CMAS Case Analysis & Practical Application 3 — Questions and Answers
Question 1: A patient with Medicare Part B is also covered by a large employer group plan. Which plan is the primary payer?
- Medicare is always primary
- The employer group plan is primary because the employer has 20 or more employees (Correct answer)
- Whichever plan the patient chooses
- Both plans pay simultaneously
Correct answer: The employer group plan is primary because the employer has 20 or more employees
When a Medicare patient is covered by an employer group plan with 20+ employees, the group plan is primary per Medicare Secondary Payer (MSP) rules.
Question 2: A claim is denied with remark code CO-4 (the procedure code is inconsistent with the modifier). Which corrective action is appropriate?
- Resubmit the exact same claim
- Review the procedure code and modifier pairing, correct the inconsistency, and resubmit a corrected claim (Correct answer)
- Write off the charge
- Appeal without making any changes
Correct answer: Review the procedure code and modifier pairing, correct the inconsistency, and resubmit a corrected claim
CO-4 indicates a coding error; the claim must be corrected before resubmission to resolve the denial.
Question 3: During patient check-in, you discover the patient's address and phone number on file are two years old. What is the best practice?
- Update information only if the patient mentions a change
- Verify and update demographic information at every visit to ensure accurate billing and communication (Correct answer)
- Update only if the patient signs a new form
- Leave the information unchanged to avoid errors
Correct answer: Verify and update demographic information at every visit to ensure accurate billing and communication
Updating demographics at each visit reduces claim rejections from incorrect information and ensures proper patient contact.
Question 4: A patient's surgery is scheduled for next week but their insurance authorization covers only office visits. What should be done immediately?
- Proceed with the surgery and bill without authorization
- Contact the insurance company to obtain a separate prior authorization specifically for the surgical procedure (Correct answer)
- Cancel the surgery permanently
- Have the patient sign an ABN and proceed
Correct answer: Contact the insurance company to obtain a separate prior authorization specifically for the surgical procedure
Surgical procedures typically require specific prior authorization separate from office visit coverage.
Question 5: A patient requests copies of their medical records and you notice a psychotherapy note in the file. Under HIPAA, how are psychotherapy notes treated?
- They are released with all other records upon standard request
- Psychotherapy notes have special protections and generally require separate, specific authorization to release (Correct answer)
- They can be released to any provider without authorization
- They must be withheld entirely under all circumstances
Correct answer: Psychotherapy notes have special protections and generally require separate, specific authorization to release
HIPAA grants psychotherapy notes extra protection beyond standard PHI, requiring specific patient authorization for most disclosures.
Question 6: An insurance company's EFT payment is $200 less than expected for a batch of claims. What is the most efficient first step to investigate?
- Call the insurance company immediately
- Reconcile the ERA/remittance advice against each claim in the batch to identify which specific claim(s) were adjusted (Correct answer)
- Post the payment as received and write off the difference
- Resubmit all claims in the batch
Correct answer: Reconcile the ERA/remittance advice against each claim in the batch to identify which specific claim(s) were adjusted
The ERA contains line-by-line adjustment reason codes that pinpoint exactly which claim and why payment differed.
Question 7: A patient who was seen for a workers' compensation injury returns for an unrelated condition. How should this visit be billed?
- Bill the workers' compensation carrier for both conditions
- Bill the patient's regular health insurance for the new condition, keeping it separate from the WC claim (Correct answer)
- Do not bill since the patient is a WC patient
- Bill Medicare regardless of age
Correct answer: Bill the patient's regular health insurance for the new condition, keeping it separate from the WC claim
Workers' compensation covers only work-related injuries; unrelated conditions must be billed to the appropriate health insurer.
CMAS Case Analysis & Practical Application 3
A patient with Medicare Part B is also covered by a large employer group plan.
Which plan is the primary payer?