Important Interview Questions with Answers

1. When a patient takes an insurance policy what are the advantages?
   1. Insurance companies take responsibility for all financial risk undergone by patients for the tenure of the policy.
   2. Coverage includes both policy buyer and his dependents.
   3. Terms and conditions of policy clearly define its scope.
   4. Medical services are covered and reimbursed only if it is within scope of policy and all conditions are met.

2. Who is responsible for submitting claims and getting paid for the service?

Physicians are responsible for submitting claims and getting paid for the services.

3. The CPT codes are updated and copyrighted annually by?

The CPT codes are updated and copyrighted annually by AMA   (American Medical Association). 

4. What is HCPCS elaborate?

HCFA Common Procedure Coding System.

5. What is HCFA elaborate?

Health Care Financing Administration.

6. What is ASA elaborate?

American Society of Anesthesiologists.

7. The code range for ASA?

The codes range from 00100 through 01999 

8. List 4 circumstances where we need to use a modifier?
   1. A service or procedure was performed by more than one physician and/or in more than one location. 
   2. vice or procedure has been increased or reduced. 
   3.   Only part of a service was performed. 
   4.   An adjunctive service was performed. 
   5.   A bilateral procedure was performed. 
   6.   A service or procedure was provided more than once. 
   7.   Unusual events occurred.

9. List common modifiers, with description?
   1. Professional Component 26
   2. Technical Component TC
   3. Bilateral Procedure 50
   4. Right side of body RT
   5. Left side of body LT
   6. Distinct Procedural Service 59

10. List common Global Bundled modifiers, with description?

1. Unrelated E/M during post-op period 24
2. Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service  25
3. Surgical care only 54
4. Postoperative management only 55
5. Preoperative management only 56
6. Decision for surgery               57
7. Distinct procedural service 59
8. Unplanned return to operating or procedure room 78
9. unrelated procedure that was performed by the same physician during a postoperative period 79

List common modifiers, with description video: https://youtu.be/N65jDvYe1l8?si=KEu4Rt0t06CwAH6K

Mutually Inclusive Denial| CO97 video: https://www.youtube.com/watch?v=UevF46pSGT8

11. List common place of service (POS), with description?

• What is the POS for Office?  11
• What is the POS for Urgent care Facility? 20
• What is the POS for in-Patient Hospital? 21
• What is the POS for Out-Patient Hospital? 22
• What is the POS for an Emergency Room? 23
• What is the POS for an Ambulatory Surgical Center? 24
• What is the POS for a Skilled Nursing Facility? 31
• What is the POS for a Nursing Facility? 32
• What is the POS for Hospice? 34

Place of service (POS) 19, 21, 22, 23, 24 video: https://www.youtube.com/watch?v=T9bTFl_M33g

12.  What is a Facility?

Facility is the place where the doctor sees the patient. It can be a hospital, a nursing home, a skilled nursing facility, a clinic or even the patient’s home.

13. Which is the largest insurance, what is the volume covered by this insurance?

Medicare is the nation’s largest health insurance program, which covers nearly 40 million Americans.

14. What are the expenses covered by MCR Part A and MCR Part B?

Part A covers hospital expenses 

Part B covers outpatient healthcare including Doctor Fees.

15. What is RBRVS elaborate?

Resource Based Relative Value Scale

16. What does RBRVS do?

RBRVS system is used to determine payment for Medicare Part B (Physician) services, anesthesia, radiology and Pathology

17. What is RVU elaborate?

Relative Value Units

18. What are the eligibility criteria for Medicaid?

Long term recipients of Medicaid are aged, blind and disabled who are below the poverty line.

19. What is Managed Care?

Managed Care is a system of medical management in which patients, Administrators and Providers are linked together with the common goal of improving health Care quality and reducing costs.

20. What are the different plans of managed care?
    1. HMO   – Health Maintenance Organization
    2. PPO     – Preferred Provider Organization
    3. POS     – Point of Service 

21. Do HMO patients pay deductible?

There is no deductible

22. In PPO plan what is required before hospitalization and certain outpatient service?

Requires prior approval for hospitalization and certain outpatient procedures

23. What is CHAMPUS elaborate?

Civilian Health and Medical Program of the Uniformed Services 

24. What does Railroad Medicare do?

A Medicare plan for railroad retirees administered by the Railroad Retirement Board. It follows the same rules as that of Medicare.

25. What is EDI?

Electronic Data Interchange

26. What is Policy explain?

A policy is a contract between the patient and the insurance plan – it is a certificate of coverage. 

27. What is Adjudication?

Adjudication is the operational process carried out by a plan from receipt of the claim through completion of the explanation of benefits (EOB).

28. What is Co-payment?

Co-payments are dollar amounts that the enrollee pays the provider directly towards cost sharing of certain services such as office-visits, mental health visits and hospitalizations. 

29. What is Co-insurance?

Co-insurance is another form of cost sharing paid by the enrollee directly to the provider and is based on a percentage of allowed services.

30. What is the Filing limit?

Filing limit is the deadline for claims submission. 

Every insurance carrier has its own filing limit. 

31. Explain Workers compensation?

A requirement of the federal government for employers of patients who are injured or become sick on the job.

32. What is CHAMPVA elaborate?

Civilian Health and Medical Program for the Veteran Administration

33. What is POS and who offers this plan type?

Point Of Service is a type of plan offered by HMO

34. BCBS started on?

Started in 1929 by a University Professor

35. Under SSA when were the two insurance programs established?

Under the Social Security Act, two insurance programs were established in 1965

36. What is TOS?

Type of Service is the specialty in which the service is rendered.

37. The insurance is also called as?

The insurance company is also called the “Carrier”

38. What is Block # 17 in HCFA?

Name of the Referring provider

39. What is block # 25 HCFA?

Federal TAX ID

40. What is block # 32 in HCFA?

Service Location

41. What is Block # 33 in HCFA?

Billing Provider Address

42. Explain Ambulatory Services?

Various healthcare services are offered in a medical facility, like checkups, immediate care, surgeries, and outpatient services. You don’t have to stay overnight for these services.

43. Explain Appeal?

A process used by a patient or provider to request the health plan to reconsider a claim decision.

44. Explain Benefit Period?

A period of time for which covered services (or benefits) are eligible for payment.

45. Explain Coordination of Benefits?

A contractual stipulation that diminishes the benefits within one agreement to the degree to which those benefits are accessible under a subsequent contract. This measure is implemented to avert duplicate payments for a singular service.

46. Explain Enrollee?

A person who is registered and qualified for coverage in a health insurance plan. This person is also referred to as the “insured.”

47. Explain Experimental Procedure?

Any service or supply that is in the developmental stage or is in the process of human or animal testing

48. What does EOB mean?

Explanation of Benefits

49. What is the fee for service payment system?

A setup where the insurance company either repays the group member or directly pays the healthcare provider for each eligible medical cost after the expense has been accrued.

50. What are Mandated Benefits?

Specific components of health care coverage required by state or federal government.

51. What is Medicare Part A?

A segment of the Medicare law offers benefits for hospitalization, extended care, and nursing home care to Medicare beneficiaries with no premium payment.

52. What is Medicare Part B?

A component of the Medicare law that furnishes medical-surgical benefits to Medicare beneficiaries in exchange for a nominal premium..

53. What is partial Day treatment?

A program provided by licensed psychiatric facilities offering either day or evening treatment for mental health or substance abuse. This type of care serves as an alternative to inpatient treatment.

54. What is POS?

Place of service

55. What is Pre-Authorization?

Approval is required for specific procedures or hospital admissions. When care is received within the network, the primary care physician or specialist typically obtains pre-authorization. In the case of out-of-network services, it is the member’s responsibility to secure pre-authorization.

56. What is Pre-existing condition?

A pre-existing condition refers to an illness or health condition that you or another member had before applying for health insurance. In certain instances, these conditions may be subject to a waiting period for benefits or may be excluded from coverage.

57. What is a Skilled Nursing Facility?

A licensed institution, or a separate section of a hospital, that delivers ongoing skilled nursing care and related services for patients in need of medical care, nursing assistance, or rehabilitation services.

58. What is modifier 52 explained?

Reduced Services

59. When a patient takes an insurance policy what are the advantages?

1. Coverage extends to both the policy buyer and their dependents.
2. The terms and conditions of the policy explicitly outline its scope.
3. Medical services are… (The sentence seems incomplete. If you have more details or specific information you’d like to add, please provide them, and I’ll be happy to assist further.).
4. Insurance companies assume financial responsibility for all risks encountered by policyholders during the policy’s duration.

60. What questions Need to be asked to claim CLAIM NOT ON FILE?

1.verify the patient’s eligibility. get the  effective date of the policy 

2.check the timely filing limit

3.Ask  whether they are the primary or sec insurance for this pt.

4.Ask  whether the claim can be faxed  if yes get the fax# and  whose attention.

5.If not verify the claims mailing address and payor id.

61. What questions Need to be asked for a claim IN PROCESS?

1.date of received
2.normal processing time for claim

3.claim #
4.get the  date on which the claim is expected to complete processing
5.call ref #

62. What are the Questions Need to be asked for Claims applied to Patient DEDUCTIBLE?

1.process date
2.Allowed amt
3.How much  was applied towards the deductible
4.was the claim processed in/out of network
5.what is the patient’s annual  ded amt
6.how much has been met so far
7.claim #
8.if the  process date is more than 30 days  request  for a EOB
9. call ref#.

63. What are the important points that need to be applied while drafting notes?.

• For what you called – DOS.
• Where you called – INSURANCE Name.
• Whom did you talk to – Rep Name.
• What is the current status of the claim…
• What is the Resolution?

CMS1500 FORM how to fill ? STEP BY STEP INSTRUCTION Video  https://www.youtube.com/watch?v=Pov-xh8BIco

Revenue cycle management (RCM) complete Story Video https://www.youtube.com/watch?v=NY-2gP8ME5w&t=121s

MEDICARE VS MEDICAID video https://www.youtube.com/watch?v=mEc8A9qTVek

Mock-Call_Duplicate denial | Code: CO18 video: https://www.youtube.com/watch?v=irNDjTvLiOo&t=38s

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