Medical Billing Software Medical Billing General 5 — Questions and Answers
Question 1: A patient's insurance plan has a $2,000 out-of-pocket maximum. Once met, what happens to the patient's cost-sharing?
- The patient pays a flat $20 copay for all remaining visits
- The insurance covers 100% of covered services for the rest of the benefit period (Correct answer)
- The deductible resets immediately
- The patient is automatically enrolled in a supplemental plan
Correct answer: The insurance covers 100% of covered services for the rest of the benefit period
After the out-of-pocket maximum is reached, the insurance plan pays 100% of covered in-network services for the remainder of the plan year.
Question 2: Which type of medical billing software feature automates the process of verifying patient eligibility before an appointment?
- Charge capture module
- Real-time eligibility verification (Correct answer)
- Claim scrubbing engine
- Denial management dashboard
Correct answer: Real-time eligibility verification
Real-time eligibility verification queries payer databases electronically to confirm a patient's active coverage, benefits, and cost-sharing before the visit.
Question 3: What is a 'dirty claim' in medical billing terminology?
- A claim submitted without the patient's signature
- A claim that contains errors or missing information requiring correction before payment (Correct answer)
- A claim for services rendered outside the network
- A claim for a procedure not covered by the patient's plan
Correct answer: A claim that contains errors or missing information requiring correction before payment
A dirty claim contains incomplete, invalid, or inconsistent data that causes the payer to suspend, reject, or deny it without payment.
Question 4: Which revenue cycle metric measures the average number of days it takes to collect payment after a service is rendered?
- Denial rate
- Days in accounts receivable (DAR) (Correct answer)
- Net collection rate
- First-pass resolution rate
Correct answer: Days in accounts receivable (DAR)
Days in accounts receivable (DAR) quantifies the average time from service delivery to payment receipt, with lower values indicating a more efficient revenue cycle.
Question 5: When a provider does not participate in a patient's insurance network, how is billing typically handled?
- The claim is submitted as if the provider is in-network
- The provider bills the patient directly or submits as out-of-network with higher patient cost-sharing (Correct answer)
- The claim must be forwarded to Medicaid as secondary
- No claim is submitted and the provider absorbs the cost
Correct answer: The provider bills the patient directly or submits as out-of-network with higher patient cost-sharing
Out-of-network providers bill at their standard rate, and patients typically owe higher cost-sharing; the provider may bill the patient for balances not covered by the plan.
Question 6: What is the purpose of a 'claim scrubber' in medical billing software?
- To remove duplicate patient records from the database
- To automatically review claims for errors before submission to the payer (Correct answer)
- To purge claims older than seven years from the system
- To reformat paper claims into electronic format
Correct answer: To automatically review claims for errors before submission to the payer
A claim scrubber is an automated tool that checks submitted claims against coding rules, payer edits, and CCI edits to catch errors before the claim reaches the payer.
Question 7: Under HIPAA's minimum necessary standard, how should a billing department handle protected health information (PHI)?
- Share all patient records with any staff member who requests them
- Access and disclose only the minimum PHI needed to accomplish the intended billing purpose (Correct answer)
- Encrypt all records and never share them with payers
- Require patient consent before submitting any claim
Correct answer: Access and disclose only the minimum PHI needed to accomplish the intended billing purpose
The minimum necessary standard requires covered entities to limit PHI use and disclosure to the least amount needed to complete the specific task at hand.
Medical Billing Software Medical Billing General 5
A patient's insurance plan has a $2,000 out-of-pocket maximum.
Once met, what happens to the patient's cost-sharing?