HAC Healthcare Accounting Billing & Reimbursement 3 — Questions and Answers
Question 1: A provider submits a claim and receives a denial with Claim Adjustment Reason Code (CARC) 29. What is the most likely issue?
- The service was not medically necessary
- The claim was not submitted within the required timely filing period (Correct answer)
- The patient's deductible has not been met
- The procedure code is invalid
Correct answer: The claim was not submitted within the required timely filing period
CARC 29 indicates the claim was denied because it was not submitted within the payer's required timely filing limit.
Question 2: Under the Medicare Outpatient Prospective Payment System (OPPS), payments are determined by which grouping system?
- Diagnosis-Related Groups (DRGs)
- Ambulatory Payment Classifications (APCs) (Correct answer)
- Resource-Based Relative Value Scale (RBRVS)
- Case Mix Index (CMI)
Correct answer: Ambulatory Payment Classifications (APCs)
OPPS uses Ambulatory Payment Classifications (APCs) to bundle and pay for outpatient hospital services.
Question 3: What does the term 'superbill' refer to in a physician's office billing workflow?
- An itemized invoice sent to the hospital for physician services
- A document that captures diagnosis and procedure codes for a patient encounter used to generate a claim (Correct answer)
- An EOB sent from the insurer to the patient
- A monthly summary of all charges submitted to Medicare
Correct answer: A document that captures diagnosis and procedure codes for a patient encounter used to generate a claim
A superbill is an encounter form or charge ticket that lists the diagnosis and procedure codes documented during a patient visit, which is then used to create the billing claim.
Question 4: Which of the following best describes 'coordination of benefits' (COB)?
- The process of allocating hospital costs to different departments
- A process that determines the order in which multiple health plans pay a claim to prevent overpayment (Correct answer)
- A contract between a provider and insurer establishing reimbursement rates
- The reconciliation of Medicare cost reports at year-end
Correct answer: A process that determines the order in which multiple health plans pay a claim to prevent overpayment
COB is the process used when a patient has more than one insurance policy to determine which plan pays first (primary) and which pays second (secondary) to avoid duplicate payments.
Question 5: In value-based reimbursement, what is a 'shared savings' arrangement?
- Splitting revenue equally between the hospital and physician group
- A model where providers and payers share in cost savings achieved when spending falls below a benchmark (Correct answer)
- A pay-for-performance bonus distributed to all staff members
- An agreement to split the cost of expensive medical equipment
Correct answer: A model where providers and payers share in cost savings achieved when spending falls below a benchmark
In shared savings models, if total healthcare costs come in below a pre-set benchmark, the provider organization receives a percentage of the savings as a bonus payment.
Question 6: A claim has been denied because the procedure requires a referral that was not obtained. Which type of denial is this?
- Clinical denial
- Technical/administrative denial (Correct answer)
- Duplicate claim denial
- Coordination of benefits denial
Correct answer: Technical/administrative denial
A missing referral or prior authorization is an administrative requirement failure, making this a technical or administrative denial.
Question 7: What is the 'birthday rule' used for in healthcare billing?
- Determining when a patient's deductible resets each year
- Determining which parent's insurance is primary for a dependent child when both parents have coverage (Correct answer)
- Calculating the age-based premium for a Medicare Advantage plan
- Establishing the timely filing deadline based on the patient's date of birth
Correct answer: Determining which parent's insurance is primary for a dependent child when both parents have coverage
The birthday rule states that when a child is covered under both parents' plans, the parent whose birthday falls earliest in the calendar year provides the primary insurance.
HAC Healthcare Accounting Billing & Reimbursement 3
A provider submits a claim and receives a denial with Claim Adjustment Reason Code (CARC) 29.
What is the most likely issue?