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TICO PRACTICE FINAL PAPER 2026 COMPLETE
RESPONSE SET GRADED A+
◉ Security involves the safekeeping of patient information by: I. Setting office policies to protect PHI from alteration, destruction, tampering, or loss II. Allowing full access to all employees to the electronic medical records III. Giving employees a policy on confidentiality to read IV. Requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality, including termination A. I and IV B. I, II, and IV C. II, III, and IV D. II and III Answer: A. I and IV ◉ Dr. Taylor's office has a new medical assistant (MA) who is responsible for blood collection for lab specimens. Because the MA is new, she often misses when obtaining blood on the first stick. To be sure the office is billing for all services, the office now has a rule
that all patients will be billed a minimum of two blood draws to demonstrate the work that is being done for lab collection. Which statement is true regarding this rule? A. The rule covers the office and allows them to get paid for all services performed. B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error. C. The rule would be legal if changed to only bill for two blood draws on the patients the MA misses on the first stick. D. The rule is only legal if the clinic is in a hospital-based office. Answer: B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error. ◉ An example of an overpayment that must be refunded is _____________? A. Payment based on a reasonable charge. B. An unprocessed voided claim. C. Incorrect posting of an EOB. D. Duplicate processing of a claim Answer: D. Duplicate processing of a claim
A. Yes, if it is a policy in writing it must be followed. B. Yes, if it is a written policy and everyone in the office adheres to it. C. No, it is considered fraud to write off the patients' responsibility for all patients. D. No, it is a violation of Stark law to write off patients' responsibility. Answer: C. No, it is considered fraud to write off the patients' responsibility for all patients. ◉ Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)? A. Collectors are allowed to threaten legal action even if it will not be pursued. B. The FDPCA does not apply to medical practices. C. Collectors are allowed to contact debtors repeatedly. D. Collectors are not allowed to contact debtors at odd hours. Answer: D. Collectors are not allowed to contact debtors at odd hours. ◉ Which of the following is an allowed collection policy after a patient files for bankruptcy? A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected.
B. Any co-payments or deductibles that are past due and owed by the patient can be collected. C. Unpaid claims for dates of service occurring before the date of the bankruptcy and any co-pays or deductibles adjudicated on that same claim. D. Discuss a payment arrangement with the patient to settle the past due account. Answer: A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected. ◉ A patient with an acute myocardial infarction is brought by ambulance to the emergency department. The patient is taken into the cardiac catheterization lab. Angioplasty and a stent was placed in the LAD. The patient's insurance requires preauthorization for all surgical procedures. Which of the following statements is true for most payers? A. If the biller did not obtain authorization prior to the procedure being performed, the surgical services will not be paid. B. Because this was an emergency, it is acceptable to obtain authorization following the surgery. C. Because this was an emergency, a preauthorization is not required. D. If the biller did not obtain authorization prior to the procedure being performed, the entire claim will not be paid. Answer: B. Because this was an emergency, it is acceptable to obtain authorization following the surgery.
A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim. B. Write off the claim. The patient is not responsible for claims denied for not being submitted within the timely filing period. C. Resubmit the claim with a different date of service that is within the timely filing period. D. Transfer the balance to patient responsibility and try to collect from the patient. Answer: A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim. ◉ Incorrect entry of the patient demographics can have an effect on many areas of the practice. What documents are necessary to verify demographics? I. Photo Identification II. Insurance card III. Credit card information IV. Social Security card V. Patient completed demographic form A. I and V B. II and IV C. II, IV and V
D. I, II, and V Answer: D. I, II, and V ◉ CMS has a standard enrollment form in which the provider agrees to: I. Submit claims to Medicare II. Have authorization from the Medicare beneficiary to file claims III. Retain all source documentation and medical records IV. Submit claims within 60 days of the date of service V. Submit all claims with a group NPI number VI. Research and correct claim discrepancies. A. I, II, and IV B. II, IV, and V C. I, III, IV, and VI D. I, II, III, and VI Answer: D. I, II, III, and VI ◉ Ms. Turner had surgery one month ago for hernia repair. She is still in the post-operative period and comes in today to the see the same physician that performed the hernia repair surgery about a lump that she noticed on her tailbone. The physician performs an examination and the diagnosis is that she has a pilonidal cyst which is unrelated to the surgery. Can the physician bill an E/M service for today's visit during the post-operative period?
A. 11642
B. 11442
C. 11642, 12051- 51
D. 11442, 12051-51 Answer: C. 11642, 12051- 51 ◉ 55 - year-old female presents to the office with ongoing history of type I diabetes which has been controlled with insulin. During the exam the physician notes that gangrene has set in due to the diabetic peripheral angiopathy on her left great toe. Patient is recommended to see a general surgeon for treatment of the gangrene on her left great toe. A. I96, E10.9, Z79. B. E11.52, I96, Z79. C. E10. D. I96, E11.52 Answer: C. E10. ◉ What is the correct HCPCS Level II code for Depo-Provera (medroxyprogesterone acetate) injection of 100 mg? A. J B. J1050 x 100
C. J1020 x 5 D. J1030 x 3 Answer: B. J1050 x 100 ◉ The provider performs an office visit with an expanded problem focused history, expanded problem focused exam and low MDM to manage the patient's hypertension. The provider also destroys two plantar warts. How is this reported? A. 99213-25, 17110 B. 99213-25, 17110- 59 C. 99213, 17110- 25 D. 99213, 17110-59 Answer: A. 99213-25, 17110 ◉ HMO plans require the enrollee to: Answer: To have referrals to see a specialist that is generated by the patient's PCP ◉ What are PPOs (preferred provider organizations)? Answer: Organizations in which medical professionals and facilities provide services to subscribed clients at reduced rates. ◉ What is a covered entity? Answer: Health plans, clearinghouses, and any entity transmitting health information is considered to be as is stated by the Privacy Rule.
undeserved benefits or payment from a federal healthcare program, or billing for services that were not performed. Answer: Fraud ◉ A claim is submitted for a patient on medicare with a higher fee schedule that a patient on Insurance ABC. What is this considered under CMS? Answer: Abuse ◉ A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statue? Answer: FCA (False claims act) ◉ What act is "upcoding or unbundling services" considered under? Answer: The false claims act ◉ A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor? Answer: TILA (truth in lending act) ◉ A patient is seen in your clinic. Her husband calls later in the day to ask for information about the visit. The practice pulls the patients privacy authorization to see if they can speak to the husband. What act does this action fall under? Answer: HIPAA ◉ Medicare was passed into law under what Act? Answer: SSA
◉ Are healthcare regulations the same in each state? Answer: No, they will vary from state to state. ◉ A physician's office (covered entity) discovers that the billing company (Business associate) is in breach of their contract. What is the first steps to be taken. Answer: Take steps to correct the problem and end the violation. ◉ OIG, CMS, and the DOJ are the government agencies enforcing what laws? Answer: Federal fraud and abuse laws ◉ Do fraud and abuse penalties include the ability to refile claims in question? Answer: No ◉ A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are an OB/Gyn office, they bull every patient for a urinalysis. What does this violate? Answer: FCA ◉ Medical records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate? Answer: Minimum necessary
◉ In addition to the standardization of the codes what other identifier is used on all claims? Answer: A unique identifier for employers and providers ◉ The federal false claims act allows for claims to be reviewed for how many years after an incident? Answer: Seven years ◉ Entities that have been identified as having improper billing practices are defined by CMS as a violation of what standard? Answer: Abuse ◉ What penalties can be imposed for Fraud and / or abuse related to the US code? Answer: Monetary penalties ranging from $10k to $50k (before inflation) for each item or service, imprisonment, and exclusion from federal healthcare programs. ◉ How long after being identified should a practice return medicare over payments? (days) Answer: 60 days ◉ A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? Answer: A covered entity
◉ According to the privacy rule, what health information may not be de-identified? Answer: The physician provider number ◉ A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? Answer: A breach ◉ A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate? Answer: TILA ◉ When a practice sends an electronic claim to a commercial health plan for payment, what is this considered? Answer: A transaction ◉ While working in a large practice, medicare over-payments are found in several patient accounts. The manager states that the practice will keep the money until medicare asks for it back. What does this action constitute? Answer: Fraud ◉ What were the eight standard EDI transactions adopted under? Answer: HIPAA
◉ If a provider is excluded from federal health plans, what does that mean? Answer: They many not participate in Medicare, Medicaid, VA programs, or Tricare and They cannot bill for services or provide services, order services, or prescribe medication to any beneficiary of a federal plan. ◉ What is the purpose of the privacy rule? Answer: To protect patient privacy ◉ A records request is received from a health plan for three dates of service in a chart months apart. What should the biller do? Answer: Copy each date of service individually and send to the health plan. ◉ Is a healthcare consulting firm considered a covered entity? Answer: No ◉ A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every medicare patient you send them for radiology services. What does this offer violate? Answer: The Anti-kickback law ◉ How many national priority purposes are under the Privacy rule to disclose PHI without an individuals authorization? Answer: 12
◉ What are the 12 national priority purposes under the privacy rule? Answer: 1. Required by law
- Public health activities
- Victims of abuse / neglect/ domestic violence
- Health oversight activities
- Judicial and administrative proceedings
- Law enforcement purposes
- decedents
- cadaver organ / eye / tissue donation
- Research
- Serious threat to health or safety
- Essential government functions
- Workers comp. ◉ What types of entities doe conditions of participation apply to for health plans? Answer: Hospitals, clinics, transplant centers, psychiatric hospitals, etc ◉ What is the key term that distinguishes fraud from abuse? Answer: "knowingly" ◉ Federal agencies are required to pay clean claims within how many days? Answer: 30
