CMRT Revenue Cycle Management 4 — Questions and Answers
Question 1: When a patient has both Medicare Part A and an employer group health plan, which payer is typically primary?
- Medicare is always primary
- The employer group plan is primary if the employer has 20 or more employees (Correct answer)
- Medicare is primary only if the patient is retired
- The patient chooses which plan pays first
Correct answer: The employer group plan is primary if the employer has 20 or more employees
Under Medicare Secondary Payer (MSP) rules, the employer's group plan is primary when the employer has 20+ employees and the patient is an active employee.
Question 2: What is the function of the National Provider Identifier (NPI) in revenue cycle management?
- It authenticates the patient's insurance eligibility in real time
- It uniquely identifies healthcare providers on all HIPAA standard transactions (Correct answer)
- It encrypts protected health information during claim transmission
- It assigns a reimbursement rate to each provider specialty
Correct answer: It uniquely identifies healthcare providers on all HIPAA standard transactions
The NPI is a unique 10-digit identifier required on all HIPAA electronic transactions to identify the rendering, billing, and referring providers.
Question 3: A hospital bills Medicare for an inpatient stay. Under which payment system is reimbursement calculated?
- Resource-Based Relative Value Scale (RBRVS)
- Ambulatory Payment Classification (APC)
- Diagnosis-Related Group (DRG) (Correct answer)
- Per diem rate schedule
Correct answer: Diagnosis-Related Group (DRG)
Medicare reimburses inpatient hospital stays using the Inpatient Prospective Payment System (IPPS), which assigns a fixed payment based on the patient's DRG.
Question 4: Which of the following best describes 'balance billing' in a managed care setting?
- Billing the secondary insurer after the primary pays
- Billing the patient for the difference between the provider's charge and the contracted rate (Correct answer)
- Sending itemized statements to patients with large balances
- Applying leftover credits to future patient accounts
Correct answer: Billing the patient for the difference between the provider's charge and the contracted rate
Balance billing occurs when a provider bills the patient for the difference between their charge and the payer-contracted rate, which is prohibited for in-network providers under most contracts.
Question 5: A coder assigns a higher-level E/M code than is supported by the documentation. This is an example of:
- Downcoding
- Upcoding (Correct answer)
- Unbundling
- Modifier abuse
Correct answer: Upcoding
Upcoding means assigning a billing code that reflects a higher level of service than what was actually documented or performed.
Question 6: What is the purpose of an Advance Beneficiary Notice (ABN) in Medicare billing?
- To notify Medicare of a patient's change of address
- To inform a Medicare beneficiary that a service may not be covered and they may be responsible for payment (Correct answer)
- To request prior authorization for a surgical procedure
- To document that a patient refuses a recommended treatment
Correct answer: To inform a Medicare beneficiary that a service may not be covered and they may be responsible for payment
An ABN is given to Medicare beneficiaries before providing a service that may not be deemed medically necessary, so they can decide whether to proceed knowing they may owe the cost.
Question 7: Which internal control best reduces the risk of duplicate claim payments in the revenue cycle?
- Requiring two-signature approval for all refund checks
- Implementing claim scrubbing software that flags duplicate submissions (Correct answer)
- Conducting annual fee schedule reviews
- Requiring patients to sign financial responsibility forms
Correct answer: Implementing claim scrubbing software that flags duplicate submissions
Claim scrubbing software identifies duplicate claims before submission, preventing overpayment requests and payer-side denials.
CMRT Revenue Cycle Management 4
When a patient has both Medicare Part A and an employer group health plan, which payer is typically primary?