CMM Revenue Cycle Management & Medical Billing 3

Question 1

A practice manager is evaluating whether to appeal a denied claim. Which factor is MOST important to assess first?

Accepted Answer

Whether the appeal deadline specified in the payer contract has passed

Answer

Payer contracts and regulations specify strict appeal timelines; missing the deadline forfeits the right to appeal regardless of the validity of the denial.

Question 2

Which of the following is an example of upcoding, a fraudulent billing practice?

Accepted Answer

Billing for a 99213 when documentation only supports a 99212

Answer

Upcoding is billing for a higher-level service than what is documented; billing a 99213 when documentation only supports a 99212 is a classic example.

Question 3

A medical practice wants to improve patient collections. Which strategy has been shown to be MOST effective?

Accepted Answer

Collecting patient responsibility amounts at the time of service

Answer

Research consistently shows that collecting patient balances at the point of service dramatically improves collection rates, as the likelihood of payment declines significantly over time.

Question 4

In value-based payment models, which metric directly measures whether a practice's spending on a patient population aligns with the payer's budget target?

Accepted Answer

Per Member Per Month (PMPM) cost

Answer

PMPM cost measures total expenditures divided by enrolled members and is the core financial metric in capitation and shared savings contracts.

Question 5

Which federal program requires providers to submit cost reports annually, and uses those reports to reconcile interim payments made throughout the year?

Accepted Answer

Medicare Fee-for-Service (Traditional Medicare)

Answer

Traditional (Fee-for-Service) Medicare requires cost reports from institutional providers to reconcile actual costs against interim payments made during the fiscal year.

(CMM) Certified Medical Manager Practice Test

(CMM) Certified Medical Manager Practice Test

CMM Revenue Cycle Management & Medical Billing 3