Free Medical Billing General Question and Answers — Questions and Answers
Question 1: What is the acronym of Early and Periodic Screenings-Diagnosis-and Treatment?
- Collection Ratio
- EPSDT (Correct answer)
- V.I. Payment
- Electronic Claim
Correct answer: EPSDT
EPSDT stands for Early and Periodic Screening, Diagnostic, and Treatment. It is a mandatory Medicaid benefit for children under 21, ensuring comprehensive and preventative healthcare services. The acronym directly represents the full name of this crucial program, which aims to identify and address health problems early.
Question 2: Maggie visits the chiropractor once every week and has Medicaid. Maggie is told by the chiropractor that she must pay a $25 copay for each visit even though she has Medicaid. There is no copay on Marge's insurance card. When Maggie questions the billing office, they inform her that her insurance only pays $17 for each chiropractic visit and that it would be cheaper for her to pay the $25 out-of-pocket. In accordance with Medicaid rules:
- Maggie should ask to pay $17 per visit.
- It is illegal to bill Medicaid patients without signed consent. (Correct answer)
- it is illegal to bill Medicaid patients before billing Medicaid first.
- Maggie should call Medicaid to see if her copay has changed.
Correct answer: It is illegal to bill Medicaid patients without signed consent.
Medicaid is a payer of last resort, and providers are generally prohibited from balance billing Medicaid patients for services covered by Medicaid. If a provider wishes to bill a Medicaid patient for services not covered or for amounts exceeding Medicaid's allowed charges, they must obtain a signed Advance Beneficiary Notice (ABN) or similar waiver from the patient *before* providing the service, clearly stating the patient's financial responsibility. Without such consent, billing the patient directly for the difference is illegal.
Question 3: The time frame for filing a claim with Medicare is:
- 120 days
- 365 days (Correct answer)
- 90 days
- 180 days
Correct answer: 365 days
Medicare generally requires claims to be filed within one calendar year (365 days) from the date of service. This timeframe ensures timely processing and payment for healthcare providers. Claims submitted after this period may be denied, impacting reimbursement and requiring providers to adhere strictly to this deadline.
Question 4: A test costs $400 and is provided. The patient is responsible for $23.56 while the insurance company pays $300. What are the terms for the contractual discount and the patient's obligation?
- $76.44, coinsurance (Correct answer)
- $100, copay
- $76.44, copay
- $100, coinsurance
Correct answer: $76.44, coinsurance
The contractual discount is the difference between the total cost ($400) and what the insurance company and patient pay together ($300 + $23.56 = $323.56), which is $76.44. The patient's obligation of $23.56, after the insurance has paid a portion, is known as coinsurance, which is a percentage of the cost of a covered healthcare service paid by the patient after their deductible has been met.
Question 5: The sum an insurance provider is charged for services:
- Each procedure must have a set cost for all insurance companies. (Correct answer)
- can vary based on how difficult the operation was
- varies based on the amount that the insurance pays out for that procedure.
- Must be a predetermined sum for each specific insurance provider.
Correct answer: Each procedure must have a set cost for all insurance companies.
While the *reimbursement* amount can vary based on contracts with different insurance companies, the *charge* for a specific procedure is typically set by the provider and is the same for all patients and insurance companies. This 'list price' or standard fee schedule is then subject to contractual adjustments and patient responsibility based on individual insurance plans. Therefore, the initial sum charged for services is generally consistent across all payers.
Question 6: When a patient calls, they request a copy of their most recent visit's chart. How soon must you provide them with their records?
- 7 days
- 30 days (Correct answer)
- 5 days
- 10 days
Correct answer: 30 days
Under HIPAA (Health Insurance Portability and Accountability Act) regulations, healthcare providers generally have 30 days to respond to a patient's request for access to their medical records. While they may provide them sooner, 30 days is the maximum allowable timeframe. This ensures patients have timely access to their health information, promoting transparency and patient rights.
Question 7: What distinctions exist between inpatient and pro-fee coding in terms of how they are paid for?
- Inpatient is reimbursed by ICD-10 PCS and uses ICD-10 CM diagnosis codes, while Pro-fee is reimbursed according to a fee schedule for CPT codes.
- The inpatient is compensated by IPPS for ICD-10 CMs that are classed as DRGs and uses ICD-10 PCS. Pro-fee is reimbursed on a fee schedule for CPT codes and uses ICD-10 CM diagnosis codes. (Correct answer)
- Pro-fee reimbursement is based on an ICD-10 CM fee structure and uses HCPCS, whereas inpatient reimbursement is based on IPPS and uses ICD-10 PCS diagnostic codes.
- Inpatient care is compensated by CPT codes through IPPS and uses ICD-10 CM diagnostic codes, while pro-fee services are paid according to a fee schedule for CPT codes.
Correct answer: The inpatient is compensated by IPPS for ICD-10 CMs that are classed as DRGs and uses ICD-10 PCS. Pro-fee is reimbursed on a fee schedule for CPT codes and uses ICD-10 CM diagnosis codes.
Inpatient coding uses ICD-10-CM for diagnoses and ICD-10-PCS for procedures, with reimbursement often based on Diagnosis-Related Groups (DRGs) under the Inpatient Prospective Payment System (IPPS). Pro-fee (professional fee) coding, on the other hand, uses CPT codes for procedures and ICD-10-CM for diagnoses, with reimbursement typically determined by a fee schedule. This distinction reflects the different payment methodologies for hospital services versus physician services.
Free Medical Billing General Question and Answers
What is the acronym of Early and Periodic Screenings-Diagnosis-and Treatment?