The Medicare program has many rules and regulations. This quiz will cover some of the more common information about general Medicare coverage and the Risk Adjustment Program.
Medicare Coverage / Risk Adjustment Quiz
This quiz will evaluate your knowledge of Medicare Coverage. There is one correct answer for each question and no time limit on this quiz.
Each correct answer is worth one point. Good luck.
Disclaimer - All answers are felt to be correct. However, if you disagree, please research the issue. Mistakes happen.
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Assume that an 84 year old patient (Joan) went to the Emergency Department (ED) and was formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. Joan was discharged on the 4th day. Assuming that she needs skilled nursing care, will her skilled nursing facility (SNF) stay be covered by Medicare?
Yes. Joan met the 3-day inpatient hospital stay requirement for a covered SNF stay.
No. Joan did not meet the requirements for a covered SNF stay.
Medicare's Hierarchical Condition Categories (HCC) model is based upon which coding system?
Most of the Medicare Prescription Drug Plans have a gap in coverage . This means there's a temporary limit on what the drug plan will cover for drugs. This temporary gap in prescription drug coverage is called:
the donut hole
out of pocket costs
Medicare Part D
Assume that William, age 70 visited the Emergency Department (ED) and spent one day getting observation services. Then, William was formally admitted to the hospital as an inpatient for 2 more days, then discharged. Assuming that William needs skilled nursing care, will William's SNF stay be covered by Medicare?
Yes. William met the 3-day inpatient hospital stay requirement for a covered SNF stay.
No. Even though William spent 3 days in the hospital, he was considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.
In the Risk Adjustment program from CMS, it is possible for two different patients within the same geographic community to have different payment rates.
Question 10 Explanation:
The payment rate is based the amount of risk, or medical intervention, it will take to maintain the individual patient's health. For example, a patient with a chronic illness, such as diabetes, will likely take more medical intervention, than another patient without any chronic illness.
In Medicare's Risk Adjustment program (RA), a patient's chronic conditions should be reported ________.
once every 5 years.
only once in a lifetime.
once a year.
once every 2 years.
In general, outpatient care, durable medical equipment and home health care are covered by:
Part C Medicare
Part A Medicare
Part D Medicare
Part B Medicare
According to CMS, by using the Risk Adjustment Program, CMS is able to make appropriate and accurate payments for Medicare Advantage enrollees who have differences in:
Question 13 Explanation:
The "expected costs" are based upon the patient's risk. Patients with more serious and chronic diagnoses are more at risk than those without.
With this type of Medicare fraud, the medical provider bills Medicare for unnecessary procedures, or procedures that are never performed; for unnecessary medical tests or tests never performed; for unnecessary equipment; or equipment that is billed as new but is, in fact, used.
Which of the services listed below is not covered by Part B of Medicare?
hospital outpatient care
home health care
doctor's office visits
Claims for Medicare benefits must be submitted within ______ from the date of medical service.
Question 19 Explanation:
Source - Medicare Learning Network Form CMS-1500 at a glance
To be eligible for Medicare Part A and B, you must:
be a US citizen or permanent legal resident for at least five years.
have been employed under Social Security.
have been born in the United States.
If a patient is covered by both Medicare and Medicaid, which one is considered the primary insurance and, as a result, would pay for medical services first?
It depends on your age.
It depends on your health status.
Question 21 Explanation:
Medicaid never pays first for services covered by Medicare.
Source - Medicare.gov
This is a CMS payment method which provides a risk factor score for Medicare Advantage patients with chronic illness. This score reflects patient complexity and is used to calculate and adjust payments to providers.
Diagnosis Related Groups
Fee for service
The Medicare 8-minute rule applies to what medical service?
In general, all of the following, except ________ are services that are NOT covered by Part A or B of Medicare.
durable medical equipment
routine eye care and eyeglasses
A Medicare billing claim with no errors or omissions is called:
This type of claim occurs when the claim cannot be processed due to technical errors, invalid, or missing info, or claim submission instructions not being followed.
In Medicare's Risk Adjustment program, risk adjustment scores are ______ for a patient with a greater disease burden.
This type of service would be provided to an outpatient Medicare patient by a non-physician practitioner. The supervising physician, however, must be present in the office and supervise the non-physician practitioner. This type of service can be billed to Medicare as:
Part A Medicare
Fee for service
Incident to service
Question 28 Explanation:
Source - www.Medicare.gov
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