CPB Certification Exam Prep (based off Practice Exam #2) Questions & Answers

What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures? A. Utilization Review Organization B. Managed Care Organization C. Quality Assurance Organization D. External Quality, Review, Organization - ANSWERSA. Utilization Review Organization Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. The employee's spouse and children are not eligible for coverage. A. I, IV, V, and VI B. II, III, and VI C. II, IV, and V D. III, IV, and V - ANSWERSA. I, IV, V, and VI When a minor procedure is performed on a Medicare patient, what is the global period and what time frame is covered? A. 90-day global period - the day before the procedure and 90 days following the procedures. B. 10-day global period - the day of the procedure and 10 days following the procedure. C. 10-day global period - the day before the procedure and 10 days following the procedure. D. 90-day global period - the day of the procedure and 90 days following the procedure. - ANSWERSB. 10-day global period - the day of the procedure and 10 days following the procedure. Which of the following falls under the Prompt Payment Act? A. Clean claims must be paid or denied within 30 days from the date of receipt by MACs. B. Penalty fees will only be issued on clean claims if payments are 60 days overdue starting the day after the receipt date. C. Medicare and MACs have 60 days to pay or deny electronic clean claims. D. Physician needs to refund overpayments within 30 days to the Medicare Administrative Contractor (MAC) from the date of receipt. - ANSWERSA. Clean claims must be paid or denied within 30 days from the date of receipt by MACs. What is the Prompt Payment Act? - ANSWERSRequires federal agencies, such as MACs to pay or deny clean claims (also electronic claims) within 30 days from receipt. What is another term for balance billing? A. Surprise medical bill B. Medicare bill C. Unauthorized bill D. Clean bill - ANSWERSA. Surprise medical bill What is balance billing? - ANSWERSBilling patients for Medicaid covered services. Medical providers are forbidden by law to: A. Refer patients to specialists B. Balance bill patients C. Bill patients for non-covered services D. Accept co-payments - ANSWERSB. Balance bill patients What is a capitation contract? - ANSWERSMoney received before services even provided so don't have to wait for reimbursement. Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan. He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the health plan. C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees. D. Dr. Wallace is required to put the $2,000 in a mutual fund. - ANSWERSA. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. What is the deadline for filing a Medicare claim? A. 30 days from the date of service B. 90 days from the date of service C. One year from the date of service D. Two years from the date of service - ANSWERSC. One year from the date of service When a provider chooses not to participate int he Medicare program and does not accept assignment on claims, the maximum amount the provider can charge is ______ percent of the approved fee schedule amount for non-participating providers. A. 50 B. 100 C. 115 D. 25 - ANSWERSC. 115 Who develops LCDs (Local Coverage Determination)? A. CMS B. NCD C. MAC D. CPT - ANSWERSC. MAC What is another term for Qui Tam? A. Whistleblower B. Snitch C. Liar D. Accomplice - ANSWERSA. Whistleblower What is a nonphysician practitioner? - ANSWERSSomeone who assists or acts in place of physician. Which is NOT a nonphysician practitioner? A. Physician Assistant B. Clinical social workers C. Resident D. Certified nurse midwife - ANSWERSC. Resident Which of the following is NOT in the HIPAA Privacy Rule? A. Doctor's office leaving a message on the patient's answering machine to confirm an appointment time. B. Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI). C Physician must obtain a patient's written consent and authorization before using or disclosing PHI to carry out treatment. D. Patient is given greater access to his own medical record(s) and control over how his PHI is used. - ANSWERSB. Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI). Relative Value Units (RVUs) are payment components consisting of: A. Practice Expense; Diagnostic services; Payment Rate B. Actual time of the physician work; Place of service; Geographic adjustment C. Physician work; Practice Expense; Professional liability/malpractice insurance D. Patient classification system; Geographic adjustment; Practice Expense - ANSWERSC. Physician work; Practice Expense; Professional liability/malpractice insurance