NHI Medical Office Procedures & Billing 4 — Questions and Answers
Question 1: A provider who has signed a contract with an insurance company agreeing to accept the payer's fee schedule is called a:
- Non-participating provider
- Participating provider (Correct answer)
- Capitated provider
- Concierge provider
Correct answer: Participating provider
A participating provider has contracted with a payer and agrees to accept the payer's allowed amount as payment in full, minus patient cost-sharing.
Question 2: When a claim is submitted with an incorrect patient date of birth, the claim will most likely be:
- Paid at a reduced rate
- Denied for eligibility mismatch (Correct answer)
- Forwarded to a secondary payer
- Automatically corrected by the clearinghouse
Correct answer: Denied for eligibility mismatch
An incorrect date of birth can cause the patient's eligibility to not match payer records, resulting in an eligibility-related denial.
Question 3: The 'filing deadline' in medical billing refers to:
- The date a patient must pay their balance
- The time limit within which a claim must be submitted to a payer (Correct answer)
- The deadline for updating fee schedules
- The last date a provider can see a patient
Correct answer: The time limit within which a claim must be submitted to a payer
Each payer sets a timely filing deadline by which claims must be submitted; claims filed after this deadline are typically denied.
Question 4: Which of the following is an example of fraud in medical billing?
- Billing for a service that was not documented due to an oversight
- Intentionally billing for services never rendered to increase reimbursement (Correct answer)
- Accidentally selecting the wrong CPT code
- Submitting a claim to the wrong payer first
Correct answer: Intentionally billing for services never rendered to increase reimbursement
Fraud involves deliberate, intentional acts such as billing for services not performed in order to obtain payment unlawfully.
Question 5: A 'modifier' in CPT coding is used to:
- Replace a diagnosis code when unknown
- Provide additional information about a procedure without changing its definition (Correct answer)
- Bill for unlisted procedures
- Indicate that a service was denied by insurance
Correct answer: Provide additional information about a procedure without changing its definition
A CPT modifier is a two-digit code appended to a CPT code to indicate special circumstances without altering the procedure's core meaning.
Question 6: Prior authorization is most commonly required for:
- Annual wellness visits
- Emergency room services
- Elective surgeries and certain high-cost procedures (Correct answer)
- Routine blood pressure checks
Correct answer: Elective surgeries and certain high-cost procedures
Prior authorization is typically required by insurance plans for non-emergency, elective, or high-cost procedures to confirm medical necessity before services are rendered.
Question 7: Which of the following describes 'accounts receivable' (A/R) in a medical office?
- Money owed by the practice to suppliers
- Money owed to the practice for services already rendered (Correct answer)
- Total revenue collected during the current month
- Patient deposits held before service
Correct answer: Money owed to the practice for services already rendered
Accounts receivable represents the total outstanding balances owed to a medical practice by patients and insurance payers for services already provided.
NHI Medical Office Procedures & Billing 4
A provider who has signed a contract with an insurance company agreeing to accept the payer's fee schedule is called a: