Medical Billing Software Professional Standards & Competencies 2 — Questions and Answers
Question 1: A medical biller discovers that a colleague has been upcoding services to increase reimbursements. What is the biller's professional obligation?
- Ignore it since it doesn't affect their own work
- Report it through appropriate compliance channels (Correct answer)
- Confront the colleague directly and demand they stop
- Adjust their own billing to match the colleague's practices
Correct answer: Report it through appropriate compliance channels
Billers have a professional and legal obligation to report suspected fraud through compliance channels such as a compliance officer or hotline.
Question 2: Which organization offers the Certified Professional Biller (CPB) credential specifically for medical billing professionals?
- American Health Information Management Association (AHIMA)
- American Academy of Professional Coders (AAPC) (Correct answer)
- Healthcare Financial Management Association (HFMA)
- National Association of Healthcare Access Management (NAHAM)
Correct answer: American Academy of Professional Coders (AAPC)
The AAPC awards the CPB credential to billing professionals who pass their examination and meet experience requirements.
Question 3: When a payer requests additional documentation to support a claim, what is this process called?
- Remittance advice
- Prior authorization
- Medical necessity review
- Additional documentation request (ADR) (Correct answer)
Correct answer: Additional documentation request (ADR)
An ADR is a formal payer request for supporting records to validate that billed services were medically necessary and properly documented.
Question 4: A biller receives a patient complaint about a confusing Explanation of Benefits (EOB). What competency is most important for resolving this situation?
- Advanced coding skills
- Patient communication and education (Correct answer)
- Knowledge of payer contract negotiations
- Accounts receivable management
Correct answer: Patient communication and education
Effective patient communication allows billers to explain insurance terminology, patient responsibility amounts, and EOB line items clearly.
Question 5: Which federal law establishes criminal penalties for knowingly submitting false claims to federal healthcare programs?
- HIPAA
- The False Claims Act (Correct answer)
- The Stark Law
- ERISA
Correct answer: The False Claims Act
The False Claims Act imposes civil and criminal liability on individuals or entities that knowingly submit fraudulent claims to government programs like Medicare and Medicaid.
Question 6: A medical billing specialist is reviewing a superbill and notices a diagnosis code that does not support medical necessity for the ordered procedure. What should they do first?
- Submit the claim with the procedure code and omit the diagnosis
- Query the provider for clarification before submitting (Correct answer)
- Select a different diagnosis code that does support the procedure
- Submit the claim as-is to avoid delaying reimbursement
Correct answer: Query the provider for clarification before submitting
Querying the provider is the correct first step to ensure documentation is accurate before claim submission, preserving compliance and integrity.
Question 7: Continuing education units (CEUs) are required for most billing certifications primarily to ensure that professionals:
- Can bill for more complex procedures
- Stay current with changing regulations, codes, and payer policies (Correct answer)
- Qualify for higher salary ranges
- Meet state licensure requirements
Correct answer: Stay current with changing regulations, codes, and payer policies
CEUs ensure credentialed billers remain knowledgeable about annual code updates, regulatory changes, and evolving payer requirements.
Medical Billing Software Professional Standards & Competencies 2
A medical biller discovers that a colleague has been upcoding services to increase reimbursements.
What is the biller's professional obligation?