AAPC Practice Management & Billing Ethics 2 — Questions and Answers
Question 1: What is a 'payer mix' in practice management?
- A list of billing codes
- The proportion of patients covered by different insurance types (Medicare, Medicaid, commercial, self-pay) (Correct answer)
- A list of approved payers for a provider
- The ratio of claims paid to claims denied
Correct answer: The proportion of patients covered by different insurance types (Medicare, Medicaid, commercial, self-pay)
Payer mix describes the breakdown of a practice's revenue sources by insurance type, directly affecting financial performance since different payers reimburse at different rates.
Question 2: What is 'credentialing' in healthcare practice management?
- Billing for clinical services
- The process of verifying a provider's qualifications, licenses, and experience to grant privileges or payer enrollment (Correct answer)
- Obtaining prior authorizations
- Posting payments to provider accounts
Correct answer: The process of verifying a provider's qualifications, licenses, and experience to grant privileges or payer enrollment
Credentialing verifies that providers meet the required standards of education, training, and licensure before they can treat patients or be enrolled with payers.
Question 3: What is the National Provider Identifier (NPI)?
- A billing code for services
- A unique 10-digit identification number assigned to healthcare providers for use in standard transactions (Correct answer)
- A Medicare claim number
- A patient identification number
Correct answer: A unique 10-digit identification number assigned to healthcare providers for use in standard transactions
The NPI is a HIPAA standard unique identifier for covered healthcare providers, required on all HIPAA-covered electronic transactions including claims.
Question 4: What is a 'charge master' (chargemaster) in a hospital setting?
- The lead billing specialist
- A comprehensive list of all billable services, supplies, and fees that a hospital uses to generate patient charges (Correct answer)
- A payer fee schedule
- A coding audit tool
Correct answer: A comprehensive list of all billable services, supplies, and fees that a hospital uses to generate patient charges
The charge master is a hospital's internal price list containing all items and services that can be billed, including assigned CDM codes and standard prices.
Question 5: What is a 'first-pass resolution rate' in billing operations?
- The speed of claim submission
- The percentage of claims paid on the first submission without denials or rejections (Correct answer)
- The ratio of paper to electronic claims
- The percentage of patients with insurance
Correct answer: The percentage of claims paid on the first submission without denials or rejections
First-pass resolution rate measures billing efficiency; a high rate indicates claims are submitted cleanly and accurately the first time, reducing rework costs.
Question 6: What is the purpose of the OIG Work Plan in healthcare compliance?
- To outline Medicare fee schedule updates
- To identify areas where OIG will focus audits and investigations of healthcare providers during the fiscal year (Correct answer)
- To update CPT codes annually
- To provide billing training for new coders
Correct answer: To identify areas where OIG will focus audits and investigations of healthcare providers during the fiscal year
The OIG Work Plan lists ongoing and planned audit and investigative activities, helping providers proactively review their own practices in areas of heightened scrutiny.
AAPC Practice Management & Billing Ethics 2
What is a 'payer mix' in practice management?