CBCS - Certified Billing and Coding Specialist Payer Types and Policies Questions and Answers

Question 1

A 68-year-old patient covered by traditional Medicare receives medically necessary inpatient care at a skilled nursing facility (SNF) following a qualifying three-day hospital stay. Which part of Medicare is responsible for covering the SNF charges?

Accepted Answer

Medicare Part A

Answer

Medicare Part A, also known as Hospital Insurance, covers costs associated with inpatient hospital care, skilled nursing facility care, hospice, and home health care.

Question 2

A 72-year-old patient has both Medicare and a state Medicaid plan. The patient receives services from a physician who accepts both types of insurance. How should the claim be processed?

Accepted Answer

The claim should be submitted to Medicare first, and Medicaid will be the secondary payer.

Answer

Federal law establishes Medicaid as the "payer of last resort." This means that all other available third-party payers, including Medicare, must be billed and pay their portion before a claim can be submitted to Medicaid.

Question 3

Which of the following is a defining characteristic of most Health Maintenance Organization (HMO) plans?

Accepted Answer

It requires patients to select a Primary Care Physician (PCP) to manage their care.

Answer

A core feature of most HMO plans is the requirement for members to choose a Primary Care Physician (PCP). This PCP acts as a "gatekeeper," managing the patient's overall care and providing referrals for specialist services.

Question 4

A patient with a Preferred Provider Organization (PPO) plan chooses to see a specialist who is not in the PPO network. Which of the following outcomes is most likely?

Accepted Answer

The patient will likely have a higher coinsurance or copayment and a separate, higher deductible for out-of-network services.

Answer

PPO plans offer members the flexibility to see out-of-network providers. However, this flexibility typically comes at a higher cost to the patient in the form of increased cost-sharing responsibilities (copayments, coinsurance, and deductibles) compared to using in-network providers.

Question 5

A patient is treated for an acute injury that occurred at their workplace. The patient provides their commercial health insurance card at check-in. What is the correct procedure for the billing specialist?

Accepted Answer

Open a workers' compensation claim and bill that carrier directly.

Answer

When an injury or illness is work-related, the claim must be submitted to the workers' compensation insurance carrier, not the patient's personal health insurance. A separate case file should be created, and billing must be directed to the entity responsible for the workers' compensation coverage.

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS - Certified Billing and Coding Specialist Payer Types and Policies Questions and Answers