CRCR Certification Questions and Answers: Healthcare Revenue Cycle, Exams of Social Sciences

Download CRCR Certification Questions and Answers: Healthcare Revenue Cycle and more Exams Social Sciences in PDF only on Docsity!

CRCR CERTIFICATION QUESTIONS AND ANSWERS

T/F Consents are signed as part of the post-service process - Answers- False T/F Patient service costs are calculated in the pre-serviceprocess for scheduled patients

• Answers- True T/F The patient is scheduled and registered for service is a time-of-service activity - Answers- False T/F The patient account is monitored for payment is a time-of-service activity - Answers- False T/F Case management and discharge planning services are a post-service activity - Answers- False T/F Sending the bill electronically to the health plan is a time-of-service activity - Answers- False Revenue Cycle Initiatives - Answers- Healthcare Dollars & Sense:pt financial comm. best practices, best practices for price transparency, medical accounts resolution PFC Best Practices - Answers- 6 areas:Annual staff training, training program topics, process observation, executive level metrics reporting, technology verification, feedback and response Where individuals and small businesses can compare and purchase qualified health benefit plans - Answers- Health Insurance Marketplace/Health Insurance exchange Medical Debt Task Force - Answers- developed a best practice workflow that builds off of HFMA's previous patient friendly billingwork and spansthe patient-centric revenue cycle. The following statements describe best practices established by the Medical Debt Task Force - Answers- Educate patients, coordinate to avoid duplicate patient contacts, be consistent in key aspects of account resolution, follow best practices for communication Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) - Answers- standardized method for evaluating patients' perspective on hospital care Hard Costs - Answers- loss of future revenue Soft Costs - Answers- customer's passing on information about their negative experience to potential patients or through social media channels

Post Acute Services - Answers- include skilled nursing , home health, durable medical equipment, hospice, and assisted living Skilled Nursing Facility (SNF) - Answers- institution (skilled nursing home/rehabilitation center) engaged in provided skilled nursing care for injured/disabled/sick persons Durable Medical Equipment (DME) - Answers- Medical equipment that is prescribed by a doctor for use in the home Home Health Agency (HHA) - Answers- public agency or private organization Level 1 Modifier - Answers- usually provide info about performance of a procedures/apply to CPT/consist of 2 numbers Level 2 Modifiers - Answers- used for OPPS/provide addtl detail ab out an anatomical location or about a procedure or service/apply to HCPCS codes/consist of either 2 letters or a 1 letter & 1 number Correct Coding Initiative(CCI) E - Answers- purpose is to ensure that the most comprehensive groups of codes, rather than the component parts, are billed. THe program consists of edits that are implemented within providers' claim processing systems Ethics Violations - Answers- Financial misconduct/Overcharging/Theft of property/ Falsifying records to boos reimbursement/miscoding claims Affordable Care Act (ACA) - Answers- includes provisions to improve the quality of care/reform the healthcare delivery system/encourage pricing transparency and modernized financing systems/address the issues of waste,fraud, and abuse Accountable Care Organization (ACO) - Answers- delivery system of physicians, hospitals, and other healthcare providers, who work collaboratively to manage and coordinate the care of a patient population. Includes appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients Bundled Payments for Care Improvement (BPCI) - Answers- initiative was developed by the Center for Medicare and Medicaid Innovation to link payments for multiple services beneficiaries receive during an episode of care Balance Sheet - Answers- statement is a summary of the organizations wealth as of the date of the statement. it represents the summary of the organizations assets, liabilities and accumulated excesses from operations less any accumulated losses. Income Statement - Answers- ties directly to the balance sheet and is the summary of the organizations revenues and expenses and any excess or loss from operations

Cash Flow Statement - Answers- this statement is the summary of how cash was used and where it was obtained Accrual Accounting - Answers- revenue is recorded when it is earned to permit the alignment of revenue with the associated expenses. Cash Accounting - Answers- records revenue when payment is received Fund Accounting - Answers- record keeping method to manage categories of netassets to ensure compliance with the restrictions on those funds Gross Revenue - Answers- the total incurred charges entered for all patients for the services they received Net Revenue - Answers- financial services must estimate the dollar amount of contractual, discount orother allowances that will be applied against those revenues. ASC 606 change to Accounting rules - Answers- created 2 types of adjustment to incurred charges:explicit price concessions and implicit price concessions Explicit Price Concessions - Answers- represent the discounted contractual agreements between the provider and the payers which specify the payments due from the payers Implicit Price Concessions - Answers- applied to amounts that are expected to be paid by patients, based on the expected payment results for a specific portfolio of receivables Net Patient Service Revenue - Answers- defined as the total incurred charges, less the explicit price concession, less any applicable implicit price concession(s)as applied to the specific portfolio of accounts HFMA's MAP Keys - Answers- strategic KPI's that set the standard for patient centric revenue cycle excellence in the healthcare industry Net Days in A/R - Answers- Net A/R from the balance sheet / Avg daily new patient service revenue from the income statement Aging Analysis - Answers- important to age from date of service to understand the impact that timely billing, or lack of timely billing, has on collection of accounts receivable Discharge Not Final Billed (DNFB) - Answers- portion of the accounts receivable that identifies charges for patients where services are completed but the provider has not been able to bill the claim

Activities to be completed before bill submission - Answers- completion of all charging/completion of final medicare record coding/inclusion of insurance verification activities Cost to Collect - Answers- revenue cycle cost / total patient service cash collected Net Collection Rate - Answers- lets you know how much actual cash you collected as a percentage of what was available to collect. it is the ratio of cash to net revenue Resource Coordination - Answers- reserving rooms and/or equipment , ordering devices or supplies , ensuring that professional staff (physicians, nurses, and/or technicians) is available Scheduled Inpatient - Answers- EX: major surgery patients and obstetrical patients Scheduled Outpatient Services - Answers- Routine diagnostic testing in radiology (nuclear med/US/CT/PET/MRI's), Pulmonary function testing, interventional radiology, cardiology testing, neurology, ambulatory surgery, pain management, laboratory testing Non Acute: Skilled Nursing - Answers- patients are admitted into skilled nursing units or facilities (SNF)when they no longer meet criteria for acute care, but still need an inpatient level of skilled nursing care or rehabilititation services Bipartisan Budget Act - Answers- 2018 provided a permanent exceptions process for the physical therapy and speech language pathology and the separate occupational therapy caps Local Coverage Determinations - Answers- guidelines that Medicare established to determine which diagnoses, signs, or symptoms are payable. 270 Health Care Eligibility Benefit Inquiry - Answers- 270 transaction is the outbound inquiry from the provider to the health plan. Includes the IDnumber/DOB of insured party Medicare - Answers- government-sponsored program which is financed through taxes and general revenue funds Medicaid - Answers- federally aided, state operated program to provide health and long term care coverage for low-income individuals or families Tricare - Answers- healthcare program of the United States Departmentof Defense Military Health System Commercial Indemnity Plans - Answers- plans cover almost all services without authorization requirements

837 - I or UB 04 paper form - Answers- hospital inpatient and outpatient services are submitted to medicare and medicare advantage plans electronically using these forms 837 - P orCMS 1500 paper form - Answers- Physician servicesare submitted electronically using these forms Medicaid programs cover: - Answers- inpatient/outpatient hospital services/physician,midwife and nurse practioner services/nursing home services for persons aged 21+/pregnancy related servicess/family planning services and supplies/lab and XR services Tricare Prime - Answers- HMOtype program Tricare Standard and Extra - Answers- fee-for-service plan available to all non-active duty beneficiaries throughout the US Tricare for Life - Answers- supplement to the medicare program and only available to individuals who are also enrolled in Medicare Part A and Part B benefits HMO's - Answers- supply the beneficiary with a directory of physicians from which to choose a PCP/physician coordinates the beneficiary's care (benef. must contact their PCPto be referred to a specialist or obtain prior auth for non emergency hospital services Preferred Provider Organization (PPO) - Answers- where a third party payer contracts with a group of medical care providers who furnish services at lower than usual fees in return for guarantees of a certain volume of patients Exclusive Provider Organization (EPO) - Answers- form of PPOin which a very select group of providers is chosen to provide benefits to one or a very limited number of entities, usually a single employer Point of Service Plan (POS) - Answers- healthcare insurance plan that allows the member to select providers either in network or out of network; beneficiaries are enrolled in an HMObut have the option to go outside of the network for an addtl cosst Managed care health plans use prior auths and utilization management review to determine care is medically necessary - Answers- includes pre cert/pre auth, referrals, notification, Site-of-Service Limitations, Case Management, Discharge Planning Constructing a Price Estimate - Answers- Verify/Identify/Obtain total charges Emergency Medical Treatment and Labor Act (EMTALA) - Answers- requires hospitalsto provide a medical screening examination and nay needed stabilizing treatment to every person present at an EDand requesting medical eval or treatment

EMTALA prohibits - Answers- inquiries about health plan or liability payer (TPL)information if the inquiry will delay examination or treatment Emergency Department (ED) - Answers- patients initially triaged by medical personnel, where quick reg record is generated to specifically allow order entry. After triage patient is either placed in a bed or may return to waiting room Master Patient Index (MPI) - Answers- data collection includes patients full legal name, SSN, and/or DOB Newborn Admissions - Answers- Mother's reg info is used to generate the newborn registration record; once baby is named then the newborn record will be separated from mother's record Attending Physician - Answers- physician who wrote the order for service and is the physician in charge of the patient's care for a specific period of time. Also referred to as the admitting physician Admission Orders: Inpatient - Answers- patients are admitted to inpatient status 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 there is not an anticipation of improvement in the patient's condition within 24 hours Admission Orders: Observation - Answers- observation is an outpatient status used to evaluate patients for possible inpatient admission or to resolve problems where the treatment is expected to last less than 24 hours. Patient is placed on a bed either on a regular unit or in a separate observation unti Two Midnight Rule - Answers- allows hospitals to account for total hospital time (including OP time directly preceding the inpatient admission)when determining if an inpatient admission order should be written based on the expectation that the Medicare beneficiary will stay in the hospital for 2 or more midnights receiving medically necessary care Durable Power of Attorney - Answers- legal document that allows the patient to name a "patient advocate" who is at least 18 years of age to act on the patient's behalf according to the patient's wishes Living Will - Answers- allows a person to state his/her treatment wishes in writing, but does not name a patient advocate Preferred Units - Answers- surgical/orthopedic/critical care/ critical cardiac care/ telemetry/cardiology/ pediatrics/ obstetrical/ general medical/ and oncology Discharge Process - Answers- A. Physician must write the discharge order B. Case Management discharge lanning must be finalized C. Appropriate discharge instructions

must be provided to the patient D. Access services must review the patient's record to see if the patient qualifies for courtesy discharge, and if not, notification must be sent for the patient to see a financial counselor prior to discharge E. when the patient leaves, the registration system must be updated to reflect the correct date and time of discharge, and the correct disposition code Discharge Planning - Answers- starts as soon as patient is admitted into the facility or even before Discharge Planning includes - Answers- an estimate of how long the patient will be in the hospital/what the expected outcome will be/whether there will be any special requiremens on discharge/what needs to be facilitated to effectively discharge the patient in an appropriately timely manner Types of Case Management Reviews - Answers- Prospective Review (pre-cert) / Concurrent Review & Discharge Planning (during) / Retrospective Review (after) Purpose of Case Management - Answers- monitor the progression of high resource consumptive cases to help ensure effective utilization of resources during the care of the patient and maximize patient outcomes Charges are recorded - Answers- room &bed charges are typically posted from the midnight census/ ancillary charges can be posted or scanned barcoded Resource Management - Answers- allows more timely and accurate billing and collecting, which improves net collections and cash flow/ ensures that bills do not have to be held for late charges / decreases research efforts generally as questions related to duplicate charges, charge codes, and so forth are reduced Charge Master - Answers- a list of services/procedures, room accommodations, supplies, drugs/biologics, and/or radiopharmaceuticals that may be billed to a hospital inpatient or outpatient and includes the charge specific data needed for claim submission Charge Description Master (CDM) - Answers- unique identifier number assigned to a given line item in the chargemaster Department Number - Answers- number assigned to a particular department denotes the revenue generating area Current Procedural Terminology (CPT) Codes - Answers- codes that describe services, procedures, and drugs Revenue Codes - Answers- 4 digit number code established by the National Uniform Billing (NUBC)that categorizes/classifies a line item in the chargemaster

General Ledger (GL) Number - Answers- a number used for accounting purposes that directs the revenue to the appropriate department Level 1 HCPCS Codes - Answers- approved american medical associations cpt- 4 codes/all cpt-4 codes are included within the hcpcps code listing/these 5 digit hcpcs codes are numeric Level IIHCPCS Codes - Answers- CMS developedcodes for classifying supplies and non-physician services such as DME,ambulance services, medical and surgical supplies and drugs/ level IIbegin with single letter followed by 4 numeric digits Level III HCPCS Codes - Answers- contain codes assigned and maintained by medicare admin contractors these codes begin with a letter W-Z followed by 4 numeric digits/ these codes are not common and are used basically to describe new procedures not yet developed in level I and II Health Information Management (HIM) - Answers- responsible for the management of all patient medical records HIM Required - Answers- plays role in ensuring the accuracy of the codes documented on the claim Activities of HIM - Answers- ensuring the security and completion of electronic and hardcopy medical records, transcribing physician dictation including histories and physicals operative reports and discharge summaries/ analyzing information necessary for decision support/performing chart analysis/reviewing the medical record, assigning diagnosis and procedure codes and classifying data for reimbursement Hard-Coded - Answers- when the code is assigned via the chargemaster / typically only utilized for procedure coding Soft-Coded - Answers- when HIM coder is responsible for reviewing and/or assigning the diagnosis or procedure codes UB- 04 - Answers- standard HOSPITAL claim form/ contains 81 form locators and is used by hospitals, hospice, rural health clinics, SNF for submitting claims CMS 1500 - Answers- standard PROFESSIONAL service claim form/ contains 33 major items, subdivided into a total of 55 detailed items and is used by professional service providers (physic., allied health prof, certified registered nurse anesthetists, home health agencies, medical equipment suppliers)for submitting claims for services to health plans Condition Codes - Answers- used by provider to describe conditions or events that apply to the period being billed on the claim

Occurrence Codes - Answers- provides addtl info pertaining to the period being billed on the claim Occurrence Span Code - Answers- used for an event that spans a period of time Value Codes - Answers- related dollar or unit amounts represent data of a monetary nature that are necessary for the processing of a claim Claim Edits - Answers- rules developed to verify the accuracy and completeness of claims based on each health plan's policies Council for Affordable Quality Healthcare (CAQH) - Answers- multi-stakeholder collaboration of more than 130 organizations working to develop operating rules to simplify healthcare admin transactions/ their goal is to ensure that detailed, real-time response becomes the standard for claims-related healthcare transactions Electronic Data Interchange (EDI) - Answers- technology used for translating, standardizing, and sending transactions electronically Loops - Answers- electronic data sets including more information than is represented on the paper form Counting Inpatient Days - Answers- day begins at midnight and ends 24 hours later AKA midnight to midnight method including the day of admission, counts as a full day Interim Billing - Answers- in the acute care setting is typically used for extended inpatient stays. Should contact health plans to see if interim billing is permitted Rural Health Clinic (RHC) - Answers- UB04/837I in the hospital outpatient billing format is usedto bill medicare and some qualifying medicare advantage plansfor RHC services/ this requires the use of revenue codes for the purposes of generating billing and/or payments Billing RHC Services - Answers- on UB04/837I specific CPTcodes are collapsed into a single revenue code (520/521) these codes will be usedto determine medical necessity Non-RHC Services - Answers- include inpatient services; services provded to medicare beneficiaries in a Part A skilled nursing facility; and ancillary services including lab EKGs pulmonary function testing, and the technical component of XR services Non- RHC Services are billiable - Answers- under the fee schedule to Medicare Part B Hospice - Answers- to be eligible to elect hospice care under Medicare, the individual must be entitled to Medicare Part A benefits and must also be certified as being terminally ill

Hospice SNF Patients - Answers- hospice benefits for a medicare beneficiary who is in a SNFcover the professional management of the individual's hospice care but do not cover the room and board for the individual Care in a SNF - Answers- covered if patient requires skilled nursing services or skill rehabilitation services/ patient requires skilled services on a daily basis/ as a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF/ ancillary services (lab pharm XR)are available if needed on an emergency basis Covered SNFServices - Answers- room &board/ physical Speech or Occup Therapy/ Respiratory Therapy/ Medical Social Services Hospital-Based Physicians (HBP) - Answers- physicians who perform services in a general acute-care hospital setting HBP Examples - Answers- ER Physic/anesthesiologists/radiologists/pathologists Billing Issues with HBP's - Answers- they are contracted with the hospital but may not be contracted with a patient's health plan Beneficiary Appeals - Answers- any enrolled individual in medicare dissatisfiedwith the govt claim determination is entitled to reconsiderationof the decision, a hearing, and a judicial review of the final decision after hearing. Level 1 of ProviderAppeals - Answers- redetermination by a medicare administrative contractor (MAC) Level 2 of Provider Appeals - Answers- Reconsideration by a Qualified Independent Contractor (QIC) Level 3 Provider Appeals - Answers- Administrative Law Judge (ALJ) Hearing or REview by office of medicare hearing and appeals LEvel 4 Provider Appeals - Answers- REview by the Medicare Appeals Council Level 5 Provider Appeals - Answers- Judicial review in US District ourt Clean Claim - Answers- claim for reimbursement submitted to a third-party payer that has all information and documentation required for the payer to make a decision on payment or denial Electronic Worklist - Answers- functionality that identifies claims that remain unpaid a specific number of days from the initial billing date Medicare Common Working File (CWF) - Answers- host of databases that houses all beneficiary claim history and entitlement information.

Lien - Answers- claim against real or personal property that secures payment of a debt or performance fo some other acct Security Interest - Answers- when personal property is used as collateral Health &Human Services (HHS) Income definition - Answers- money wages and salaries, net receipts from self employment, regular payments from social security, unemployment compensation, workers comp, veterans payments, public assistance and alimony and child support Affordable Care Act(ACA) - Answers- lays out requirements for:community health needs assessments, policies related to financial assistance, emergency medical care, billing and collections activities Extraordinary Collections Actions (ECA) - Answers- legal actions/selling the debt to a third party/reporting adverse information to credit bureaus or agencies, deferring or denying medically necessary care because of non payment for previously provided care that is covered by FAP Consumer Credit Protection Act - Answers- major components Truth in Lending act/restrictions on garnishment, fair credit reporting acct, fair debt collection practices Act Truth in Lending Act - Answers- establishes disclosure rules for consumer credit sales and consumer loans Restrictions on Garnishment - Answers- legal proceeding whereby money or property due or belonging to a debtor but in the possession of another is applied to the payment of the debt of the plaintiff Fair Credit Reporting Act - Answers- affects those who issue or use reports on consumers in connection with the approval of credit and protects consumer's rights and has exact standard that limits the use of consumer credit reports Fair Debt Collection Practices Act - Answers- applies only to third-party collection agencies that collect consumer debt.

• Answers-