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bigt246823 bigt246823
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Posts: 560
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6 years ago
To determine the benefits payable under the COB provision, use all of the following guidelines EXCEPT:
 
  a. Compute the normal liability (NL), both Basic and Major Medical benefits, that would be payable in the absence of Medicare (perform a line-for-line calculation).
  b. Determine the amount the provider is allowed to collect.
  c. Use the greater of number one or number two as the base.
  d. Compare the amount paid by Medicare to the base.



(Q. 2) The most common methods for coordinating group health plans include all of the following EXCEPT:
 
  a. Nonduplication of Medicare
  b. Maintenance of benefits
  c. Out-of-state benefits
  d. Medicare supplemental coverage



(Q. 3) Identify and explain the circumstances in which separate allowances are warranted for pre-operative services.
 
  What will be an ideal response?



(Q. 4) What is considered a rehabilitation benefit? Explain work hardening programs and their relationship to such benefits. Discuss vocational rehab as well.
 
  What will be an ideal response?



(Q. 5) What happens when an MCPmember requests to see a specialist?
 
  a. The PCP must discuss the request with the member.
  b. The request is denied.
  c. The request must always be in regard to hospitalization.
  d. The PCP chooses the specialist.



(Q. 6) What does ZPIC stand for?
 
  a. Zero Program Integrity Contractor
  b. Zone Processing Integrity Contractor
  c. Zone Program Integrity Contractor
  d. Zone Program Integrated Contractor



(Q. 7) What is considered to be an occupational illness?
 
  a. Sunburn while on vacation
  b. Illness caused by inhaling or ingesting a hazardous agent
  c. Illness taking less than one year to develop
  d. Food poisoning while eating lunch with coworkers



(Q. 8) Toward the end of an auditing phase, many companies perform an Audit of the Findings as a step before which of the following?
 
  a. A noncompliance order is issued
  b. The auditors are paid
  c. A malpractice case is avoided
  d. A compliance plan is created



(Q. 9) Which of the following is a step in a second opinion process?
 
  a. A request is made by the claims examiner for a second opinion.
  b. The patient's chart remains private from the second opinion doctor.
  c. An internal review is done.
  d. All records are forwarded to the MCP's chief medical officer for a determination.



(Q. 10) All of the following are part of processing an MCP claim EXCEPT:
 
  a. Checking the member's eligibility
  b. Checking the member's contract
  c. Determining financial responsibility
  d. Assuring a second opinion
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wrote...
6 years ago
1)  C

2)  C

3)  Answer:
The immediate preoperative visit in the hospital or elsewhere is generally necessary to examine the patient, complete the hospital records, and initiate the treatment program. Charges for these procedures are included in the surgical allowance. However, a separate allowance may be warranted for preoperative services in the following circumstances:
a. When the preoperative visit is the initial visit (i.e., in an emergency room), and prolonged detention or evaluation is required to prepare the patient or to establish the need for the surgery.
b. When the preoperative visit is a consultation. Be sure the physician has not up coded a preoperative visit to increase benefits. An example is a surgeon billing for a consultation prior to surgery when in fact the visit was a simple preoperative visit.
c. When procedures that are not usually part of the basic surgical procedure (i.e., bronchoscopy prior to chest surgery) are provided during the immediate preoperative period.
d. When a procedure could normally be performed in the office, but under certain circumstances requires hospitalization.

4)  Answer:
If an employee is found to have a permanent disability, some states allow for a rehabilitation benefit. This benefit can be provided to retrain the employee in a physical ability which will help him to seek future employment.
Some states participate in a work hardening program, wherein an employee is assigned therapy similar to their work in an attempt to strengthen them and build up their endurance toward a full day's work. Often employees in such a program will be returned to work on a limited or restricted basis. Physicians, therapists, employers, insurance carriers, and all others concerned with the employee's case must keep in constant communication to ensure that the patient is not returned to work either sooner or later than possible.
Many states also allow for vocational rehabilitation or retraining in a different job field when the employee is unable to return to his former position. This can include courses in colleges and vocational schools, or on-the-job training programs. Often employees are paid a weekly allowance while they are attending school and for a limited time after graduation. The time after graduation is to allow them time to locate a job. The employee is then considered to be off temporary disability and returned to work. Vocational rehabilitation can also include job guidance, resume preparation, and placement services.

5)  A

6)  C

7)  B

8)  D

9)  C

10)  D
bigt246823 Author
wrote...
6 years ago
Thanks for your help!
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