Certified Revenue Cycle Representative (CRCR) Practice Exam

Which statement is NOT a unique billing rule specific to providers?

1. A patient may be balance billed for the non-contracting physician's charges above the health plan's reimbursement amount.

2. Aggregate payments made to a hospice are subject to a cap amount calculated by the MAC.

3. Medicare reimbursement for hospice care is made at predetermined rates for each day of care.

4. When billing services on a UB-04/837-I, specific CPT codes are collapsed into a revenue code.

The correct answer is: A patient may be balance billed for the non-contracting physician's charges above the health plan's reimbursement amount.

The statement indicating that a patient may be balance billed for the non-contracting physician's charges above the health plan's reimbursement amount is reflective of a broader concept in healthcare billing and is not unique to providers. Balance billing occurs commonly in instances where patients receive services from out-of-network providers, and it represents a legally recognized practice in various cases, particularly when no contract exists between the provider and the insurer. In contrast, the other statements relate to specific billing rules and regulations that are distinct to particular services and settings: - The aggregate payments made to a hospice being subject to a cap amount calculated by the Medicare Administrative Contractor (MAC) points to a regulatory framework that governs hospice payments specifically. - Medicare's determination to reimburse hospice care at predetermined rates for each day of care indicates the structured approach of Medicare to handle hospice billing. - The collapsing of specific CPT codes into a revenue code when billing services on a UB-04/837-I illustrates a practice that aligns with hospital billing protocols, indicating a systematic decision rather than an isolated billing practice. These elements reflect unique aspects of billing rules tailored to certain services or provider statuses, making them distinct from the more generalized practice of balance billing for out-of-network services.