AAPC CPB Final

AAPC CPB Final Health plan, clearinghouses, and any entity transmitting health information is considered by the Privacy Rule to be a: ANS: covered entity Which of the following is not a covered entity in the Privacy Rule ANS: healthcare consulting firm A request for medical records is received for a specific date of service from patient's insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken? ANS: release reqt to ins co How many national priority purposes under the Privacy Rules for disclosure of specific PHI without an individual's authorization or permission? ANS: 12 A health plan sends a request for medical records in order to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information? ANS: no A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor? ANS: Truth in Lending Act Which of the following situations allows release of PHI without authorization from the patient? ANS: workers comp misusing any information on the claim, charging excessively for services or supplies, billing for services not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, or billing Medicare patients at a higher fee scale that non-Medicare patients. ANS: abuse A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS? ANS: abuse According to the Privacy Rule, what health information may not be de-identified? ANS: phys provider number making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program ANS: fraud All the following are considered Fraud, EXCEPT: ANS: inadequate med recd A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on to the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? ANS: breach impermissible release or disclosure of information is discovered ANS: breach What standard transactions is NOT included in EDI and adopted under HIPAA? ANS: waiver of liability The Federal False Claim Act allows for claims to be reviewed for a standard of how many years after an incident? ANS: 7 A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every Medicare patient you send to them for radiology services. What does this offer violate? ANS: anti kickback laws A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? ANS: biz associate Medicare overpayments should be returned within ___ days after the overpayment has been identified ANS: 60 HIPAA mandated what entity to adopt national standards for electronic transactions and code sets? ANS: HHS Entities that have been identified as having improper billing practices is defined by CMS as a violation of what standard? ANS: abuse In addition to the standardization of the codes (ICD-10, CPT, HCPCS, and NDC) used to request payment for medical services, what must be used on all transactions for employers and providers? ANS: unique id A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statute? ANS: False Claims Act Medicare was passed into law under the title XVIII of what Act? ANS: SS Act While working in a large practice, Medicare overpayments are found in several patient accounts. The manager states that the practice will keep the money until Medicare asks for it back. What does this action constitute? ANS: fraud A practice agrees to pay $250,000 to settle a lawsuit alleging that the practice used X-rays of one patient to justify services on multiple other patients' claims. The manager of the office brought the civil suit. What type of case is this? ANS: qui tam OIG, CMS, and Department of Justice are the government agencies enforcing ________. ANS: fed abuse and fraud laws A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate? ANS: TILA An insurance plan that provides a gatekeeper to manage the patient's health care is known as a/an ANS: HMO a corporate umbrella for management of diversified healthcare delivery systems ANS: IPO An employee has signed up for a program through her employer. It allows her to put pre-tax money away from her paycheck in order to pay for out-of-pocket healthcare expenses. She may contribute up to $2650 (2018) per year. If she does not use all of the money during the current year, she forfeits it. What is this? ANS: FSA Which option is not considered an MCO? ANS: HSA A Medicare patient presents after slipping and falling in a neighbor's walkway. The cement had a large crack, which caused the pavement to raise and be unsteady. The neighbor has contacted his homeowner's insurance and they are accepting liability and have initiated a claim. How should the visit be billed? ANS: Homeowners, then Medicare Insurance coverage provided by an organization that is not an employer (such as a membership organization or credit card company that offer benefits to its members) is what kind of group insurance? ANS: association group office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician? ANS: non par A patient presenting for care does not have an insurance card and is billed CPT 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed? ANS: file a claim to Medicaid w EOB Medicare part without a monthly charge if worked for 10+ years ANS: A Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient and are reimbursed by ANS: capitation Which of the following is NOT evaluated in the credentialing process? ANS: phys req for priviledges HSA is ____________________ to employees ANS: tax free income What type of plan allows an insurer to administer straight indemnity insurance, an HMO, or a PPO insurance plans to its members? ANS: triple option A healthcare organization with 2 hospitals, 20 clinics, and 3 urgent care centers belongs to an ACO program. They have been in the shared savings program for two years and are now eligible to move large payments to a population-based model as they have been successful in keeping costs down and have met all the CMS benchmarks set for them. What type of ACO is this? ANS: Pioneer What is the largest health program in the United States? ANS: Medicare a unique 10-digit identification number required by HIPAA ANS: NPI Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct? ANS: All plans offer HMOs A new physician comes in to the prac