CCA Medical Claims and Healthcare Coverage 2 — Questions and Answers
Question 1: What does 'reasonable and customary' refer to in medical claims evaluation?
- The amount Medicare pays for a specific service
- The actual amount charged by the treating physician
- The typical range of fees charged for a service in a specific geographic area (Correct answer)
- The maximum amount allowed under state law
Correct answer: The typical range of fees charged for a service in a specific geographic area
Reasonable and customary (R&C) represents the prevailing fees charged for specific medical services in a particular geographic area, used as a benchmark to assess whether charges are appropriate.
Question 2: Under HIPAA regulations, a claims adjuster can obtain a claimant's medical records:
- Without authorization since adjusters are considered healthcare professionals
- Only through a court order in all circumstances
- With the claimant's written authorization or a valid legal process such as a subpoena (Correct answer)
- Only if the claimant's attorney submits a formal request
Correct answer: With the claimant's written authorization or a valid legal process such as a subpoena
HIPAA requires a valid patient authorization or legal process such as a subpoena for the release of protected health information to third parties including insurance adjusters.
Question 3: A 'peer review' in medical claims handling involves:
- Injured workers reviewing each other's claims for accuracy
- A qualified medical professional evaluating the appropriateness of another physician's treatment (Correct answer)
- Insurance adjusters reviewing medical bills with their supervisors
- A claimant reviewing their own medical records for errors
Correct answer: A qualified medical professional evaluating the appropriateness of another physician's treatment
Peer review involves a qualified medical professional assessing whether the treatment provided was medically necessary, appropriate for the diagnosis, and consistent with accepted clinical standards.
Question 4: What is a medical lien in personal injury claims?
- A type of supplemental health insurance policy
- A healthcare provider's legal right to share in settlement proceeds for unpaid medical bills (Correct answer)
- A document authorizing emergency medical treatment
- A court order requiring ongoing medical treatment
Correct answer: A healthcare provider's legal right to share in settlement proceeds for unpaid medical bills
A medical lien gives healthcare providers who treated an injury victim the legal right to be reimbursed from any settlement or judgment the patient receives for their injuries.
Question 5: What is the significance of establishing 'causation' when evaluating a medical claim?
- It determines which physician a claimant must use for treatment
- It establishes the connection between the incident and the claimant's medical condition or injury (Correct answer)
- It sets the statute of limitations for filing the medical claim
- It determines the geographic jurisdiction governing the claim
Correct answer: It establishes the connection between the incident and the claimant's medical condition or injury
Causation establishes whether the claimant's injury or medical condition was caused by or directly related to the insured incident, which is fundamental to determining coverage and liability.
Question 6: An 'aggravation' of a pre-existing condition in claims handling means:
- The claimant is exaggerating the severity of their injuries
- A prior condition was worsened by the incident, potentially creating additional compensable liability (Correct answer)
- The medical treatment itself has made the condition worse over time
- The adjuster is escalating claim denial efforts
Correct answer: A prior condition was worsened by the incident, potentially creating additional compensable liability
Aggravation occurs when an incident makes a pre-existing condition worse than it otherwise would have been, and adjusters must evaluate the portion of disability attributable to the new incident.
Question 7: What is the purpose of a 'life care plan' in serious injury claims?
- To determine the claimant's eligibility for life insurance benefits
- To outline and project costs for all future medical and care needs of a catastrophically injured person (Correct answer)
- To establish life expectancy for settlement valuation purposes only
- To schedule the claimant's return-to-work program
Correct answer: To outline and project costs for all future medical and care needs of a catastrophically injured person
A life care plan, prepared by a certified specialist, documents all projected future medical, rehabilitative, and personal care needs along with their projected costs for catastrophically injured claimants.
CCA Medical Claims and Healthcare Coverage 2
What does 'reasonable and customary' refer to in medical claims evaluation?