COBGC Reimbursement and Billing 1 — Questions and Answers
Question 1: What is the fee schedule used for Medicare OB/GYN reimbursement?
- The Medicare Physician Fee Schedule based on the Resource-Based Relative Value Scale (RBRVS) (Correct answer)
- A flat rate for all services
- Negotiated rates like commercial insurance
- No fee schedule exists
Correct answer: The Medicare Physician Fee Schedule based on the Resource-Based Relative Value Scale (RBRVS)
Medicare uses the RBRVS system to assign relative values to services based on work, practice expense, and malpractice cost.
Question 2: What is a clean claim?
- A claim submitted with all required information, correctly coded, and free of errors (Correct answer)
- Any claim that is paid
- A claim with no diagnosis codes
- A paper claim only
Correct answer: A claim submitted with all required information, correctly coded, and free of errors
Clean claims process faster because they contain all necessary information and have no errors requiring correction.
Question 3: What is the timely filing deadline?
- The maximum time after the date of service within which a claim must be submitted to the payer (Correct answer)
- Filing within 24 hours
- No time limit exists
- Only applies to Medicare
Correct answer: The maximum time after the date of service within which a claim must be submitted to the payer
Each payer sets timely filing deadlines; missing them can result in claim denial regardless of whether services were properly rendered.
Question 4: What is a remittance advice?
- A document from the payer explaining how a claim was processed, including payments and adjustments (Correct answer)
- A patient bill
- A referral form
- A medical record
Correct answer: A document from the payer explaining how a claim was processed, including payments and adjustments
The remittance advice (ERA/EOB) details what was billed, allowed, paid, adjusted, and what the patient owes.
Question 5: What is the difference between participating and non-participating providers?
- Participating providers accept the payer's fee schedule; non-participating providers may charge higher rates (Correct answer)
- All providers are participating
- Non-participating means not licensed
- The distinction only applies to hospitals
Correct answer: Participating providers accept the payer's fee schedule; non-participating providers may charge higher rates
Participating providers agree to accept the payer's allowed amount as payment in full, while non-participating providers may balance bill patients.
Question 6: What is coordination of benefits?
- The process determining which insurance pays first when a patient has multiple coverage (Correct answer)
- Coordinating appointment schedules
- Matching benefits to diagnoses
- Only applies to dental insurance
Correct answer: The process determining which insurance pays first when a patient has multiple coverage
COB rules determine primary and secondary payer responsibility when patients have coverage from multiple insurance sources.
COBGC Reimbursement and Billing 1
What is the fee schedule used for Medicare OB/GYN reimbursement?