. According to the Privacy Rule, what must a Business Associate and a Covered Entity have in order to do business? - -A contract HMO plans require the enrollee to: - -To have referrals to see a specialist that is generated by the patient's primary care provider. Which of the following is NOT a component of the PPO payer model? - -Require the enrollee to maintain a Primary Care Provider. Under the Privacy Rule a health plan, clearinghouses, and any entity transmitting health information is considered? - -Covered entity A request for medical records is received for a specific date of service from a patient's insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken? - -Release the requested records to the insurance company. Which of the following situations allows the release of PHI without authorization from the patient? - -Workers' Compensation HIPAA mandated what entity to adopt national standards for electronic transactions and code sets? - -HHS What is the standard time frame established for record retention? - -There is no single standard for record retention; it varies by state and federal regulations. CMS defines _______ as billing for a lower level of care than is supported in documentation, making false statements to obtain undeserved benefits or payment from a federal healthcare program, or billing for a service that was not performed. - -Fraud A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS? - -Abuse A person that files a claim for a Medicare Beneficiary knowing that the service is not correctly reported is in violation of what statute? - -False Claims Act Which of the following actions is considered under the False Claims Act? - -Up-coding or unbundling services A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor? - -Truth in Lending Act Medicare was passed into law under the title XVIII of what Act? - -Social Security Act Which of the following statements are true regarding healthcare regulations? - -Healthcare regulations may vary by state and by payer A physician office (covered entity) discovers that the billing company (business associate) is in breach of their contract. What is the first step to be taken? - -Take steps to correct the problem and end the violation OIG, CMS, and the Department of Justice are the government agencies enforcing ______? - -Federal fraud and abuse laws Fraud and Abuse penalties do NOT include: - -Ability to re-file claims in question A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are an OB/GYN office they bill every patient for a urinalysis. What does this violate? - -False Claims Act Individuals have the right to review and obtain copies of the PHI. What is excluded from the right of access? - -Psychotherapy notes Medical Records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate? - -Minimum Necessary Patient has questions and concerns regarding the Privacy Practices in the clinic should be addressed by what party? - -Privacy Official What standard transactions are NOT included in EDI and adopted under HIPAA? - -Waiver of liability The Federal False Claim Act allows for claims to be reviewed for how many years after an incident? - -Seven years While working in a large practice, Medicare overpayments are found in several patient accounts. The manager states that the practice will keep the money until Medicare asks for it back. What is that action considered? - -Fraud What penalties can be imposed for Fraud and/or Abuse related to the United States Code? - -a. Monetary penalties ranging from $10,000 to $50,000 for each item or service b. Imprisonment c. Exclusion from Federal Healthcare Programs (d.) All of the above Medicare overpayments should be returned within ____ days after the overpayment has been identified? - -60 days What entities are exempt from HIPAA and not considered to be covered entities? - -Workers Compensation A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? - -A business associate A hospital records transported is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box onto the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? - -A breach When a practice sends an electronic claim to a commercial health plan for payment, what is this considered? - -A transaction Which statement is true regarding the Prompt Pay Act? - -Federal agencies are required to pay all clean claims within 30 days of the receipt. Review the policy: Collections policy: Invoices not paid within 60 days begin our collection process. Invoices not paid within 120 days are subject to patient dismissal and submission to our collections agency and notification to your insurance plan. According to this policy, at what age is a balance owed by the patient considered bad debt and sent to the collection agency? - -120 days When accepting debit cards in a medical practice, which act requires the office to disclose specific information before completing a transaction? - -Electronic Funds Transfer Act A claim has been denied as not medically necessary. The biller has checked the medical record and the medical policy and verified it is not covered according to the carrier's medical policy. What is the next action the biller should take? - -Check with the provider to appeal the claim and if necessary write off the balance. A provider removes a skin lesion in an ASC and receives a denial from the insurance company that states "lower level of care". What steps should the biller take? - -Check with the provider and write an appeal explaining why the service required the ASC. A claim was resubmitted to Medicare through a clearinghouse 60 days after the date of service and the claim was denied. The biller checked the clearinghouse claim status system and determined Medicare did not receive the claim. What action should the biller take? - -Check the clearinghouse reports and appeal the denial with proof of the claims submission. What does a high number of days in A/R indicate for a medical practice? - -The practice potentially has a problem in the revenue cycle. What should be included in a financial policy? A. Convey that the patient balances are due at the time of service B. List insurances the providers are contracted with C. List insurances the providers are not contracted with D. List the practice's policy for out-of-network insurance policies E. List the patients on the Medicaid roster - -A, B, D Which statement is true about a patients insurance? - -Verification should happen at each visit. Which option below is the better way to ask the patient about their current demographic information? - -What is your current address? Review the following office policy: Financial policy: You are responsible for paying all co-pays at the time of service. Co-pays, co-insurance, deductibles and non-covered services can not be waived by our office, as it is a requirement placed on you by your insurance carrier... Co-pay collection fee: If we must bill you for your co-pay, you may be required to pay a $20 co-pay collection fee. When must a co-pay be collected from the office by the patient to avoid a penalty? - -At the time of service. When a provider wants to give a discount on services to a patient, which option is acceptable? - -The provider must discount the change prior to billing the insurance carrier. What is a prompt pay discount? - -A discount given to self-pay patients when they pay for the service at the time of the visit. Which act protects information collected by the consumer reporting agencies? - -Fair Credit Reporting Act What steps should be taken when a medical office receives notice that a patient has filed bankruptcy? - -Obtain the case number, verify the case filing, and verify the provider is listed as the creditor, stop all collection efforts for balances filed under the bankruptcy. Which statement is true regarding denials? - -Denials should be reviewed to determine whether additional information is needed, if errors need to be corrected, or if the denial should be appealed. When should patient invoices (statements) be sent to the patient? - -As soon as the RA is posted and a balance is transferred to the patient. Which statement is true regarding patient balances? - -Small balance for which processing cost exceeds potential collections may be automatically written off according to the financial policy of the practice. What documents are needed for a successful appeal? - -Copies of the RA, medical record, and original claim, along with a letter detailing why the claim should be paid. A biller receives a request for medical records for patient A for DOS 05/15/20XX. Patient A's entire medical record (multiple dates of service) was copied and sent to the insurance carrier. Which statement below is true? - -This is a violation of HIPAA. Once a credit balance for an insurance carrier has been identified, what action should the biller take? - -Research to determine if it is a true overpayment, and then submit a refund to the insurance carrier for the overpayment. When a patient files Chapter 7 bankruptcy, which statement is true? - -Most medical debt is discharged, the provider will write off amounts owed. Which bankruptcy chapter combines the debt of the debtor and reduces the monthly payments allowing a potential for a provider to receive a portion of what is owed? - -Chapter 13 Review the following accounts receivable management policy: ... Insurance balances will be referred to internal follow-up staff for follow up at 45 days post initial claim and personal balances will be referred at the time the patient becomes responsible for all balances as soon as the charge is entered. Personal balances will be eligible for referral to an outside collection agency after 3 statements have been sent. Based on this policy, when does follow-up of insurance balances begin? When are patient balances eligible for an outside collection agency? - -45 days post initial claim After 3 statements have been sent A patient receiving inpatient care in a critical access hospitable would be covered under which part of Medicare? - -Part A Which of the following services does Medicare consider preventative? - -Screening for depression Bone mass measurements Glaucoma screening *All of the above* Medicare statutorily excluded services are? - -Non-covered items and services Not reimbursed by Medicare *Both A and B* A Medicare patient has prescription drug coverage, but does not have Medicare Advantage. What Medicare coverage does the patient have for his medications? - -Part D Medigap policies must conform to minimum standards identified as federal and state laws clearly be identified as - -Medicare Supplemental Insurance Dr. Allen who is a non-PAR provider who doesn't accept assignment preforms an appendectomy on a 67 year old Medicare patient. The physician's UCR for the surgery is $1500.00. Medicare's approved fee for this procedure is $1100.00. What is the limiting charge that this non-PAR provider can charge to this Medicare patient? - -$1201.75 A Medicare patient is seen by a participating provider. A claim is sent for $123.00 and an EOMB is received that states the approved amount is $100.00. If the patient has met their deductible, what should the reimbursement on this claim be from Medicare? - -$80.00 A Medicare patient is seen by her physician. The physician has opted out of the Medicare program. The patient and physician have a private contract. The charges for the service rendered are $300.00. Medicare's approved amount would be $200.00. What can the office charge this patient? - -$300.00 A Medicare patient presents for her pelvic, pap, and breast examination (PPB). The patient is not sure when she had her last PPB. As she is checking out, the front desk rep has her sign an ABN. The service is billed and denied for frequency. Can the patient be balance billed and why or why not? - -No. The ABN must be signed before the service is preformed. Medicare Advantage plans fall under which part of Medicare? - -Part C EPSDT is a program associated with: - -Medicaid Medicaid's minimum eligibility is based on which of the following criteria: - -Federal Poverty Level A 21 year-old patient presents for fillings for two of his teeth. Are these services covered under EPSDT? - -No, because the patient is not under the