Case Analysis & Practical Application Flashcards

A patient calls saying they cannot afford their $800 bill and asks for a payment plan. Your office has a financial hardship policy. What is the appropriate next step?

Answer: Review the hardship policy with the patient, offer an affordable payment plan, and document the agreement in writing

Offering a documented payment plan per office policy is both compliant and supportive of patient financial access.

You receive a fax intended for another physician's office containing a different patient's PHI. What is the correct response under HIPAA?

Answer: Notify the sending party of the misdirected fax, do not read or use the information, and securely destroy the fax

Misdirected PHI must be reported to the sender and securely destroyed — retaining or using it violates HIPAA.

A provider wants to add a modifier -25 to a preventive visit claim that also includes a significant, separately identifiable E/M service. Which statement is correct?

Answer: Modifier -25 is appropriate when a significant, separately identifiable E/M service is provided on the same day as a preventive visit

Modifier -25 should be appended to the additional E/M service code to indicate it is separate from the preventive visit.

During an annual compliance audit, it is discovered that a staff member has been accessing records of patients not under their care. Which regulation is primarily implicated?

Answer: HIPAA Privacy and Security Rules

Unauthorized access to patient records by staff violates HIPAA's Privacy Rule minimum necessary standard and Security Rule access controls.

A claim for a hospital inpatient stay is submitted under an incorrect DRG code, resulting in an overpayment. The error is discovered 60 days later. What must the practice do under the Affordable Care Act?

Answer: Report and return the overpayment within 60 days of identifying it to avoid False Claims Act liability

The ACA's 60-day rule requires providers to report and return identified overpayments or face False Claims Act exposure.

A patient presents an insurance card from an HMO but the treating physician is not in the HMO network. What should you do before the appointment?

Answer: Inform the patient that the physician is out-of-network, explain potential cost implications, and offer to help them find an in-network provider if preferred

Patients must be informed of network status before service to make an informed decision about their care and financial responsibility.

A medical office manager notices that the number of 99215 codes billed has increased 40% this quarter without a corresponding increase in patient volume. What is the most appropriate next step?

Answer: Conduct an internal coding and documentation audit to determine if the E/M level selections are supported by the medical records

An internal audit is the appropriate first step to identify whether coding patterns reflect legitimate documentation or potential upcoding.