Ch11- Government Carriers

Question 1

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

Answer 1

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.

Question 2

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

Answer 2

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.

Question 3

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.

Answer 3

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.

Question 4

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.

Answer 4

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.

Question 5

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

Answer 5

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.

Question 6

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.

Answer 6

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.

Question 7

Which coverage under TRICARE is a Medicare wrap around plan?
a. TRICARE for Life
b. TRICARE Reserve Select
c. TRICARE Prime
d. CHAMPVA

Answer 7

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.

Question 8

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.

Answer 8

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.

Question 9

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

Answer 9

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.

Question 10

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

Answer 10

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

Question 11

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

Answer 11

b. TRICARE Select

Rationale: TRICARE Select is a fee-for-service option that allows the enrollees the most choices.

Question 12

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

Answer 12

d. Cross-over

Rationale: The transfer of claims information from Medicare to Medigap is called cross-over.

Question 13

Who sells Medicare Supplement Insurance policies or Medigap?
a. Private insurance companies
b. Healthcare providers
c. Medicare
d. Medicaid

Answer 13

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.

Question 14

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

Answer 14

c. Department of Defense

Rationale: TRICARE, formerly known as CHAMPUS, is the Department of Defense healthcare program for military families and retirees.

Question 15

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

Answer 15

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.

Question 16

What is the term used for a supplemental policy for Medicare?
a. Medicare Secondary
b. Medicare Plus
c. Medigap
d. Medifill

Answer 16

c. Medigap

Rationale: Medigap is a Medicare supplemental policy to help cover costs that are not covered by Medicare.

Question 17

What does the Clinical Prior Authorization (PA) Program assist in monitoring?
a. Medicaid eligibility requirements
b. Drug interactions
c. Drug classes that require additional monitoring
d. Procedures that need prior authorization

Answer 17

c. Drug classes that require additional monitoring

Rationale: Clinical Prior Authorization (PA) Program was implemented to manage drug classes that require additional monitoring, ensuring drugs are being prescribed for the right patients and the appropriate reasons, as well as monitoring drug expenditures.

Question 18

Andrew has selected TRICARE Prime as his health plan. Who will be responsible for coordinating his health care, maintaining his medical records, and referrals to specialists when needed?
a. PCN – Primary Care Networker
b. PCP – Primary Care Provider
c. PCM – Primary Care Manager
d. PCC – Primary Care Coordinator

Answer 18

c. PCM – Primary Care Manager

Rationale: TRICARE Prime is a managed care model in which the insured will be assigned a primary care manager who will be responsible for coordination of care, medical record maintenance, and referrals.

Question 19

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a program associated with which insurance carrier(s)?
a. All insurance carriers
b. Commercial insurance carriers
c. Medicaid
d. Medicare

Answer 19

c. Medicaid

Rationale: EPSDT is a benefit of Medicaid that provides comprehensive and preventive healthcare services for enrolled children under the age of 21.

Question 20

What is timely filing for TRICARE and CHAMPVA?
a. 120-days from the date of service
b. 180-days from the date of service
c. 90-days from the date of service
d. 1-year from the date of service

Answer 20

d. 1-year from the date of service

Rationale: TRICARE and CHAMPVA both have a one-year timely filing limit. There are exceptions allowed for retroactive benefit issues when the time frame for filing goes back to your eligibility date. In those cases, once notified, 180 days are allowed to submit a claim.

Question 21

To determine the Medicare coverage and payment policy for a service or procedure, which of the following resources will indicate if a service or procedure is payable, noncovered, or bundled into another service?
a. PC/TC indicator
b. Global surgery indicators
c. Status codes
d. Quality indicators

Answer 21

c. Status codes

Rationale: Status codes should be reviewed to determine the status of a code, i.e. A= Active code, B=Bundled code, D=Deleted, etc.

Question 22

Barbara’s late husband, Joe, was a lieutenant in the Navy. He served for 30 years, retiring 10 years prior to his death. His Death was due to a service connected disability. Barbara will still have healthcare coverage as Joe’s widow under which of the following healthcare programs?
a. CHAMPVA
b. Medicare
c. TRICARE
d. CHAMPUS

Answer 22

a. CHAMPVA

Rationale: The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is the healthcare program in which the Department of Veterans Affairs covers spouses, widows and widowers, and the children of a veteran who is rated permanently and totally disabled due to a service connected disability, died of a service-connected disability, or died on active service and the dependents are not eligible for TRICARE.

Question 23

What is MAC an acronym for?
a. Medical Access Center
b. Medicare Advantage Contractor
c. Medicare Administrative Contact
d. Medicare Administrative Contractor

Answer 23

d. Medicare Administrative Contractor

Rationale: Medicare Administrative Contractor (MAC) administers and processes claims for Medicare Part A and Part B services organized in multi-state regions.

Question 24

How often are Medicaid agencies required to report EPSDT performance information?
a. Quarterly
b. Weekly
c. Annually
d. Monthly

Answer 24

c. Annually

Rationale: State Medicaid agencies must inform all Medicaid-eligible individuals under the age of 21 that EPSDT services are available, provide or arrange for the provision of screening services for all children, arrange for corrective treatment as determined by the health screenings, and report the performance information on an annual basis.

Question 25

What criteria is Medicaid’s minimum eligibility based on?
a. Under the age of 50
b. U.S. citizenship
c. Federal poverty level
d. State poverty level

Answer 25

c. Federal poverty level

Rationale: Medicaid eligibility must meet a variety of conditions and allow for variances from state to state, however, the minimum eligibility factor that all Medicaid programs have in common is the federal poverty level (FPL) which is a pre-determined annual income amount for a family of four.

Question 26

Which of the following services does Medicare NOT consider preventive?
a. Depression screening
b. Bone mass measurements
c. Glaucoma screening
d. Dentures

Answer 26

d. Dentures

Rationale: Screenings for a variety of medical conditions, as well as annual wellness visits, vaccinations for influenza, pneumonia, and Hepatitis B are deemed preventive. A comprehensive listing of preventive services can be accessed on the CMS website. Dentures and most dental care are not covered.

Question 27

What part of Medicare would a patient receiving inpatient care in a critical access hospital be covered under?
a. Part D
b. Part C
c. Part A
d. Part B

Answer 27

c. Part A

Rationale: Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities for Medicare patients.

Question 28

Medicare’s payment amount for services are determined by which of the following formulas?
a. Total RVU X Conversion factor(CF) = Medicare payment
b. Sustainable growth rate (SGR) X Geographic Practice Cost Index (GPCI) = Medicare payment
c. Total Practice Expense (PE) X Conversion factor(CF) = Medicare payment
d. Total Malpractice insurance (MP) X Conversion factor (CF) = Medicare payment

Answer 28

a. Total RVU X Conversion factor(CF) = Medicare payment

Rationale: Medicare payments are determined based on the Total RVU X Conversion Factor. The complete formula includes [(Work RVU X Work GPCI) + (RVUPE X PE GPCI) + (MP RVU X MP GPCI)] = Total RVU X Conversion Factor = Medicare payment

Question 29

How often is the conversion factor updated by CMS?
a. Annually
b. Semi-annually
c. Quarterly
d. Monthly

Answer 29

a. Annually

Rationale: The conversion factor is updated annually.

Question 30

Dr. Allen who is a non-PAR provider performs an appendectomy on a 67-year-old Medicare patient. The physician’s UCR for the surgery is $1500. Medicare’s approved fee for this procedure is $1100. What is the limiting charge that this non-PAR provider can charge to this Medicare patient?
a. $1265
b. $1500
c. $1201.75
d. $1100

Answer 30

c. $1201.75

Rationale: A non-PAR provider’s fee schedule is 95% of Medicare approved amounts for PAR providers, which sets the fee at $1045 ($1100 X .95). The provider’s limiting charge would be 115% of the Medicare approved amount for non-PAR ($1045 X 115% = $1201.75)

Question 31

Albert has purchased a Medigap policy to supplement his Medicare benefits. To which entity will Albert pay his monthly premium?
a. MAC
b. Medicaid
c. Medicare
d. Medigap insurance company

Answer 31

d. Medigap insurance company

Rationale: Premiums for Medigap policies are paid directly to the Medigap insurance company, not to CMS, MAC’s, or Medicaid.