Ch11- Government Carriers Flashcards
A Medicare patient is seen by her physician. The physician has opted out of the Medicare program. The patient and physician have a private contract. The charges for the services rendered are $300.00. Medicare’s approved amount would be $200.00. What can the office charge this patient?
a. $160.00 (80 percent of the approved amount)
b. $218.50 (115 percent of the approved amount for non-Par providers)
c. $300.00
d. $250.00
c. $300.00
Rationale: Providers that have opted-out of the Medicare cannot bill Medicare and may charge whatever they desire to patients as they are not subject to Medicare’s fee schedule or limiting charge. A condition of the contract between the provider and the patient is that the patient is liable for all provider charges without any Medicare balance billing limits.
A Medicare patient has prescription drug coverage but does not have Medicare Advantage. What Medicare coverage does the patient have for his medications?
a. Part A
b. Part B
c. Part C
d. Part D
d. Part D
Rationale: Medicare Part A is hospital insurance, Part B is medical insurance, Part C is Medicare Advantage, and Part D is the prescription drug plan.
A Medicare patient presents for her pelvic, Pap, and breast examination (PPB). The patient is not sure when she had her last PPB. As she is checking out, the front desk rep has her sign an ABN. The service is billed and denied for frequency. Can the patient be balance billed? Why or why not?
a. Yes. It does not matter when you get an ABN signed.
b. No. The ABN must be signed before the service is performed.
c. Yes, as long as the patient has met her deductible.
d. No. An ABN is not required, but the patient is required to pay at time of service or the bill has to be written off.
b. No. The ABN must be signed before the service is performed.
Rationale: The ABN must be reviewed with the patient and signed by the patient before the item or service is rendered to be valid. If it is not, the patient cannot be billed for the service if Medicare does not approve it.
A Medicare patient presents with an injury sustained at his part-time job. His injury status is verified by his company. After services are rendered, in what order are the claims submitted?
a. The workers’ compensation is primary, and Medicare is secondary.
b. Either may be filed first, whichever pays better.
c. Medicare is primary, and workers’ compensation is secondary.
d. The patient must pay for services and file claims himself.
a. The Workers’ Compensation is primary, and Medicare is secondary
Rationale: If an individual is entitled to Medicare and is covered under Workers’ Compensation because of a job-related illness or injury, Workers’ Compensation is the primary for healthcare items or services related to job-related illness or injury claims.
A Medicare patient receives services from a participating provider on January 6, 2023, but the charges are missed and were not entered into the computer. How long does the office have to bill Medicare for the services?
a. 3 months
b. 12 months
c. 6 months
d. 1 month
b. 12 months
Rationale: The Patient Protection and Affordable Care Act (ACA) amended the time period for filing Medicare fee-for service claims. Claims must be filed within one calendar year, 12 months, from the date of service.
A patient has Medicare and a Medigap policy. Box 13, signature on file, is checked off on the electronic claim submission. An EOMB is received with remittance notice MA19. What does the office need to do?
a. Nothing. This means the claim has been crossed over to the Medigap plan.
b. The biller must file the secondary insurance as the cross-over claim is not going to be sent due to missing information.
c. The biller must check the claim filed for missing information, add the missing information, and send back to Medicare for processing.
d. Nothing. The notice means that the patient is responsible for the bill.
b. The biller must file the secondary insurance as the cross-over claim is not going to be sent due to missing information.
When information is missing or incorrect in item 9, MACs do not forward a transaction record to the Medigap carrier and the following remittance notice is sent on the EOMB:
MA19—Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning the insurer. Please verify your information and submit your secondary claim directly to that insurer.
Which coverage under TRICARE is a Medicare wrap around plan?
a. TRICARE for Life
b. TRICARE Reserve Select
c. TRICARE Prime
d. CHAMPVA
a. TRICARE for Life
Rationale: TRICARE for Life is a Medicare-wrap around coverage for TRICARE eligible beneficiaries who have Medicare Part A and B. TRICARE for Life is not available to family members. Enrollment is automatic if the member has Medicare Part A and B, but you must pay Medicare Part B premiums. TRICARE for Life pays after Medicare in the U.S. and U.S. Territories but is the first payer in all other overseas areas.
A 21-year-old patient presents for fillings for two of his teeth. Are these services covered under EPSDT?
a. No, because these types of services are not covered.
b. Yes, if the patient lives in a state that covers dental services.
c. No, because the patient is not under the age of 21.
d. Yes, all services are covered under Medicaid.
c. No, because the patient is not under the age of 21.
Rationale: The EPSDT benefit provides comprehensive and preventive healthcare services for enrolled children under the age of 21.
A 45-year-old patient is diagnosed with N18.6. Based on this diagnosis, would this patient be eligible for Medicare coverage?
a. No, because he is not 65 years old.
b. Yes, because he has ESRD which is a condition that qualifies for Medicare benefits.
c. No, because Medicare only covers patients with chronic renal failure.
d. Yes, because he has acute renal failure which is a condition that qualifies for Medicare benefits
b. Yes, because he has ESRD which is a condition that qualifies for Medicare benefits.
Rationale: Medicare is a health insurance program for people age 65 and older, people under 65 with certain disabilities, and people of any age with end stage renal disease.
A physician performs a diagnostic laryngoscopy with biopsy and removal of a separate laryngeal lesion. The patient has Medicare which will pay 80% of the approved amount after deductible for these procedures. The patient has met his deductible. The approved amounts are as follows:
31505 - $75.00
31510 - $150.00
31512 - $200.00
What reimbursement should the physician receive from the health plan?
a. $220.00
b. $250.00
c. $340.00
d. $280.00
a. $220.00
Rationale: The RBRVS table shows that the multiple procedure indicator for 31510 and 31512 is 3, which means that the special endoscopic rules apply. The table also shows the base endoscopic code is 31505. No payment is made for the base code (31505) as it is bundled into the surgical codes. The highest paid code is 31512 at $200, so that is paid at 80% ($160). The second procedure is paid after the cost of the base procedure is subtracted. Code 31510 is $150, so $75 is subtracted and the remainder is $75; paid at 80% ($60). Total payment for all procedures would be $220.00.
$160 + ((150.00- 75.00)*80%) = $220.00
Which TRICARE option allows enrollees the most choices by utilizing the fee-for-service model?
a. TRICARE for Life
b. TRICARE Select
c. TRICARE Prime
d. Both a and b
b. TRICARE Select
Rationale: TRICARE Select is a fee-for-service option that allows the enrollees the most choices.
Beth has purchased a Medigap policy to supplement her Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the Medigap insurance company. What is this transfer of information is known as?
a. Data sharing
b. Cross-under
c. Shared billing
d. Cross-over
d. Cross-over
Rationale: The transfer of claims information from Medicare to Medigap is called cross-over.
Who sells Medicare Supplement Insurance policies or Medigap?
a. Private insurance companies
b. Healthcare providers
c. Medicare
d. Medicaid
a. Private insurance companies
Rationale: Medigap refers to a Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that original Medicare does not cover.
TRICARE is the healthcare program for which department of the US government?
a. Centers for Medicare and Medicaid Services
b. Department of Military Service
c. Department of Defense
d. Department of Finance
c. Department of Defense
Rationale: TRICARE, formerly known as CHAMPUS, is the Department of Defense healthcare program for military families and retirees.
Medigap policies must conform to minimum standards identified by federal and state laws. What must they clearly be identified as?
a. Medicare Selective Insurance
b. Medicare Supplement Insurance
c. Medicare Secondary Insurance
d. Medicare Subsequent Insurance
b. Medicare Supplement Insurance
Rationale: The Omnibus Budget Reconciliation Act of 1990 requires all Medigap insurance policies to conform to minimum standards including standardized benefits and consumer protection requirements. Every Medigap policy must follow federal and state laws and be clearly identified as Medicare Supplement Insurance.
