Medical Office Procedures & Billing Flashcards

A provider who has signed a contract with an insurance company agreeing to accept the payer's fee schedule is called a:

Answer: Participating provider

A participating provider has contracted with a payer and agrees to accept the payer's allowed amount as payment in full, minus patient cost-sharing.

When a claim is submitted with an incorrect patient date of birth, the claim will most likely be:

Answer: Denied for eligibility mismatch

An incorrect date of birth can cause the patient's eligibility to not match payer records, resulting in an eligibility-related denial.

The 'filing deadline' in medical billing refers to:

Answer: The time limit within which a claim must be submitted to a payer

Each payer sets a timely filing deadline by which claims must be submitted; claims filed after this deadline are typically denied.

Which of the following is an example of fraud in medical billing?

Answer: Intentionally billing for services never rendered to increase reimbursement

Fraud involves deliberate, intentional acts such as billing for services not performed in order to obtain payment unlawfully.

A 'modifier' in CPT coding is used to:

Answer: Provide additional information about a procedure without changing its definition

A CPT modifier is a two-digit code appended to a CPT code to indicate special circumstances without altering the procedure's core meaning.

Prior authorization is most commonly required for:

Answer: Elective surgeries and certain high-cost procedures

Prior authorization is typically required by insurance plans for non-emergency, elective, or high-cost procedures to confirm medical necessity before services are rendered.

Which of the following describes 'accounts receivable' (A/R) in a medical office?

Answer: Money owed to the practice for services already rendered

Accounts receivable represents the total outstanding balances owed to a medical practice by patients and insurance payers for services already provided.