HAC Medicare & Medicaid Billing 3 — Questions and Answers
Question 1: What is the primary function of a Medicare Administrative Contractor (MAC)?
- To set Medicare premium rates nationally
- To process and pay Medicare Part A and Part B claims for a geographic jurisdiction (Correct answer)
- To enroll beneficiaries in Medicare Advantage plans
- To audit Medicaid managed care organizations
Correct answer: To process and pay Medicare Part A and Part B claims for a geographic jurisdiction
MACs are private contractors that process Medicare fee-for-service claims and perform related administrative functions within designated jurisdictions.
Question 2: Which modifier is appended to a CPT code to indicate that only the professional component of a service was performed?
- Modifier 26 (Correct answer)
- Modifier TC
- Modifier 59
- Modifier 25
Correct answer: Modifier 26
Modifier 26 indicates the professional component only, while modifier TC indicates the technical component only for split-billing of diagnostic services.
Question 3: A hospital bills Medicare for a patient who also has employer group health insurance (EGHI) through a current employer. Which payer is primary?
- Medicare is always primary for Medicare beneficiaries
- The EGHI plan is primary because it is employer-sponsored (Correct answer)
- The patient chooses which payer is primary
- Medicare Part A is primary; Medicare Part B is secondary
Correct answer: The EGHI plan is primary because it is employer-sponsored
Medicare Secondary Payer (MSP) rules require EGHI through a current employer to be primary when the employer has 20 or more employees.
Question 4: Under Medicaid, the Federal Medical Assistance Percentage (FMAP) represents:
- The percentage of claims Medicaid denies annually
- The federal government's share of each state's Medicaid expenditures (Correct answer)
- The maximum allowable fee for any Medicaid service
- The portion of premiums paid by Medicaid enrollees
Correct answer: The federal government's share of each state's Medicaid expenditures
FMAP is the ratio at which the federal government matches state Medicaid spending, varying by state based on per capita income.
Question 5: A claim is submitted with an ICD-10-CM code as the principal diagnosis, but CMS considers it a 'symptom' that should be replaced by its underlying cause. This is an example of a violation of which guideline?
- MS-DRG optimization rules
- UHDDS principal diagnosis selection guidelines (Correct answer)
- Outpatient first-listed diagnosis rules
- Place of service coding requirements
Correct answer: UHDDS principal diagnosis selection guidelines
UHDDS guidelines for inpatient claims require the principal diagnosis to be the condition established after study that caused the admission, not a sign or symptom.
Question 6: Which Medicare program was established to pay hospitals for treating a disproportionate share of low-income patients?
- Medicare Advantage (MA)
- Disproportionate Share Hospital (DSH) Adjustment (Correct answer)
- Critical Access Hospital (CAH) Program
- Merit-based Incentive Payment System (MIPS)
Correct answer: Disproportionate Share Hospital (DSH) Adjustment
The DSH adjustment provides additional Medicare payments to hospitals that serve a high percentage of Medicaid and low-income Medicare patients.
Question 7: When a Medicaid beneficiary receives services from a non-participating (out-of-network) provider in a non-emergency situation, the typical outcome is:
- Medicaid pays the full claim at the in-network rate
- The claim is denied and the provider cannot bill the patient (Correct answer)
- The provider bills the patient directly for all charges
- Medicaid pays at a reduced out-of-network rate
Correct answer: The claim is denied and the provider cannot bill the patient
In most Medicaid managed care plans, out-of-network non-emergency services are denied, and federal rules generally prohibit providers from balance-billing Medicaid patients.
HAC Medicare & Medicaid Billing 3
What is the primary function of a Medicare Administrative Contractor (MAC)?