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CRCR Certification Exam Questions and Answers 2022/2023 Latest Exam Guide The disadvantages of outsourcing include all of the following EXCEPT: a) The impact of customer service or patient relations b) The impact of loss of direct control of accounts receivable services c) Increased costs due to vendor ineffectiveness d) Reduced internal staffing costs and a reliance on outsourced staff - ☑☑️d️) Reduced internal staffing costs and a reliance on outsourced staff The Medicare fee-for service appeal process for both beneficiaries and providers includes all of the following levels EXCEPT: a) Medical necessity review by an independent physician's panel b) Judicial review by a federal district court c) Redetermination by the company that handles claims for Medicare d) Review by the Medicare Appeals Council (Appeals Council) - ☑☑️b️) Judicial review by a federal district court Business ethics, or organizational ethics represent: a) The principles and standards by which organizations operate b) Regulations that must be followed by law c) Definitions of appropriate customer service d) The code of acceptable conduct - ☑☑️a️) The principles and standards by which organizations operate A portion of the accounts receivable inventory which has NOT qualified for billing includes: a) Charitable pledges b) Accounts created during pre-registration but not activated c) Accounts coded but held within the suspense period d) Accounts assigned to a pre-collection agency - ☑☑️a️) Charitable pledges Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are Medicare established guideline(s) used to determine: a) Medicare and Medicaid provider eligibility b) Medicare outpatient reimbursement rates c) Which diagnoses, signs, or symptoms are reimbursable b) Educating staff on regulations c) Systematic procedures to ensure that the provisions of regulations imposed by a government agency are being met d) The development of operational policies that correspond to regulations - ☑☑️c️) Systematic procedures to ensure that the provisions of regulations imposed by a government 10. Case Management requires that a case manager be assigned a) To patients of any physician requesting case management b) To a select patient group c) To every patient d) To specific cases designated by third party contractual agreement - ☑☑️b️) To a select patient group Pricing transparency is defined as readily available information on the price of healthcare services, that together with other information, help define the value of those services and enable consumers to a) Identify, compare, and choose providers that offer the desired level of value b) Customize health care with a personally chosen mix of providers c) Negotiate the cost of health plan premiums d) Verify the cost of individual clinicians - ☑☑️a️) Identify, compare, and choose providers that offer the desired level of value Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons based on a monthly fee is known as a a) MSO b) HMO c) PPO d) GPO - ☑☑️b️) HMO In a Chapter 7 Straight Bankruptcy filing a) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt b) The court liquidates the debtor's nonexempt property, pays creditors, and begins to pay off the largest claims first. All claims are paid some portion of the amount owed c) The court vacates all claims against a debtor with the understanding that the debtor may not apply for credit without court supervision d) The court establishes a creditor payment schedule with the longest outstanding claims paid first - ☑☑️a️) The court liquidates the debtor's nonexempt property, pays creditors, and discharges the debtor from the debt 14. The core financial activities resolved within patient access include: a) Scheduling, pre-registration, insurance verification and managed care processing b) Scheduling, insurance verification, clinical discharge processing and payment posting of point of service receipts c) Scheduling, registration, charge entry and managed care processing d) Scheduling, pre-registration, registration, medical necessity screening and patient refunds - ☑☑️a️) Scheduling, pre-registration, insurance verification and managed care processing 15. Which of the following is NOT contained in a collection agency agreement? d) Are focused on verifying required third-party payer information - ☑☑️b️) Should take place between the patient or guarantor and properly trained provider representatives The purpose of a financial report is to: a) Provide a public record, if requested b) Present financial information to decision makers c) Prepare tax documents d) Monitor expenses - ☑☑️b️) Present financial information to decision makers Which statement is an EMTALA (Emergency Medical Treatment and Active Labor Act) violation? a) Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician b) Initial registration activities may occur so long as these activities do not delay treatment or suggest that treatment with not be provided to uninsured individuals c) Co-payments may be collected at the time of service once the medical screening and stabilization activities are completed d) Signage must be posted where it can be easily seen and read by patients - ☑☑️a️) Registration staff may routinely contact managed are plans for prior authorizations before the patient is seen by the on-duty physician A claim is denied for the following reasons, EXCEPT: a) The health plan cannot identify the subscriber b) The frequency of service was outside the coverage timeline c) The submitted claim does not have the physicians signature d) The subscriber was not enrolled at the time of service - ☑☑️c️) The submitted claim does not have the physicians signature Any provider that has filed a timely cost report may appeal an adverse final decision received from the Medicare Administrative Contractor (MAC). This appeal may be filed with a) A court appointed federal mediator b) The Department of Health and Human Services Provider Relations Division c) The Office of the Inspector General d) The Provider Reimbursement Review Board - ☑☑️d️) The Provider Reimbursement Review Board Charges, as the most appropriate measurement of utilization, enables a) Generation of timely and accurate billing b) Managing of expense budgets c) Accuracy of expense and cost capture d) Effective HIM planning - ☑☑️a️) Generation of timely and accurate billing Ambulance services are billed directly to the health plan for a) All pre-admission emergency transports b) Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility c) The portion of the bill outside of the patient's self-pay d) Transports deemed medically necessary by the attending paramedic- ambulance crew - ☑☑️c️) The portion of the bill outside of the patient's self-pay An individual enrolled in Medicare who is dissatisfied with the government's claim determination is entitled to reconsideration of the decision. This type of appeal is known as a) A beneficiary appeal b) A Medicare supplemental review c) A payment review d) Determine the correct primary payer and notify incorrect payer of overpayment - ☑☑️a️) Designate the overpayment for charity care EFT (electronic funds transfer) is a) An electronic claim submission b) The record of payments in the hospital's accounting system c) An electronic confirmation that a payment is due d) An electronic transfer of funds from payer to payee - ☑☑️d️) An electronic transfer of funds from payer to payee Revenue cycle activities occurring at the point-of-service include all the following EXCEPT: a) The monitoring of charges b) The provision of case management and discharge planning services c) Providing charges to the third-party payer as they are incurred d) The generation of charges - ☑☑️c️) Providing charges to the third-party payer as they are incurred Medicare beneficiaries remain in the same "benefit period" a) Up to hospitalization discharge b) Until the beneficiary is "hospitalization and/or skilled nursing facility-free" for 60 consecutive days c) Each calendar year d) Up to 60 days - ☑☑️b️) Until the beneficiary is "hospitalization and/or skilled nursing facility-free" for 60 consecutive days Key Performance Indicators (KPIs) set standards for accounts receivables (A/R) and a) Provide evidence of financial status b) Provide a method of measuring the collection and control of A/R c) Establish productivity targets d) Make allowance for accurate revenue forecasting - ☑☑️b️) Provide a method of measuring the collection and control of A/R Recognizing that health coverage is complicated and not all patients are able to navigate this terrain, HFMA best practices specify that a) The patient accounts staff have someone assigned to research coverage on behalf of patients b) Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions c) Patient coverage education may need to be provided by the health plan d) A representative of the health plan be included in the patient financial responsibilities discussion - ☑☑️b️) Patients should be given the opportunity to request a patient advocate, family member, or other designee to help them in these discussions When there is a request for service, the scheduling staff member must confirm the patient's unique identification information to a) Check if there is any patient balance due b) Verify the patient's insurance coverage if the patient is a returning customer c) Confirm that physician orders have been received d) Ensure that she/he accesses the correct information in the historical database - ☑☑️d️) Ensure that she/he accesses the correct information in the historical database Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Explain to the patient their financial responsibility and to determine the plan for payment b) Allow the patient time to compare prices with other providers c) Lock-in the prices A nightly room charge will be incorrect if the patient's a) Discharge for the next day has not been charted b) Condition has not been discussed during the shift change report meeting c) Pharmacy orders to the ICU have not been entered in the pharmacy system d) Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system - ☑☑️d️) Transfer from ICU (intensive care unit) to the Medical/Surgical floor is not reflected in the registration system Which of the following is required for participation in Medicaid? a) Meet income and assets requirements b) Meet a minimum yearly premium c) Be free of chronic conditions d) Obtain a health insurance policy - ☑☑️a️) Meet income and assets requirements HFMA best practices call for patient financial discussions to be reinforced a) By issuing a new invoice to the patient b) By copying the provider's attorney on a written statement of conversation c) By obtaining some type of collateral d) By changing policies to programs - ☑☑️b️) By copying the provider's attorney on a written statement of conversation A Medicare Part A benefit period begins: a) With admission as an inpatient b) The first day in which an individual has not been a hospital inpatient not in a skilled nursing facility for the previous 60 days c) Upon the day the coverage premium is paid d) Immediately once authorization for treatment is provided by the health plan - ☑☑️a️) With admission as an inpatient If further treatment can only be provided in a hospital setting, the patient's condition cannot be evaluated and/or treated within 24 hours, or if there is not an anticipation of improvement in the patient's condition with 24 hours, the patient a) Will remain in observation for up to 72 hours after which the patient is admitted as an inpatient b) Will be admitted as an inpatient c) Will be discharged and if needed, designated to a priority one outpatient status d) Will have his/her case reviewed by the attending physician, a consulting physician and the primary care physician and a future course of care will then be determined - ☑☑️b️) Will be admitted as an inpatient It is important to have high registration quality standards because a) Incomplete registrations will trigger exclusion from Medicare participation b) Incomplete registrations will raise satisfaction scores for the hospital c) Inaccurate registration may cause discharge before full treatment is obtained d) Inaccurate or incomplete patient data will delay payment or cause denials - ☑☑️d️) Inaccurate or incomplete patient data will delay payment or cause denials Medicare will only pay for tests and services that a) Constitute appropriate treatment and are fairly priced b) Have solid documentation c) Can be demonstrated as necessary d) Medicare determines are "reasonable and necessary" - ☑☑️d️) Medicare determines are "reasonable and necessary" c) Complete registration and insurance approval before service d) Register the patient after he or she is placed in a bed on that service unit. - ☑☑️c️) Complete registration and insurance approval before service The first and most critical step in registering a patient, whether scheduled or unscheduled, is a) Having the patient initial the HIPAA privacy statement b) Verifying insurance to activate the patient medical record c) Verifying the patient's identification d) Check the schedule for treatment availability - ☑☑️c️) Verifying the patient's identification The legal authority to request and analyze provider clam documentation to ensure that IPPS services were reasonable and necessary is given to a) Recovery Audit Contractors (RAC) b) The Office of the U.S. Inspector General (OIG) c) All health plans d) State insurance commissioners - ☑☑️b️) The Office of the U.S. Inspector General (OIG) An advantage of a pre-registration program is a) The opportunity to reduce processing times at the time of service b) The ability to eliminate no-show appointments c) The opportunity to reduce the corporate compliance failures within the registration process d) The marketing value of such a program - ☑☑️c️) The opportunity to reduce the corporate compliance failures within the registration process Claims with dates of service received later than one calendar year beyond the date of service, will be a) Denied by Medicare b) The provider's responsibility but can be deemed charity care c) Fully paid with interest d) The full responsibility of the patient. - ☑☑️a️) Denied by Medicare This concept encompasses all activities required to send a request for payment to a third-party health plan for payment of benefits a) Third-party invoicing b) Account resolution c) Claims processing d) Billing - ☑☑️c️) Claims processing The ACO investment model will test the use of pre-paid shared savings to a) Raise quality ratings in designated hospitals. b) Encourage new ACOs to form in rural and underserved areas c) Attract physicians to participate in the ACO payment system d) Invest in treatment protocols that reduce costs to Medicare - ☑☑️b️) Encourage new ACOs to form in rural and underserved areas Chapter 13 Bankruptcy, debtor rehabilitation, is a court proceeding a) That establishes a payment priority order to creditors' claims b) That classifies the debtor as eligible for government financial assistance for housing, medical treatment and food as debts are paid c) That creates a clear court-supervised payment accountability plan going forward d) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment - ☑☑️d️) That reorganizes a debtor's holdings and instructs creditors to look to the debtor's future earnings for payment d) Are the evidence cited in quality review - ☑☑️a️) Are the primary source for clinical data required for reimbursement by health plans and liability payers A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgments based on all of the following EXCEPT: a) The patient's home care coverage b) Current medical needs c) The likelihood of an adverse event occurring to the patient d) The patient's medical history - ☑☑️a️) The patient's home care coverage Medicare has established guidelines called the Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) that establish a) Provider and physician reimbursement for specific diagnoses and tests b) Prospective Medicare patient financial responsibilities for a given diagnosis c) Reasonable and customary prices for services in a given area d) What services or healthcare items are covered under Medicare - ☑☑️d️) What services or healthcare items are covered under Medicare What are some core elements if a board-approved financial assistance policy? a) Payment requirements, staffing hours, and admission policies b) Case management, payment methods, and discharge policies c) Deposit requirements, pre-registration calling hours, and charity care policy d) Eligibility, application process, and nonpayment collection activities - ☑☑️d️) Eligibility, application process, and nonpayment collection activities The ICD-10 codes set and CPT/HCPCS code sets combines provide a) Pricing floors for services b) The financial data required for activity-based costing c) Patients an overview of services covered by their health insurance plan d) The specificity and coding needed to support reimbursement claims - ☑☑️d️) The specificity and coding needed to support reimbursement claims A recurring/series registration is characterized by a) A creation of multiple registrations for multiple services b) The creation of one registration record for multiple days of service c) The creation of multiple patient types for one date of service d) The creation of one registration record per diagnosis per visit - ☑☑️b️) The creation of one registration record for multiple days of service Under EMTALA (Emergency Medical Treatment and Labor Act) regulations, the provider may not ask about a patient's insurance information if it would delay what? a) Complete course of treatment b) Medical screening and stabilizing treatment c) Admission to observation status d) Transfer to another facility - ☑☑️b️) Medical screening and stabilizing treatment In resolving medical accounts, a law firm may be used as: a) An independent auditor of a financial assistance policy b) Legal counsel to patients regarding financing options c) An independent broker of patient financial assistance from banks d) A substitute for a collection agency - ☑☑️d️) A substitute for a collection agency The unscheduled "direct" admission represents a patient who: a) Is admitted from a physician's office on an urgent basis b) Arrives at the hospital via ambulance for treatment in the emergency room c) Is an ambulatory patient who collapses in the hospital lobby d) Assets liquidity, Income, expenses, credit worthiness - ☑☑️b️) Patient and guarantor's income, expenses and assets For scheduled patients, important revenue cycle activities I the Time of Service stage DO NOT INCLUDE: a) Pre-registration record is activated, consents are signed, and co-payment is collected b) Positive patient identification is completed, and patient is given an armband c) Final bill is presented for payment d) Preprocessed patients may report to a designated "express" desk - ☑☑️c️) Final bill is presented for payment The Electronic Remittance Advice (ERA) data set is : a) Used for Electronic Funds Transfers between hospitals and a bank b) A standardized form that provides 3rd party payment details to providers c) Required for annual Medicare quality reporting forms d) Safeguards the Electronic claims process - ☑☑️b️) A standardized form that provides 3rd party payment details to providers Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: a) Patient financial communications best practices specific to staff role b) Financial assistance policies c) Documenting the conversation in the medical records d) Available patient financing options - ☑☑️c️) Documenting the conversation in the medical records All of the following information should be reviewed as part of schedule finalization EXCEPT: a) The results of any and all test b) The service to be provided c) The arrival time and procedure time d) The patient's preparation instructions - ☑☑️a️) The results of any and all test Indemnity plans usually reimburse: a) Only for contracted Services b) A claim up to 80% of the charges c) A certain percentage of the charges after the patient meets the policy's annual deductible d) A patient for out-of-pocket charges - ☑☑️c️) A certain percentage of the charges after the patient meets the policy's annual deductible Because 501(r) regulations focus on identifying potential eligible financial assistants patients hospitals must: a) Capture their experience with such patients to properly budget b) Hold financial conversations with patients as soon as possible c) Build the necessary processes to handle the potentially lengthy payment schedule d) Expedite payment processing of normal accounts receivable to protect cash flow - ☑☑️b️) Hold financial conversations with patients as soon as possible Which option is a benefit of pre-registering a patient for services a) The patient arrival process is expedited, reducing wait times and delays b) The verification of insurance after completion of the services c) Service departments have the ability to override schedules and block time to reduce testing volume d) The patient receiving multiple calls from the provider - ☑☑️a️) The patient arrival process is expedited, reducing wait times and delays d) The process of closing an account - ☑☑️a️) The data collection steps for scheduling and pre-registering a patient Insurance verification results in which of the following a) The accurate identification of the patient's eligibility and benefits b) The consistent formatting of the patient's name and identification number c) The resolution of managed care and billing requirements d) The identification of physician fee schedule amounts and the NPI (national provider identifier) numbers - ☑☑️a️) The accurate identification of the patient's eligibility and benefits A four-digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line item in the charge master is known as a) HCPCs codes b) ICD-10 Procedural codes c) CPT codes d) Revenue codes - ☑☑️d️) Revenue codes The importance of Medical records being maintained by HIM is that the patient records: a) Are evidence used in assessing the quality of care b) Are the primary source for clinical data required for reimbursement by health plans and liability payers c) Are the strongest evidence and defense in the event of a Medicare Audit d) Are the evidence cited in quality review - ☑☑️b️) Are the primary source for clinical data required for reimbursement by health plans and liability payers Medicare patients are NOT required to produce a physician order to receive which of these services a) Diagnostic Mammography, flu vaccine, or B-12 shots b) Diagnostic Mammography, flu vaccine, or pneumonia vaccine c) Screening Mammography, flu vaccine or pneumonia vaccine d) Screening Mammography, flu vaccine or B-12 shots - ☑☑️c️) Screening Mammography, flu vaccine or pneumonia vaccine Patients should be informed that costs presented in a price estimate may a) Vary from estimates, depending on the actual services performed b) Be guaranteed if the patient satisfies all patient financial responsibilities at the time of registration c) Be lower as price estimates use the highest market price d) Only determine the percentage of the total that the patient is responsible for and not the actual cost - ☑☑️a️) Vary from estimates, depending on the actual services performed Ambulance services are billed directly to the health plan for a) All pre-admission emergency transports b) Transport deemed medically necessary by the attending paramedic- ambulance crew c) Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility d) The portion of the bill outside of the patient's self-pay - ☑☑️c️) Services provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility In Chapter 7 straight bankruptcy filling a) The court establishes a creditor payment schedule with the longest outstanding claims paid first b) Bundled Payment c) Fixed Contracting d) Contracted Rebating - ☑☑️d️) Contracted Rebating The standard claim form used for billing by hospitals, nursing facilities, and other in-Patient services is called the a) UB-04 b) 1500 c) COST REPORT d) REMITTANCE NOTICE - ☑☑️a️) UB-04 To maximize the value derived from customer complaints, all consumer complaints should be a) Responded to within two business days b) Tracked and shared to improve the customer experience c) Handled by a specially trained "service" team d) Brought immediately to management's attention - ☑☑️a️) Responded to within two business days The HCAHPS (hospital consumer assessment of healthcare providers and systems) Initiative was launched to a) Gather national date on overall trust in the nation's health care system b) Create a national database on physician quality c) Provide a standardized method for evaluating patient's perspective on hospital care. d) Provide data for building shared savings reimbursement for quality procedures. - ☑☑️c️) Provide a standardized method for evaluating patient's perspective on hospital care. Health Plan Contracting Departments do all of the following EXCEPT a) Establish a global reimbursement rate to use with all third-party payer b) Review all managed care contracts for accuracy for loading contract terms into the patient accounting system c) Review payment schemes to ensure that the health plan and provider understand how reimbursements must be calculated d) Review contracts to ensure the appeals process for denied claims is clearly specified - ☑☑️a️) Establish a global reimbursement rate to use with all third- party payer The benefit of Medicare Advantage Plan is a) It is a less costly plan compared to traditional Medicare b) Patients may retain a primary care physician and see another physician for a second opinion at no charge c) Patients generally have their Medicare-coverage healthcare through the plan and do not need to worry about "part" or "part b" benefits d) Patients receive significant discounting on services contracted by the federal government - ☑☑️c️) Patients generally have their Medicare-coverage healthcare through the plan and do not need to worry about "part" or "part b" benefits Once the EMTALA requirements are satisfied a) Third-party payer info should be collected from the patient and the payer should be notified of the ED visit b) An initial registration record is completed so that the proper coding can be initiated c) The patient then assumes full liability for services unless a third-party payer is notified or the patient applies for financial assistance within the first 48 hours d) The remaining registration processing is initiated either at the bedside or In a registration area - ☑☑️a️) Third-party payer info should be collected from the patient and the payer should be notified of the ED visit Which option is a government-sponsored health care program that is financed through Taxes and general revenue funds a) Medicaid b) Medicare c) Insurance exchange d) Social security - ☑☑️b️) Medicare It is important to calculate reserves to ensure a) Stable financial operations and accurate financial reporting b) Collateral for credit c) Expense coverage in the event of a revenue short fall d) Coverage of B/D write offs and charity care costs - ☑☑️a️) Stable financial operations and accurate financial reporting Successful account resolution begins with a) Educating patients on their estimated financial responsibility b) Collecting all deductibles and copayments during the pre-service stage c) Accurate documentation of services d) Patient compliance with the course of treatment - ☑☑️b️) Collecting all deductibles and copayments during the pre-service stage An individual enrolled in Medicare who is dissatisfied with the government's claim determination is entitled to reconsideration of the decision. This type of appeal is known as a) A Medicare determination appeal b) A payment review c) A Medicare supplemental review d) A beneficiary appeal - ☑☑️d️) A beneficiary appeal A portion of the accounts receivable inventory which has NOT qualified for billing includes a) Charitable pledges b) Accounts assigned to a pre-collection agency c) Accounts coded but held within the suspense period d) Accounts created during pre-registration but not activated - ☑☑️a️) Charitable pledges Checks received through mail, cash received through mail, and lock box are all examples of a) Highly fraud prone processes b) Payment methods in which the majority of fraud occurs c) Payment methods being phased out for more secure payment method options d) Control points for cash posting - ☑☑️d️) Control points for cash posting Recognizing that health coverage is complicated and not all patients are able to navigate this terrain, HFMA best practices specify that a) A representative of the health plan be included in the patient financial responsibilities discussion b) The patient accounts staff have someone assigned to research coverage on behalf of patients c) Patients should be given the opportunity to request a patient advocate, family member or other designee to help them in these discussions d) Patient coverage education may need to be provided by the health plan - ☑☑️c️) Patients should be given the opportunity to request a patient advocate, family member or other designee to help them in these discussions Once the price is estimated in the pre-service stage, a provider's financial best practice is to a) Allow the patient time to compare prices with other providers a) Timely and remind patients of their financial responsibilities b) Consistent, clear and transparent c) Current and report the status of a patients claim d) Timely, comprehensive and specifying next steps - ☑☑️b️) Consistent, clear and transparent Key performance indicators (KPIs) set standards for accounts receivables (A/R) and a) Establish productivity targets b) Provide a method of measuring the collection and control of A/R c) Provide evidence of financial status d) Make allowance for accurate revenue forecasting - ☑☑️b️) Provide a method of measuring the collection and control of A/R When Recovery Audit Contractors (RAC) identify improper payments as over payments, the claims processing contractor must a) Assume legal responsibility for repaying the overage amount b) Make recovery of the overpayment the top processing priority c) Send a demand letter to the provider to recover the over payment amount d) Conduct an audit of all the effected providers claims within the past twelve months - ☑☑️c️) Send a demand letter to the provider to recover the over payment amount A recurring/series registration is characterized by a) The creation of one registration record for multiple days of service b) The creation of multiple registrations for multiple services c) The creation of one registration record per diagnosis per visits d) The creation of multiple patient types for one date of service - ☑☑️a️) The creation of one registration record for multiple days of service It is important to have high registration quality standards because a) Inaccurate or incomplete patient data will delay payment or cause denials b) Incomplete registrations will trigger exclusion from Medicare participation c) Inaccurate registration may cause discharge before full treatment is obtained d) Incomplete registrations will raise satisfaction scores for the hospital - ☑☑️a️) Inaccurate or incomplete patient data will delay payment or cause denials When recovery audit contractors (RAC) identify improper payments as overpayments the claims processing contractor must a) Assume legal responsibility for repaying the overage amount b) Make recovery of the overpayment the top processing priority c) Send a demand letter to the provider to recover the over payment amount d) Conduct an audit of all the effected providers claims within the past 12 months - ☑☑️c️) Send a demand letter to the provider to recover the over payment amount Internal controls addressing coding and reimbursement changes are put I place to guard against a) Underpayments b) Denials c) Compliance fraud by upcoding d) Charge master error - ☑☑️c️) Compliance fraud by upcoding The patient discharge process begins when a) The physician writes the discharge orders b) Clinical services are completed, and patient accounts have all the info necessary to bill c) The physician writes the discharge orders and the third-party payer sign-off on the necessity of the services provided d) The price of service to their covering health plan - ☑☑️b️) The service providers that typically participate in the service, e.g. Radiologists, pathologists, etc. Telemed seeks to improve a patient's health by a) Permitting 2-way real time interactive communication between the patient and the clinical professional b) Using high-compression fiber optics to transmit medical data c) Providing relevant, on-demand consumer medical education d) Providing physician access to the most current medical research - ☑☑️a️) Permitting 2-way real time interactive communication between the patient and the clinical professional A large number of credit balances are not the result of overpayments but of a) Posting errors in the patient accounting system b) Incorrect claim submissions c) Inadequate staff training d) Banking transaction errors - ☑☑️a️) Posting errors in the patient accounting system Across all care settings, if a patient consents to a financial discussion during a medical Encounter to expedite discharge, the HFMA best practice is to a) Have a patient financial responsibilities kit ready for the patient containing all of the required registration forms and instructions b) Make sure that the attending staff can answer questions and assist in obtaining required patient financial data c) Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow d) Decline such request as finance discussions can disrupt patient care and patient flow - ☑☑️c️) Support that choice, providing that the discussion does not interfere with patient care or disrupt patient flow The office of inspector general (OIG) publishes a compliance work plan a) Monthly b) Quarterly c) Semi-annually d) Annually - ☑☑️d️) Annually Through what document does a hospital establish compliance standards? - ☑☑️C️ode of Conduct What is the purpose OIG work plan? - ☑☑️I️dentify Acceptable compliance programs in various provider setting If a Medicare patient is admitted on Friday, what services fall within the three- day DRG window rule? - ☑☑️N️on-diagnostic services provided on Tuesday through Friday What does a modifier allow a provider to do? - ☑☑️R️eport a specific circumstance that affected a procedure or service without changing the code or its definition. If outpatient diagnostic services are provided within three day of the admission of a Medicare beneficiary to an IPPS (Inpatient Prospective Payment System) hospital, what must happen to - ☑☑️T️hey must be billed separately to the Part B carrier What is a recurring or series registration? - ☑☑️O️ne registration record is created for multiple days of service Which of the following is a step in the discharge process? - ☑☑️H️ave case management services complete the discharge plan The hospital has a APC (ambulatory payment classification)-based contract for the payment of outpatient services. Total anticipated charges for the visit are $2,380. The approved APC payment rate is $780. Where will the patients' benefit package be applied? - ☑☑️T️o the approved APC payment rate A patient has met the $200 individual deductible and $900 of the $1000 co- insurance responsibility. The co-insurance rate is 20%. The estimated insurance plan responsibility is $1975.00. What amount of coinsurance is due from the patient? - ☑☑️$️100 When is a patient considered to be medically indigent? - ☑☑️T️he patient's outstanding medical bills exceed a defined dollar amount or percentage of assets. What patient assets are considered in the financial assistance applications? - ☑☑️S️ources of readily available funds, such as vehicles, campers, boats and savings accounts If the patient cannot agree to payment arrangements, what is the next option? - ☑☑️W️arn the patient that unpaid accounts are placed with collection agencies for further processing What core financial activities are resolved within patient access? - ☑☑️S️cheduling, pre-registration, insurance verification, and managed care processing What is an unscheduled direct admission? - ☑☑️A️ patient who arrives at the hospital via ambulance for treatment in the emergency department When is it not appropriate to use observation status? - ☑☑️A️s a substitute for an inpatient admission Parents who require periodic skilled nursing or therapeutic care receive services from what type of program? - ☑☑️H️ome health agency Every patient who is new to the healthcare provider must be offered what? - ☑☑️A️ printed copy of the provider's privacy notice Which of the following statements applies to self-insured insurance plans? - ☑☑️T️he employer provides a traditional HMO (health maintenance organization) health plan In addition to the member's identification number, what information is records in a 270 transaction? - ☑☑️N️ame What process does a patients' health plan use to retroactively collect payments from liability, automobile, or worker's compensation plans? - ☑☑️S️ubrogation In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - ☑☑️D️RG (diagnosis- related groups) rates What restriction does a managed care plan place on locations that must be used if the plan is to pay for the service provided? - ☑☑️S️ite-of-service limitation Which of the following statements applies to private rooms? - ☑☑️I️f the medical necessity for a private room is documented in the chart, the patient's insurance will be billed for the differential. What type of plan restricts benefits for nonemergency care to approve providers only? - ☑☑️A️ POS (point-of-service) plan What does scheduling allow provider staff to do? - ☑☑️R️eview the appropriateness of the service requested When an adult patient is covered by both his own and his spouse's health insurance plan, which of the statements is true? - ☑☑️T️he patient's insurance plan is primary Mrs. Jones, a Medicare beneficiary, was admitted to the hospital on June 20, 2010. As of the admission date, she had only used 8 inpatient days in the current benefit period. If she is not discharged, on what date will Mrs. Jones exhaust her full coverage days. - ☑☑️A️ugust 9, 2010 In order to meet eligibility guidelines for healthcare benefits, Medicaid beneficiaries must fall into a specified need category and meet what other types of requirements. - ☑☑️I️ncome and asset Fee-for-service plans pay claims based on a percentage of charges. How are patients out-of-pocket costs calculated? - ☑☑️T️hey are calculated quarterly Indemnity plans usually reimburse what? - ☑☑️A️ certain percentage of charges after patient meets policy's annual deductible. Departments that need to be included in Charge master maintenance include all EXCEPT: - ☑☑️Q️uality Assurance Using HIPPA standardized transaction sets allow providers to: - ☑☑️S️ubmit a standardized transaction to any of the health plans with which it conducts business. Which of the following is NOT included in the standardized quality measures? - ☑☑️C️ost of services The ACO investment model will test the use of pre-paid shared savings to: - ☑☑️E️ncourage new ACOs to form in rural and underserved areas. Any healthcare insurance plan that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons on a monthly fee is known as: - ☑☑️H️MO Ambulance services are billed directly to the health plan for: - ☑☑️S️ervices provided before a patient is admitted and for ambulance rides arranged to pick up the patient from the hospital after discharge to take him/her home or to another facility. Any provider that has filed a timely cost report may appeal in an adverse final decision received from the Medicare Administrative Contractor (MAC), the appeal may be filed with: - ☑☑️T️he Provider Reimbursement Review Board. ICD-10-CM and ICD-10-PCD code sets are modifications of: - ☑☑️I️CD-9 Codes. For scheduled payments, important revenue cycle activities in the time-of- service stage DO Not include: - ☑☑️O️btaining or updating patient and guarantor information Hospital can only convert an inpatient case to observation if: - ☑☑️T️he hospital utilization review committee determines before the patient is discharged and prior to billing that an observation setting would be more appropriate. Hospital need which of the following information sets to assess a patient's financial status? - ☑☑️D️emographic, Income, Assets and Expenses. The disadvantage of outsourcing includes all, of the following Except - ☑☑️R️educes internal staffing costs and a reliance on outsourced staff. Marinating routine contact with health plan or liability payer, making sure all required information is provided and all needed approvals are obtained is the responsibility of who: - ☑☑️C️ase Management A claim is denied for the following reasons EXCEPT: - ☑☑️T️he submitted claim does not have the physician signature All Hospitals are required to establish a written financial assistance policy that applies to: - ☑☑️A️ll emergency and medically necessary care Examples of ethics violation that impact the revenue cycle include all of the following EXCEPT: - ☑☑️S️eeking payment options for self-pay Verbal orders from a physician for a service(s) are: - ☑☑️A️cceptable if given to "qualified" staff as defined in a hospitals policies and procedures Medicare has established guidelines called Local Coverage Determination (LCD) and National Coverage Determination (NCD) that establish: - ☑☑️W️hat serviced or healthcare items are covered under Medicare A decision on whether a patient should be admitted as an inpatient or become an outpatient observation patient requires medical judgement based on all of the following EXCEPT: - ☑☑️T️he patient's home care coverage What is the first step of the daily cash reconciliation process? - ☑☑️O️btaining cash, check, credit card and debit card payment from that day The healthcare industry is vulnerable to compliance issues, in large part due to the complexity of the statutes and regulations pertaining to: - ☑☑️M️edicare and Medicaid payments The correct coding initiative program consist of: - ☑☑️E️dits that are implemented within provider's claim processing system The Affordable Health Care Act legislated the development of Health Insurance Exchange, where individuals and small businesses can: - ☑☑️P️urchase health benefits plans regardless of insured's health status Before classifying and subsequently writing off an account to financial assistance or bad debit, the hospital must establish policy define appropriate criteria, implement procedures for identifying accounts and: - ☑☑️M️onitor compliance The Electronic Remittance Advice (ERA) data sets are: - ☑☑️A️ standardized for that provides 3rd party payment details to providers The first and most critical step in registering a patient, whether scheduled or unscheduled is: - ☑☑️V️erifying the patient's identification The standard claim form used for the billing by hospitals, nursing facilities, and other inpatient services is called the: - ☑☑️U️B-04 A four-digit number code established by the National Uniform Billing Committee (NUBC) that categorizes/classifies a line in the charge master is known as: - ☑☑️R️evenue codes Internal controls addressing coding and reimbursement charges are put in place to guard against: - ☑☑️C️ompliance fraud by "upcoding" The first thing a health plan does when processing a claim is: - ☑☑️C️heck if the patient is a health plan beneficiary and what is the coverage Outsourcing options should be evaluated as - ☑☑️A️ny other business service purchase Insurance verification results in which of the following: - ☑☑️T️he accurate identification of the patient's eligibility and benefits EMTLA and HFMA best practices specify that in an Emergency Department setting: - ☑☑️N️o patient financial discussions should occur before a patient is screened and stabilized The HCCAHPS (Hospital Consumer Assessment of Healthcare Provider's and Systems) initiative was launched to: - ☑☑️P️rovide a standardized method for evaluation patients' perspective on hospital care All of the following are potential causes of credit balances EXCEPT: - ☑☑️A️ patient's choice to build up a credit against future medical bills Medicare will only pay for tests and services that: - ☑☑️C️an be demonstrated as necessary This was developed to promote and ensure healthcare quality and value and also to protect consumers and workers in the healthcare system. This directive is called: - ☑☑️J️oint Commission for Acceleration of Healthcare Organizations (JCAHO) safety standards It is important to calculate reserves to ensure: - ☑☑️A️ stable financial operations and accurate financial reporting An advantage of a pre-registration program in - ☑☑️T️he opportunity to reduce processing times at the time of service To be eligible for Medicaid, an individual must: - ☑☑️M️eet income and asset requirements The patient discharge process begins when: - ☑☑️T️he physician writes the order Appropriate training for patient financial counseling staff must cover all of the following EXCEPT: - ☑☑️D️ocumenting the conversation in the medical records Patients should be informed that costs presented in a price estimation may: - ☑☑️O️nly determine the percentage of the total that the patients is responsible for and not the actual cost. Any healthcare insurance plan that providers or insures comprehensive health maintenance and services for an enrolled group of persons based on a monthly fee is known as a - ☑☑️H️MO Chapter 11 Bankruptcy permits a debtor to: - ☑☑️W️ork out a court-supervised plan with creditors A portion of the accounts receivable inventory which has NOT qualified for billing includes: - ☑☑️A️ccounts created during pre-registration but not activated Overall aggregate payments made to a hospice are subject to a computed "cap amount" calculated by: - ☑☑️T️he Medicare Administrative Contractor (MAC) at the end of the hospice cap period What are some elements of a board-approved financial assistance policy: - ☑☑️E️ligibility application process and nonpayment collection activities Which of the following is usually covered on a Conditions of Admissions form: - ☑☑️P️atient's bill of rights. Net Accounts Receivable is - ☑☑️T️he amount an entity is reasonably confident of collection form overall accounts A common billing issue with hospital-based physician's is - ☑☑️T️hey are not contracted with the patient's health plan to provide services HFMA's patient financial communications best practices specify that patients should be told about the types of services provided and - ☑☑️T️he services providers that typically participate in the service, radiologist, pathologist, ect. What data required to establish a new MPI (master patient index) entry - ☑☑️T️he patient's full legal name, date of birth and sex Through what document does a hospital establish compliance standards? - ☑☑️C️ode of Conduct Code of Conduct - ☑☑️I️dentify Acceptable compliance programs in various provider settings If outpatient diagnostic services are provided within three days of the admission of a Medicare Beneficiary to an IPPS hospital, what must happen to these charges - ☑☑️T️hey must be combined with the inpatient bill and paid under the MS-DRG system Why is the OIG pursuing the Medicare Secondary Payer initiative? - ☑☑️I️t reviews Medicare payments for beneficiaries who have other insurance and assesses the effectiveness of procedures in preventing inappropriate Medicare payments for beneficiaries with other insurance coverage. Departments that need to be included in Charge Master maintenance include all EXCEPT: - ☑☑️Q️uality Assurance Using HIPPAA standardized transaction sets allows providers to: - ☑☑️S️ubmit a standardized transaction to any of the health plans with which it conducts business. Any healthcare insurance that provides or ensures comprehensive health maintenance and treatment services for an enrolled group of persons on a monthly fee is known as a: - ☑☑️H️MO Any provider that has filed a timely cost report may appeal in an adverse final decision received from the Medicare Administrative Contractor (MAC), this appeal may be filed with: - ☑☑️T️he Provider Reimbursement Review Board. For scheduled payments, important revenue cycle activities in the time-of- service stage DO NOT include: - ☑☑️O️btaining or updating patient and guarantor information Hospitals can only convert an inpatient case to observation if: - ☑☑️T️he hospital utilization review committee determines before the patient is discharged and prior to billing that an observation setting would be more appropriate. HIPPA privacy rules require covered entities to take all of the following actions EXCEPT: - ☑☑️U️se only designated software platforms to secure patient data. The four-digit number code established by the National Uniform Committee (NUBC that categorizes/classifies a line in the charge master is known as: - ☑☑️R️evenue codes During pre-registration, a search for the patient's MPI number is initiated using which of the following data sets: - ☑☑️P️atient's full legal name and date of birth or the patient's Social Security number Claims with dates of service received later than one calendar year beyond the date of service will be - ☑☑️D️enied by Medicare For scheduled patients, important revenue cycle activities in the time-of-service stage DO NOT include: - ☑☑️F️inal bill is presented for payment If a medical service requires authorization, who is typically responsible for obtaining the authorization: - ☑☑️T️he provider scheduling The fundamental approach in managing denials is - ☑☑️T️o analyze the type and sources of denials and consider process changes to eliminate further denials Outsourcing options should be evaluated as: - ☑☑️A️ny other business service purchase EMTALA and HFMA best practices specify that, in an Emergency Department Setting: - ☑☑️N️o patient financial discussions should occur before a patient is screened and stabilized The HCAHPS (Hospital Consumer Assessment of Healthcare Provider's and Systems) initiative was launched to: - ☑☑️P️rovide a standardized method for evaluation patients' perspective on hospital care All of the following are steps in safeguarding collections EXCEPT: - ☑☑️P️lacing collections in a lock-box for posting review the next business day What data are required to establish a new MPI (Master Patient Index) entry - ☑☑️T️he patient's full legal name, date of birth and sex Hospital can only convert an inpatient case to observation if the hospital utilization review committee determines this status before the patient is discharged and: - ☑☑️P️rior to billing, that an observation setting will be more appropriate Which of the following techniques is an acceptable way to complete the MSP (Medicare Secondary Payer) screening for a liability situation? - ☑☑️A️sk if the current service is related to an accident What do the MSP (Medicare Secondary Payer) disability rules require? - ☑☑️T️hat the patient is younger than 65 years Why do managed care plans have agreements with hospitals, physicians, and other healthcare providers to offer a range of services to plan members? - ☑☑️T️o reduce healthcare costs What are numbered receipts used for? - ☑☑️T️o ensure that all payments are properly accounted for and deposited. Which of the following items are considered valid proof of income documents? - ☑☑️C️opies of paycheck stubs from the most recent three months The important message from Medicare IM provides beneficiaries with information concerning what? - ☑☑️R️ight to appeal a discharge decision if patient disagrees with the plan What are some component of the charge master? - ☑☑️R️oom charges and detailed ancillary charges According to the Department of Health and Human Services guidelines, which of the following is not considered income? - ☑☑️S️ale of property, house or car Most managed care plans do not permit patient balance billing except for what circumstances? - ☑☑️d️eductible and copayment requirements The situation where neither the patient nor spouse is employed is described to the payer using: - ☑☑️A️ condition code The regulations and requirements for creating accountable care organizations, which allowed providers to begin creating these organization were finalized. - ☑☑️2️010 Which services are hospice programs required to provide on an around-the clock basis? - ☑☑️P️hysician, nursing, and pharmacy What is the purpose of the initial step in the outpatient testing scheduling process? - ☑☑️I️dentify the correct patient in the provider's database or add the patient to the database The time needed to prepare the patient before services is the difference between the patient's arrival time and which of the following? - ☑☑️S️cheduled time. Medicare guidelines require that when a test is ordered for which an LCD or NCD exists, the information provided on the order must include which of the following? - ☑☑️D️ocumentation of the medical necessity for the test. What Is an advantage of a preregistration program? - ☑☑️I️t reduces processing times at the time of service What data a required to establish a new MPI? - ☑☑️T️he patients full legal name, date of birth and sex A mother and father both cover their 16-year-old child as a dependent on their health insurance plans, which both follow the birthday rule. The mothers date of birth is 1/19/1968; and the fathers date of birth is 7/19/1967. Whose plan is the primary payer? - ☑☑️T️he mothers plan What is a co-payment? - ☑☑️T️he fixed amount that is due for a specific service? A patient's annual out-of-pocket limitation is $3,000 excluding deductible. To date this calendar year the patient has satisfied the $500 deductible and has paid $2300 in coinsurance to coinsurance to various providers. For the balance of the calendar year, what is the maximum amount of coinsurance the patient will owe? - ☑☑️$️700.00 What type of plan allows the subscriber to pay lower premium costs in return for a higher deductible? - ☑☑️C️onsumer directed health plan What is a characteristic of a managed care contracting methodology? - ☑☑️P️rospectively set rates for inpatient and outpatient services Which provision protects the patient from medical expenses that exceed a pre- set level? - ☑☑️S️top loss What document must a primary care physician sent to HMO patient to authorize a visit to a specialist for additional testing or care - ☑☑️R️eferral