Medical Insurance- Chapter 6 Exam Questions with Correct Answers Fully Solved
Audit - Answers methodical review
External Audit - Answers Audit conducted by an outside organization
RAC - Answers Recovery Audit Contractor program designed to audit Medicare Claims
Internal Audit - Answers Self-audit conducted by a staff member or consultant
Prospective Audit - Answers Internal audit of claims conducted before transmission
Retrospective Unit - Answers Internal audit conducted after claims are processed and RAs have been
received
Compliant - Answers -Carefully define bundled codes and know global periods
-Clarify coding and billing questions with physicians
-Be clear on professional courtesy and discounts to uninsured/low-income patients
Rejected - Answers -Reporting only the top two of a five-level E/M code range for new or established
patient office visits
-Billing Medicare for treatment of an immediate family member
-Using Modifier -91 to report repeat laboratory testing due to laboratory errors, quality control, or
confirmation of results
First Step to calculating a Medicare payment - Answers Determine the procedure code for the service
Second Step to calculating a Medicare payment - Answers Use the Medicare Fee Schedule to find the
three RVUs - work, practice expense, and malpractice- for the procedure
Third Step to calculating a Medicare payment - Answers Use the Medicare GPCI list to find three
geographic practice cost indices
Fourth Step to calculating a Medicare Payment - Answers Multiply each RVU by its GPCI to calculate the
adjusted value
Fifth Step to calculating a Medicare Payment - Answers Add the three adjusted totals, and multiply the
sum by the conversion factor to determine the payment
Edits - Answers A computerized system used to screen claims
Downcoding - Answers A payer's review and reduction of a procedure code to a lower value than
reported by the provider
, Capitation Rate - Answers The contractually set periodic prepayment amount to a provider for specified
services to each enrolled plan member
Usual Fee - Answers Fee for a service or procedure that is charged by a provider for most patients under
typical circumstances
Allowed Charge - Answers The maximum charge allowed by a payer for a specific or procedure
Prospective Audit - Answers An internal audit conducted before claims are reported to payers
Adjustment - Answers A change to a patient's account
write-off - Answers The amount that a participating provider must deduct from a patient's account
because of a contractual agreement to accept a payer's allowed Charge
Conversion Factor - Answers Dollar amount used to multiply a relative value unit to arrive at a charge
OIG Work Plan - Answers The OIG's annual list of planned projects under the Medicare Fraud and Abuse
Initiative
Code Linkage - Answers Connection between a service and a patient's condition or illness
Medicare Physician Fee Schedule (MPFS) - Answers The RBRVS-based allowed fees
X Modifiers - Answers HCPCS modifiers that define specific subsets of modifier 59
The OIG Work Plan describes - Answers planned projects for investigating possible fraud in various
billing areas
Under Medicare's code edits, mutually exclusive codes - Answers cannot be billed together for the same
patient on the same day
In the example in Figure 6.6 on page 213, the lowest cost element in the Medicare RBRVS fees is -
Answers malpractice expense
In calculations of RBRVS fees, the three relative value units are multiplied by - Answers their respective
geographic cost indices
Medicare typically pays for what percentage of the allowed charge? - Answers 80%
If a participating provider's usual fee is $400 and the allowed amount is $350, what amount is written
off? - Answers $50
If a nonparticipating provider's usual fee is $400, the allowed amount is $350, and balance billing is
permitted, what amount is written off? - Answers zero
If a nonparticipating provider's usual fee is $400, the allowed amount is $350, and balance billing is not
permitted, what amount is written off? - Answers $50
Audit - Answers methodical review
External Audit - Answers Audit conducted by an outside organization
RAC - Answers Recovery Audit Contractor program designed to audit Medicare Claims
Internal Audit - Answers Self-audit conducted by a staff member or consultant
Prospective Audit - Answers Internal audit of claims conducted before transmission
Retrospective Unit - Answers Internal audit conducted after claims are processed and RAs have been
received
Compliant - Answers -Carefully define bundled codes and know global periods
-Clarify coding and billing questions with physicians
-Be clear on professional courtesy and discounts to uninsured/low-income patients
Rejected - Answers -Reporting only the top two of a five-level E/M code range for new or established
patient office visits
-Billing Medicare for treatment of an immediate family member
-Using Modifier -91 to report repeat laboratory testing due to laboratory errors, quality control, or
confirmation of results
First Step to calculating a Medicare payment - Answers Determine the procedure code for the service
Second Step to calculating a Medicare payment - Answers Use the Medicare Fee Schedule to find the
three RVUs - work, practice expense, and malpractice- for the procedure
Third Step to calculating a Medicare payment - Answers Use the Medicare GPCI list to find three
geographic practice cost indices
Fourth Step to calculating a Medicare Payment - Answers Multiply each RVU by its GPCI to calculate the
adjusted value
Fifth Step to calculating a Medicare Payment - Answers Add the three adjusted totals, and multiply the
sum by the conversion factor to determine the payment
Edits - Answers A computerized system used to screen claims
Downcoding - Answers A payer's review and reduction of a procedure code to a lower value than
reported by the provider
, Capitation Rate - Answers The contractually set periodic prepayment amount to a provider for specified
services to each enrolled plan member
Usual Fee - Answers Fee for a service or procedure that is charged by a provider for most patients under
typical circumstances
Allowed Charge - Answers The maximum charge allowed by a payer for a specific or procedure
Prospective Audit - Answers An internal audit conducted before claims are reported to payers
Adjustment - Answers A change to a patient's account
write-off - Answers The amount that a participating provider must deduct from a patient's account
because of a contractual agreement to accept a payer's allowed Charge
Conversion Factor - Answers Dollar amount used to multiply a relative value unit to arrive at a charge
OIG Work Plan - Answers The OIG's annual list of planned projects under the Medicare Fraud and Abuse
Initiative
Code Linkage - Answers Connection between a service and a patient's condition or illness
Medicare Physician Fee Schedule (MPFS) - Answers The RBRVS-based allowed fees
X Modifiers - Answers HCPCS modifiers that define specific subsets of modifier 59
The OIG Work Plan describes - Answers planned projects for investigating possible fraud in various
billing areas
Under Medicare's code edits, mutually exclusive codes - Answers cannot be billed together for the same
patient on the same day
In the example in Figure 6.6 on page 213, the lowest cost element in the Medicare RBRVS fees is -
Answers malpractice expense
In calculations of RBRVS fees, the three relative value units are multiplied by - Answers their respective
geographic cost indices
Medicare typically pays for what percentage of the allowed charge? - Answers 80%
If a participating provider's usual fee is $400 and the allowed amount is $350, what amount is written
off? - Answers $50
If a nonparticipating provider's usual fee is $400, the allowed amount is $350, and balance billing is
permitted, what amount is written off? - Answers zero
If a nonparticipating provider's usual fee is $400, the allowed amount is $350, and balance billing is not
permitted, what amount is written off? - Answers $50
