CRCR Claims Processing and Billing 5 — Questions and Answers
Question 1: What does 'coordination of benefits' (COB) determine in the claims billing process?
- How a provider allocates revenue across departments
- The order in which multiple insurers pay claims when a patient has more than one insurance plan (Correct answer)
- The process for writing off uncollectible balances
- How providers negotiate rates with payers
Correct answer: The order in which multiple insurers pay claims when a patient has more than one insurance plan
COB rules establish which insurer pays first (primary) and which pays second (secondary) when a patient has coverage under multiple plans.
Question 2: A claim is submitted with an incorrect patient date of birth. The claim is rejected. What type of rejection is this?
- Medical necessity rejection
- Administrative or demographic rejection (Correct answer)
- Coordination of benefits rejection
- Authorization rejection
Correct answer: Administrative or demographic rejection
Incorrect demographic information such as date of birth results in an administrative or demographic rejection because the patient cannot be identified.
Question 3: Which federal law sets the standard electronic transaction formats for healthcare claims, including the HIPAA 837 transaction set?
- The Affordable Care Act (ACA)
- The Health Insurance Portability and Accountability Act (HIPAA) (Correct answer)
- The False Claims Act (FCA)
- The Social Security Act
Correct answer: The Health Insurance Portability and Accountability Act (HIPAA)
HIPAA established standardized electronic transaction formats, including the 837P and 837I for professional and institutional claims, respectively.
Question 4: A skilled nursing facility (SNF) bills Medicare under the Prospective Payment System (PPS). What is the payment unit for SNF PPS?
- Per discharge using DRGs
- Per diem (daily rate) based on Resource Utilization Groups (RUGs) (Correct answer)
- Per visit using Ambulatory Payment Classifications
- Per episode of care over 60 days
Correct answer: Per diem (daily rate) based on Resource Utilization Groups (RUGs)
Medicare SNF PPS pays a per diem rate based on the patient's Resource Utilization Group (RUG) category, which reflects the level of care needed.
Question 5: A payer issues an Explanation of Benefits (EOB) showing a 'contractual adjustment.' What does this mean for the provider?
- The patient is responsible for the adjusted amount
- The provider must write off the difference between billed charges and the contracted allowable as a contractual adjustment and cannot bill the patient for it (Correct answer)
- The payer is requesting a refund from the provider
- The claim has been sent to collections
Correct answer: The provider must write off the difference between billed charges and the contracted allowable as a contractual adjustment and cannot bill the patient for it
A contractual adjustment represents the difference between the provider's billed charges and the contracted rate, which the provider agrees to write off per their payer contract.
Question 6: What is the primary purpose of a charge master (chargemaster) in hospital billing?
- To track patient payment histories
- To serve as a comprehensive list of all services, supplies, and procedures a hospital provides along with their standard charges and associated billing codes (Correct answer)
- To store payer contracts and fee schedules
- To schedule patient appointments and admissions
Correct answer: To serve as a comprehensive list of all services, supplies, and procedures a hospital provides along with their standard charges and associated billing codes
The charge master (CDM) is a hospital's master list of all billable items with their standard charges and corresponding procedure/revenue codes used for billing.
Question 7: Under the False Claims Act, what is the term for a private individual who files a lawsuit on behalf of the government against a provider committing fraud?
- Compliance officer
- Qui tam relator (whistleblower) (Correct answer)
- Recovery audit contractor
- Medicare administrative contractor
Correct answer: Qui tam relator (whistleblower)
A qui tam relator is a private individual, often an insider, who files a lawsuit under the False Claims Act on the government's behalf and may receive a share of recovered funds.
CRCR Claims Processing and Billing 5
What does 'coordination of benefits' (COB) determine in the claims billing process?