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NHA CMAA practice questions

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Question 1Medical Business Practices

A practice groups all of its annual physical examinations into the same afternoon block each week. Which scheduling technique does this describe?

  1. Double booking
  2. Wave scheduling
  3. Open hours scheduling
  4. Cluster scheduling Correct answer.

Explanation

Cluster scheduling reserves blocks of time for similar visit types or patient needs, which lets staff standardize room use, equipment, and staffing. It does not involve stacking patients at one time or holding time open for walk-ins.

Question 2Medical Business Practices

A patient pays a fixed $25 amount at each office visit before any other billing is applied. What is this payment called?

  1. Copayment Correct answer.
  2. Deductible
  3. Premium
  4. Coinsurance

Explanation

A copayment is a set dollar amount the plan requires the patient to pay at the time of service. Coinsurance is a percentage share, a deductible is an amount paid before coverage begins, and a premium is the cost of the policy itself.

Question 3Medical Business Practices

Which part of Medicare covers inpatient hospital stays?

  1. Part B
  2. Part D
  3. Part A Correct answer.
  4. Part C

Explanation

Medicare Part A covers hospital inpatient care, skilled nursing facility care, hospice, and some home health services. Part B covers outpatient and physician services, Part C is Medicare Advantage, and Part D covers prescription drugs.

Question 4Medical Business Practices

Which claim form does a medical office submit for Medicare and most commercial payers?

  1. UB-04
  2. ADA dental claim form
  3. CMS-1500 Correct answer.
  4. NCPDP pharmacy form

Explanation

The CMS-1500 is the standard claim format for physician and outpatient professional services, used by Medicare and most commercial payers. Other formats exist for institutional, dental, and pharmacy claims.

Question 5Medical Business Practices

Which code set is used to report medical procedures and services on a claim?

  1. NDC
  2. CPT Correct answer.
  3. MS-DRG
  4. ICD-10-CM

Explanation

Current Procedural Terminology, or CPT, codes describe the procedures and services a provider performs. ICD-10-CM codes describe diagnoses, NDC codes identify drugs, and MS-DRGs classify hospital inpatient stays.

Question 6Medical Business Practices

A practice wants to release a patient's record to a research organization. What must the practice obtain first?

  1. A court order in every case
  2. A verbal agreement from the patient's spouse
  3. Nothing, because research use is always permitted
  4. A signed patient authorization Correct answer.

Explanation

Releasing protected health information for purposes other than treatment, payment, or health care operations requires a valid written authorization from the patient. Verbal permission from a family member, a court order, or the research purpose alone does not substitute for that authorization.

Question 7Medical Business Practices

What is a deductible?

  1. A fixed fee collected from the patient at every visit
  2. An annual amount the patient pays before the plan begins paying Correct answer.
  3. The amount an insurer pays before any patient cost sharing
  4. The monthly charge for maintaining insurance coverage

Explanation

A deductible is the amount a patient must pay out of pocket each plan year before the insurer begins covering services, although some services may be exempt. It differs from a copayment, which is collected per visit, and from a premium, which is the cost of the policy.

Question 8Medical Business Practices

Which information is required when a new patient registers for a first appointment?

  1. The provider's cell phone number
  2. Names of the patient's siblings
  3. Childhood immunization dates
  4. Insurance card and photo ID Correct answer.

Explanation

Registration collects identifying data along with the insurance card and photo identification so staff can verify eligibility and benefits and set up the financial record. Unrelated personal details and provider contact information are not registration data.

Question 9Medical Business Practices

A child is covered by both parents' plans. Under the traditional birthday rule, which plan pays first?

  1. The parent with the earlier birthday Correct answer.
  2. The parent whose birthday comes later in the year
  3. The parent who claims the child as a dependent
  4. The parent with the higher annual income

Explanation

Under the birthday rule, the plan covering the parent whose birthday comes first in the calendar year is primary for the dependent. The other parent's plan is secondary and may pay remaining balances.

Question 10Medical Business Practices

An HMO patient needs to see a cardiologist. What does the practice typically need before the visit?

  1. A referral from the primary care provider Correct answer.
  2. A signed release of the patient's billing records
  3. Precertification issued by the patient's employer
  4. A cash deposit covering the specialist's full fee

Explanation

In a gatekeeper HMO model the primary care provider must issue a referral, and many plans also require prior authorization before the specialist visit to avoid a denial. A deposit or employer precertification is not the standard mechanism.

Question 11Medical Business Practices

An aging report shows that a large share of receivables is 120 days old. What does this most likely indicate?

  1. Claims are not being paid or followed up promptly Correct answer.
  2. The practice is collecting faster than expected
  3. Patients are paying copays at the front desk
  4. The fee schedule is set far too low

Explanation

An aging report sorts unpaid balances by how long they have been outstanding, so a growing 120-day bucket signals slow or failed collection, often from unpaid claims, denials, or missed patient follow-up. Low fees or prompt copay collection would not by themselves age receivables.

Question 12Medical Business Practices

What is the main purpose of an explanation of benefits?

  1. To show how a claim was processed and paid Correct answer.
  2. To replace the CMS-1500 claim form
  3. To authorize a referral to a specialist
  4. To serve as the patient's receipt for a copayment

Explanation

An explanation of benefits is issued by the payer and itemizes charges, allowed amounts, adjustments, payments, and patient responsibility so the practice can post the payment correctly. It is not a claim form, a referral authorization, or an office-issued receipt.

Question 13Medical Business Practices

Which statement describes a PPO plan?

  1. One capitation fee covers all covered services
  2. Out-of-network care is covered at higher cost Correct answer.
  3. A gatekeeper must approve every specialist visit
  4. Benefits must always be assigned to the plan

Explanation

A preferred provider organization allows members to use network providers at a lower cost or go out of network at a higher cost, usually without a referral. Gatekeeper requirements and capitation are features of HMO models.

Question 14Medical Business Practices

An employee is injured on the job. Which payer is generally responsible for the medical bill?

  1. The employee's group health plan as primary
  2. Medicare Part B
  3. The employer's workers' compensation carrier Correct answer.
  4. The patient's personal auto policy

Explanation

Injuries and illnesses arising out of employment are covered under state workers' compensation programs, which are generally primary to group health coverage for the work-related condition. Group health, Medicare, and auto policies do not assume that role in a straightforward on-the-job injury.

Question 15Medical Business Practices

What is the purpose of a superbill in a medical office?

  1. To list the practice's office supply inventory
  2. To record the practice's daily bank deposits
  3. To capture the diagnosis and procedure codes for a visit Correct answer.
  4. To serve as the patient's consent for treatment

Explanation

A superbill is the encounter form that records the services and diagnoses provided so coders and billers can build an accurate claim. It does not handle banking, consent documentation, or supply tracking.

Question 16Medical Business Practices

Which statement about the Medicaid program is accurate?

  1. Commercial insurers administer every state program
  2. Federal and state funds share the cost Correct answer.
  3. The federal government alone pays for all of it
  4. It is limited to patients aged 65 and older

Explanation

Medicaid is a joint federal–state program: the federal government sets broad requirements and matches state spending, while each state sets eligibility and covered benefits. It serves low-income people of all ages and is run by state agencies rather than commercial carriers.

Question 17Medical Business Practices

A practice wants to reduce revenue lost to missed appointments. Which approach is most appropriate?

  1. Refuse to schedule any patient more than once
  2. Set and post a written cancellation and no-show policy Correct answer.
  3. Stop sending appointment reminders
  4. Charge every patient a penalty regardless of cause

Explanation

A written policy that states the required notice and any fee, applied consistently and explained at scheduling, reduces no-shows while remaining transparent to patients. Refusing future appointments, blanket penalties, and dropping reminders do not solve the problem and can create compliance issues.

Question 18Medical Business Practices

When should staff verify a patient's insurance eligibility?

  1. Before the scheduled visit, ideally a few days ahead Correct answer.
  2. Only after the claim is denied
  3. After the provider has seen the patient
  4. At the end of the calendar year only

Explanation

Verifying eligibility before the visit lets the practice confirm coverage, copay, and any referral needs while there is still time to resolve problems, which prevents denials later. Checking only after the visit or after a denial delays collection and increases rework.

Question 19Medical Business Practices

What is the purpose of a recall system in a medical practice?

  1. To schedule staff shifts for the coming month
  2. To record the practice's supply orders
  3. To remind patients when follow-up care is due Correct answer.
  4. To track overdue payments from insurance carriers

Explanation

A recall system identifies patients who are due for follow-up visits, screenings, or chronic care checks and contacts them to schedule, supporting continuity of care and keeping the schedule full. It is not used for payroll, supply ordering, or carrier follow-up.

Question 20Medical Business Practices

A patient asks to pay a large balance in monthly installments. What should the practice do first?

  1. Review the practice's written financial policy with the patient Correct answer.
  2. Tell the patient the balance must be paid in full that day
  3. Send the account to collections immediately
  4. Write off the balance as charity care

Explanation

Payment plans should follow the practice's documented financial policy, which sets terms, minimum payments, and the approval process, and the agreement should be documented in writing. Writing off the balance or sending it to collections without following policy is premature and harms the patient relationship.

Question 21Medical Business Practices

A payer returns a claim unprocessed because the patient's date of birth is missing. How is this best classified?

  1. A claim denial
  2. A write-off
  3. A claim rejection Correct answer.
  4. A capitation payment

Explanation

A rejection means the claim was never adjudicated because of a data or formatting problem such as a missing field, so correcting and resubmitting is appropriate. A denial occurs after the payer reviews the claim and decides not to pay for a coverage or medical necessity reason.

Question 22Medical Business Practices

The allowed amount for a service is $200. The patient has met the deductible and has 20% coinsurance. How much does the patient owe?

  1. $160
  2. $20
  3. $40 Correct answer.
  4. $200

Explanation

Coinsurance is a percentage of the allowed amount, so the patient owes 20% of $200, which is $40, and the plan pays the remaining $160. Charging the full allowed amount or a 10% share would misapply the coinsurance percentage.

Question 23Medical Business Practices

A patient who is still working and covered by an active employer group health plan also has Medicare. For services covered by that group plan, which payer is generally primary?

  1. Medicaid, as the payer of last resort
  2. Medicare, because the patient is enrolled in it
  3. The employer group health plan Correct answer.
  4. The patient, who must pay the full charge

Explanation

Under Medicare Secondary Payer rules, working beneficiaries with active employer group coverage through their own or a spouse's current employment have the group plan primary for that coverage. Medicare pays secondary, and Medicaid would only consider any remainder if the patient is eligible.

Question 24Medical Business Practices

Which code set would be used to report a supply of sterile gauze and a walker provided to a patient?

  1. ICD-10-CM
  2. CPT Category I
  3. ICD-10-PCS
  4. HCPCS Level II Correct answer.

Explanation

HCPCS Level II codes cover supplies, durable medical equipment, prosthetics, orthotics, and drugs that CPT does not describe. ICD-10-CM holds diagnoses, ICD-10-PCS holds inpatient procedures, and CPT Category I holds professional services and procedures.

Question 25Medical Business Practices

A clean claim was submitted, but the payer's filing limit passed before anyone followed up on the missing payment. What is the most likely consequence?

  1. The claim becomes unrecoverable from the payer Correct answer.
  2. The claim is converted into a workers' compensation claim
  3. The payer automatically reprocesses it
  4. The patient's coinsurance percentage increases

Explanation

Payers enforce timely filing limits, and a claim that is not submitted or appealed within the limit is typically denied as untimely, which generally bars payment from the payer. Regular follow-up on aging claims prevents this outcome, and the limit is not reset automatically.

Question 26Medical Business Practices

A medical office is building its appointment template. Which visit typically requires the longest scheduled time?

  1. An established patient with a single chronic condition
  2. A new patient comprehensive visit Correct answer.
  3. A quick medication refill visit
  4. A nurse-only blood pressure check

Explanation

New patient visits usually require extra time for registration, history, medication review, and a comprehensive examination. Established patients with focused needs generally require shorter appointments.

Question 27Medical Business Practices

Which code set is used to report the diagnosis that supports medical necessity for a visit?

  1. ICD-10-CM Correct answer.
  2. CDT
  3. HCPCS Level II
  4. CPT

Explanation

ICD-10-CM classifies diagnoses and describes the patient's condition. CPT and HCPCS Level II report procedures, services, and supplies, while CDT is used in dentistry.

Question 28Medical Business Practices

When a patient arrives for a scheduled visit, which amount is generally collected at check-in?

  1. The entire allowed amount
  2. The copayment Correct answer.
  3. The deductible balance for the year
  4. The payer's portion

Explanation

A copayment is a fixed patient payment due at the time of service under many plans. Other patient responsibility, such as remaining deductible or coinsurance, may be billed after the claim is processed.

Question 29Medical Business Practices

After a patient pays $30 in cash at the front desk, where should the transaction be recorded?

  1. On the encounter form only
  2. On the payer's remittance advice
  3. In the appointment scheduler
  4. In the patient's ledger Correct answer.

Explanation

The patient ledger tracks charges, payments, adjustments, and the running balance for each patient. An encounter form captures services, and a remittance advice comes from the payer.

Question 30Medical Business Practices

Which statement describes a premium?

  1. The annual amount a patient must pay before coverage begins
  2. The share of costs after the deductible is met
  3. The fixed amount paid at each office visit
  4. The amount paid to keep an insurance policy active Correct answer.

Explanation

A premium is the periodic payment made to maintain insurance coverage, regardless of whether services are used. Copayments, coinsurance, and deductibles describe different patient cost-sharing amounts.

Question 31Medical Business Practices

Which pair of identifiers is appropriate for confirming a patient's identity at registration?

  1. Insurance member number and group number
  2. Address and telephone number
  3. Employer name and policy number
  4. Full name and date of birth Correct answer.

Explanation

Using two patient identifiers, such as full name and date of birth, helps prevent creating or accessing the wrong record. Insurance and contact details can change and are not reliable identity identifiers.

Question 32Medical Business Practices

What is the main purpose of a written financial policy in a medical practice?

  1. To document clinical findings for each visit
  2. To replace the explanation of benefits
  3. To set the fee schedule for each payer
  4. To state patient payment expectations Correct answer.

Explanation

A financial policy tells patients about copayments, balances, payment plans, and collection practices. It supports consistent collections but does not replace payer contracts or clinical documentation.

Question 33Medical Business Practices

A patient calls with a sudden illness and needs to be seen today. Which type of appointment is most appropriate?

  1. Annual wellness visit
  2. Follow-up visit for a stable condition
  3. Same-day acute visit Correct answer.
  4. New patient consultation

Explanation

Acute problems need prompt evaluation, so same-day or urgent access is appropriate. Wellness, stable follow-up, and new-patient consultations are usually scheduled in advance.

Question 34Medical Business Practices

Which statement correctly distinguishes a referral from a prior authorization?

  1. A prior authorization is issued by the patient's employer, while a referral is issued by the payer
  2. A referral sends the patient to another provider; prior authorization approves coverage Correct answer.
  3. Both terms mean the patient may see any specialist without PCP input
  4. A referral approves payment; prior authorization schedules the visit

Explanation

A referral directs the patient to another provider for care, often at the request of the primary care provider. Prior authorization is a payer decision that a service is covered before it is performed.

Question 35Medical Business Practices

A patient has private employer coverage and also qualifies for Medicaid. How is Medicaid generally billed?

  1. As the primary payer for all services
  2. Instead of the private plan when the patient is under 65
  3. Only if the private plan denies the service as experimental
  4. After the private plan processes the claim Correct answer.

Explanation

Medicaid generally pays as the payer of last resort after other coverage has been billed. Coordination of benefits rules determine how the secondary claim is processed.

Question 36Medical Business Practices

Before transmitting a claim, staff review the form for missing modifiers, invalid diagnosis codes, and mismatched dates. What is this process called?

  1. Scrubbing Correct answer.
  2. Credentialing
  3. Posting
  4. Appealing

Explanation

Claim scrubbing checks a claim for errors and missing information before submission. This reduces clean-claim rejections and denials.

Question 37Medical Business Practices

A Medicare patient is told a service is likely not covered. What form should the patient sign to acknowledge possible financial responsibility?

  1. CMS-1500
  2. EOB
  3. BAA
  4. ABN Correct answer.

Explanation

An advance beneficiary notice is given before a potentially noncovered service so the Medicare patient can decide whether to proceed and accept financial responsibility. The EOB is issued after processing, the CMS-1500 is a claim form, and a BAA is a HIPAA vendor agreement.

Question 38Medical Business Practices

Which control best protects a practice's cash receipts?

  1. Separating payment posting from bank deposit preparation Correct answer.
  2. Depositing cash only when the balance exceeds $1,000
  3. Allowing the front desk to keep cash in a drawer until month end
  4. Having one employee handle billing, deposits, and reconciliation

Explanation

Separation of duties reduces the risk that one person can take cash and conceal it in the records. Cash should also be deposited promptly and reconciled regularly.

Question 39Medical Business Practices

When posting an insurance payment, the difference between the provider's charge and the payer's allowed amount is usually recorded as:

  1. A contractual adjustment Correct answer.
  2. A refund
  3. A patient copayment
  4. A bad debt write-off for a delinquent account

Explanation

The allowed amount is the payer-approved maximum for the service, and the difference between the submitted charge and the allowed amount is a contractual adjustment. Patient responsibility is posted separately based on the explanation of benefits.

Question 40Medical Business Practices

A practice receives an electronic remittance advice (ERA). What is the most efficient use of this file?

  1. To schedule follow-up appointments
  2. To post payments and adjustments Correct answer.
  3. To update the patient's clinical history
  4. To verify the provider's network status

Explanation

An ERA contains claim payment details and can be used to electronically post payments and adjustments. This reduces manual entry errors and speeds reconciliation.

Question 41Medical Business Practices

A practice wants to send billing information to an outside billing company that will access protected health information. What agreement is required?

  1. A release of information for marketing
  2. A financial policy
  3. A business associate agreement Correct answer.
  4. A notice of privacy practices

Explanation

HIPAA requires a business associate agreement when an outside vendor handles protected health information on the practice's behalf. The notice of privacy practices informs patients but does not govern vendor access.

Question 42Medical Business Practices

A patient asks for an itemized statement of charges. What should the practice provide?

  1. A copy of the provider's contract with the payer
  2. The explanation of benefits issued to another patient
  3. A verbal estimate only, with no written detail
  4. An itemized list of charges and payments Correct answer.

Explanation

Patients are entitled to a clear accounting of charges, payments, adjustments, and the current balance. Providing itemized details supports transparency and helps resolve billing questions.

Question 43Medical Business Practices

A new physician joins the practice. What must be completed before the practice can bill insurance plans for the physician's services?

  1. Payer credentialing Correct answer.
  2. A patient satisfaction survey
  3. An OSHA inspection
  4. A marketing campaign

Explanation

A provider generally must be credentialed and enrolled with each payer before claims for that provider's services are payable. Billing before approval can result in denials.

Question 44Medical Business Practices

A patient's insurer denies a claim as "not medically necessary." Which step is most appropriate before writing off the balance?

  1. Bill the patient immediately and close the account
  2. Appeal with supporting documentation Correct answer.
  3. Change the diagnosis code to one that is usually paid
  4. Resubmit the same claim unchanged

Explanation

A medical necessity denial should be reviewed against the documentation, and an appeal should include records that support the service. Changing codes merely to obtain payment can constitute false billing.

Question 45Medical Business Practices

A practice is setting up a sliding fee scale for low-income patients. Which document is commonly used to determine eligibility?

  1. The patient's credit report
  2. The payer's fee schedule
  3. The practice's OSHA log
  4. Federal poverty guidelines Correct answer.

Explanation

Sliding fee scales commonly use federal poverty guidelines and income documentation to set discounted fees. A payer fee schedule, credit report, and OSHA log do not determine income-based eligibility.

Question 46Medical Business Practices

A practice has $240,000 in accounts receivable and average daily charges of $4,000. What is the days in A/R?

  1. 6 days
  2. 60 days Correct answer.
  3. 600 days
  4. 96 days

Explanation

Days in A/R equals total accounts receivable divided by average daily charges: $240,000 divided by $4,000 equals 60 days. This measure estimates the average time needed to collect receivables.

Question 47Medical Business Practices

A physician is offered free office space by a laboratory that will receive the practice's test referrals. Which concern does this raise?

  1. OSHA violation
  2. Anti-kickback violation Correct answer.
  3. Antitrust violation
  4. False Claims Act violation

Explanation

The Anti-Kickback Statute prohibits offering or receiving remuneration to induce referrals of items or services covered by federal health care programs. Free office space from a referral laboratory could be viewed as improper inducement.

Question 48Medical Business Practices

A biller routinely submits claims for services that were never performed. This behavior is best described as:

  1. A clerical error
  2. A timely filing issue
  3. A contractual adjustment
  4. Health care fraud Correct answer.

Explanation

Intentionally billing for services that were not provided is health care fraud because it seeks payment through false claims. A clerical error is unintentional, and a contractual adjustment is a legitimate accounting entry.

Question 49Medical Business Practices

A payer denies a claim because it was received after the filing deadline. The practice has proof it submitted the claim on time. What is the best next step?

  1. Write off the balance as bad debt
  2. Submit a new claim with a different date of service
  3. Appeal with proof of timely submission Correct answer.
  4. Bill the patient and require payment in full

Explanation

When a denial is based on timely filing but the practice has evidence of on-time submission, an appeal should include that proof, such as an electronic acceptance report. Altering the date of service would be improper.

Question 50Medical Business Practices

A patient overpays after insurance processes a claim, leaving a credit balance. What should the practice do?

  1. Refund the overpayment to the patient or payer Correct answer.
  2. Apply the credit to another patient's account
  3. Post the credit as practice revenue
  4. Keep the credit until the patient requests it

Explanation

A credit balance means the patient or payer has paid more than the amount owed. The practice should review the account and refund the overpayment according to policy and payer requirements.