CMAS Case Analysis & Practical Application 2 — Questions and Answers
Question 1: A patient calls to dispute a $150 balance on their account, claiming their insurance should have covered it. The EOB shows it was applied to their deductible. What is the medical administrative specialist's best first response?
- Write off the balance immediately
- Explain that the deductible amount is the patient's contractual responsibility per their insurance plan (Correct answer)
- Resubmit the claim to insurance as a billing error
- Transfer the patient to collections
Correct answer: Explain that the deductible amount is the patient's contractual responsibility per their insurance plan
The EOB confirming deductible application means the patient owes the balance per their insurance contract, and this should be explained clearly.
Question 2: A physician asks you to schedule a procedure that requires prior authorization. The insurance company's portal is down. Which action best protects the practice?
- Proceed with scheduling without authorization
- Call the insurance company's provider line for a verbal authorization and document the reference number (Correct answer)
- Postpone the procedure indefinitely
- Bill the patient directly and bypass insurance
Correct answer: Call the insurance company's provider line for a verbal authorization and document the reference number
A verbal authorization with documented reference number protects the practice if the portal is unavailable.
Question 3: During a chart audit, you find that a provider billed 99215 (high-complexity visit) but the documentation only supports 99213 (low-complexity). What is the correct course of action?
- Leave the claim as submitted since it has already been paid
- Initiate a corrected claim and refund the overpayment to the payer (Correct answer)
- Upgrade the documentation retroactively to match the billed code
- Void all claims from that provider
Correct answer: Initiate a corrected claim and refund the overpayment to the payer
Billing must reflect documented services; overpayments must be returned via a corrected claim to avoid fraud liability.
Question 4: A patient presents without ID or insurance card but states they have Medicaid. The eligibility verification system shows no active coverage. What should the specialist do?
- Refuse to see the patient
- Ask the patient for their Medicaid ID number and verify eligibility by phone or online portal before providing non-emergency services (Correct answer)
- Provide services and bill self-pay
- Bill Medicare instead
Correct answer: Ask the patient for their Medicaid ID number and verify eligibility by phone or online portal before providing non-emergency services
Verifying eligibility through alternative methods before service delivery protects the practice from claim denial.
Question 5: A new employee asks to access a patient's records out of curiosity after recognizing the patient as a neighbor. What is the appropriate response?
- Allow access since the employee works at the practice
- Deny access and explain that HIPAA limits record access to those with a treatment, payment, or operations need (Correct answer)
- Allow view-only access as a compromise
- Consult the patient first
Correct answer: Deny access and explain that HIPAA limits record access to those with a treatment, payment, or operations need
HIPAA's minimum necessary standard prohibits accessing PHI without a legitimate need related to TPO.
Question 6: A collection agency contacts your office requesting a patient's full medical history to help collect a debt. How should you respond?
- Send the full medical record since it is needed for billing
- Provide only the minimum necessary billing information such as dates of service and amounts owed (Correct answer)
- Refuse all communication with the agency
- Forward the request to the treating physician
Correct answer: Provide only the minimum necessary billing information such as dates of service and amounts owed
HIPAA permits disclosure to collection agencies for payment purposes but limits it to the minimum necessary billing information, not full medical records.
Question 7: Your practice receives a subpoena for a patient's medical records in a personal injury lawsuit. The patient has not signed a release. What is the correct first step?
- Immediately send all requested records
- Notify the practice's attorney and the patient before releasing records, as a subpoena alone may not override HIPAA without a court order (Correct answer)
- Shred the records to protect the patient
- Ignore the subpoena
Correct answer: Notify the practice's attorney and the patient before releasing records, as a subpoena alone may not override HIPAA without a court order
A subpoena is not automatically a court order; legal counsel must evaluate whether HIPAA authorization or a qualifying court order exists before disclosure.
CMAS Case Analysis & Practical Application 2
A patient calls to dispute a $150 balance on their account, claiming their insurance should have covered it.
The EOB shows it was applied to their deductible.
What is the medical administrative specialist's best first response?