CMAS Case Analysis & Practical Application 2

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?

Accepted Answer

Explain that the deductible amount is the patient's contractual responsibility per their insurance plan

Answer

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?

Accepted Answer

Call the insurance company's provider line for a verbal authorization and document the reference number

Answer

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?

Accepted Answer

Initiate a corrected claim and refund the overpayment to the payer

Answer

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?

Accepted Answer

Ask the patient for their Medicaid ID number and verify eligibility by phone or online portal before providing non-emergency services

Answer

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?

Accepted Answer

Deny access and explain that HIPAA limits record access to those with a treatment, payment, or operations need

Answer

HIPAA's minimum necessary standard prohibits accessing PHI without a legitimate need related to TPO.

(CMAS) Certified Medical Administrative Specialist Practice Test

(CMAS) Certified Medical Administrative Specialist Practice Test

CMAS Case Analysis & Practical Application 2