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Quizzes > Quizzes for Business > Healthcare

Take the Patient Billing and Insurance Workflow Quiz

Assess Your Knowledge of Billing and Claims Processes

Difficulty: Moderate
Questions: 20
Learning OutcomesStudy Material
Colorful paper art representing a quiz on Patient Billing and Insurance Workflow

Ready to sharpen your expertise in patient billing and insurance workflows? This engaging quiz offers 15 varied questions to help healthcare professionals and students deepen their understanding of insurance claims and billing cycles. Whether you're prepping for certification or brushing up on coding, you can also explore related Patient Access Insurance Quiz and dive into the Healthcare Billing Knowledge Quiz . Easily customize any question or answer in our intuitive quizzes editor to suit your learning needs. Joanna Weib invites you to test your skills and elevate your billing confidence today!

What is typically the first step in the patient billing workflow?
Posting payments
Claim adjudication
Charge entry
Patient registration and data capture
Patient registration and data capture must occur before any billing can take place because accurate demographic and insurance information is required. This step establishes the foundation for all subsequent billing activities.
Why is verifying patient insurance eligibility important?
To enroll patient in additional services
To audit provider performance
To file claims retroactively
To determine the coverage and benefits available
Verifying eligibility confirms what services the insurer will cover and the patient's financial responsibility. This step helps avoid claim denials and unexpected charges for the patient.
Which code set is used for reporting diagnoses on claims?
HCPCS
ICD-10-CM
NPI
CPT
ICD-10-CM is the standardized code set for reporting diagnoses on insurance claims. CPT and HCPCS are used for procedures and supplies, while NPI is an identifier.
What does timely filing refer to in the context of insurance claims?
Requesting pre-authorization promptly
Submitting claims within the insurer's deadline
Verifying eligibility annually
Posting payments as soon as they arrive
Timely filing means submitting a claim before the deadline set by the payer policy. Missing this deadline typically results in an automatic denial.
What document summarizes the details of payment from an insurance carrier?
Remittance Advice
Patient statement
Claim form
Encounter form
A Remittance Advice (RA) provides detailed payment information and any adjustments made by the insurer. It is used by the provider to post payments and reconcile accounts.
Which item number on the CMS-1500 form is designated for reporting the service dates?
Item 10
Item 32
Item 24A
Item 14
Item 24A on the CMS-1500 form is specifically used to report the start and end dates of service. Accurate dates are essential for proper claim adjudication.
When should pre-authorization be obtained for a procedure?
Before the date of service
Within 60 days of service
During payment reconciliation
After claim submission
Pre-authorization must be secured before the service is performed to confirm coverage and avoid denials. If obtained after care, the payer may refuse to honor benefits.
Which definition best describes coordination of benefits?
Process secondary insurer before primary
Ensuring primary insurer pays first before secondary processes additional benefit
Consolidating payments into one remittance
Billing multiple services on one claim
Coordination of benefits ensures the primary insurer pays its portion first, and then the secondary insurer considers any remaining covered costs. This prevents overpayment and duplication.
Which of the following is a common cause for claim denials?
Accurate procedure coding
Verified patient eligibility
Electronic submission using ANSI 837 format
Missing pre-authorization on required procedures
Claims for services requiring prior authorization will often be denied if that authorization is missing. Ensuring authorizations are in place reduces denial risk.
Which document is sent to patients explaining the claim adjudication and patient financial responsibility?
Patient encounter form
Explanation of Benefits
Remittance Advice
CMS-1500 claim form
The Explanation of Benefits (EOB) is sent to the patient to detail what the insurer paid, any adjustments, and the remaining patient responsibility. Providers use the Remittance Advice for their records.
What is the first step in payment reconciliation?
Submit corrected claims to the insurer
Verify patient's eligibility for the next visit
Match payments in the accounting system to remittance advice details
Capture patient demographic information
The initial reconciliation step is to match each payment posted in the accounting system with the corresponding details on the remittance advice. This ensures accuracy and identifies discrepancies.
In which scenario is appending modifier -25 required?
Using modifier -76 for initial encounter
Applying modifier -26 for technical component
Using modifier -59 to indicate bilateral procedures
Appending modifier -25 for a separate evaluation and management service on the same day as a procedure
Modifier -25 is used when an E/M service is performed on the same day as a procedure, but is separate and significant. It distinguishes the visit from the procedure.
Electronic professional claims are submitted in which ANSI X12 format?
X12 997
X12 271
X12 835
X12 837P
The ANSI X12 837P transaction is the standardized format for submitting professional medical claims electronically. The 835 is used for remittance advice.
What is the typical timeframe for an insurer to process a clean claim?
60 business days
45 calendar days
90 calendar days
30 calendar days
Most insurers are required to process clean claims - those without errors - within 30 calendar days. This ensures timely payment to providers.
What is the proper process for recovering an overpayment from an insurer?
Submit a credit adjustment claim and return the excess payment to the payer
Issue a patient refund without adjusting the claim
Apply the extra funds to future claims without notice
Write off the overpayment as bad debt
To comply with regulations, the provider must submit a credit adjustment and return the overpaid amount. This process corrects the payer's records and prevents compliance issues.
A claim for CPT 99213 and CPT 93000 on the same date was denied due to bundling. Which action corrects this denial?
Remove the EKG code entirely
Append modifier -59 to the EKG code to indicate a distinct service
Resubmit with date of service correction
Change the diagnosis code
Appending modifier -59 shows that the EKG (93000) was a distinct service from the office visit (99213). This modifier addresses bundling edits and supports separate payment.
If a lumbar MRI claim is denied for lack of medical necessity, what documentation should be included on appeal?
Clinical notes documenting patient symptoms and failed conservative treatments
Scheduling log
Provider's NPI number
Patient's insurance card copy
Appealing a medical necessity denial requires clinical documentation showing symptoms and prior treatments. This evidence justifies why the MRI was warranted.
Which ANSI X12 transaction set is used to transmit electronic remittance advice (ERA)?
X12 837I
X12 270
X12 835
X12 820
The ANSI X12 835 transaction is the standard format for electronic remittance advice, providing details on claim payments and adjustments from payers.
Which metric is most useful for identifying delayed payments in accounts receivable?
Clean claim rate
Coordination of benefits ratio
Denial rate
Days Sales Outstanding (DSO)
Days Sales Outstanding (DSO) measures the average number of days to collect receivables. A high DSO indicates delayed payments and potential cash flow issues.
Under NCCI edits, a comprehensive lab panel code bundles individual tests. How should a claim be corrected?
Append modifier -25 to each test code
Separate tests into individual claims
Bill only the comprehensive panel code rather than individual test codes
Use HCPCS codes instead
NCCI bundling rules require billing the single comprehensive panel code instead of unbundled individual tests. This ensures correct reimbursement and compliance.
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Learning Outcomes

  1. Identify key steps in the patient billing workflow.
  2. Analyse insurance claim submission requirements.
  3. Demonstrate accurate coding for billing procedures.
  4. Apply eligibility and authorization verification methods.
  5. Evaluate common causes of claim denials.
  6. Master payment reconciliation and patient statement processes.

Cheat Sheet

  1. Master the 10 Steps of the Medical Billing Process - Dive into each step from registering a patient to collecting payments. Mastering this process ensures smooth billing and fewer headaches. Explore the 10 Steps
  2. Accurate Medical Coding is Crucial - Nail the ICD-10 and CPT codes that tell the story of diagnoses and treatments. Proper coding is your claim's best friend, boosting approval chances every time. Dive into ICD-10 and CPT Coding
  3. Verify Insurance Coverage Before Services - Before any procedure, double-check patient benefits and eligibility. This simple move prevents unwelcome surprises and claim denials later. Verify Coverage Tips
  4. Understand Common Causes of Claim Denials - Spot missing info or coding oopsies early on. Quick fixes keep your revenue flowing without hiccups. Handle Denials Effectively
  5. Timely Claim Submission is Essential - Don't let deadlines sneak up on you! Timely submissions are the secret ingredient for swift reimbursements. Submit Claims on Time
  6. Regularly Monitor Claim Status - Stay on top of your cash flow by tracking your claims. Early detection of issues means faster resolutions and happier wallets. Track Your Claims
  7. Implement Effective Denial Management Strategies - When claims go south, a strong denial management plan is your superhero cape. Analyze, appeal, and conquer to keep your revenue cycle thriving. Denial Management Guide
  8. Ensure Proper Documentation for All Services - Detailed documentation is your backstage pass to claim approval. Clear records back every code and service you bill. Best Documentation Practices
  9. Stay Updated on Payer Guidelines and Policies - Payer rules can be trickier than a plot twist. Staying updated on guidelines ensures your claims always hit the mark. Payer Guidelines 101
  10. Utilize Technology for Claims Scrubbing - Let technology be your claim-scrubbing sidekick. Automated tools catch sneaky errors before submission, giving your claims a fighting chance. Claims Scrubbing Tools
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