Reimbursement & Claims Processing Flashcards

What is an Explanation of Benefits (EOB)?

Answer: A statement from the insurer explaining how a claim was processed and paid

An EOB is a document from the insurance company showing how a claim was adjudicated, including amounts billed, allowed, paid, and patient responsibility.

Which type of Medicare denial occurs when a service is not covered under the patient's Medicare benefit?

Answer: Coverage/benefit denial

A coverage/benefit denial means the service is not a covered benefit under the patient's Medicare plan, not a medical necessity issue.

The Resource-Based Relative Value Scale (RBRVS) used by Medicare is based on which three components?

Answer: Physician work, practice expense, and malpractice expense

The RBRVS consists of physician work RVUs, practice expense RVUs, and malpractice expense RVUs, each adjusted by a geographic practice cost index (GPCI).

What is the purpose of a Medicare Advance Beneficiary Notice (ABN)?

Answer: To inform the beneficiary that Medicare may not cover a service and that the patient may be liable

An ABN is given to Medicare patients before providing a service that may be denied as not medically necessary, informing them they may be financially responsible.

In the Medicare reimbursement system, what does 'participating provider' status mean?

Answer: The provider accepts Medicare's approved amount as payment in full and cannot balance bill

Participating providers (PAR) accept assignment and agree to accept the Medicare approved amount as payment in full, without balance billing.

Which federal law prohibits physician self-referral to entities in which the physician has a financial relationship?

Answer: Stark Law (Physician Self-Referral Law)

The Stark Law (42 U.S.C. §1395nn) prohibits physicians from referring Medicare/Medicaid patients to entities with which they have a financial relationship.