CRCR EXAM 154 Questions and Answers 2023 - CORRECT ANSWERS, Exams of Nursing

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CRCR EXAM 154 Questions and Answers 2023

What do Case Managers do? - CORRECT ANSWERSMonitor high resource cases to ensure effective utilization What is HIM responsible for? - CORRECT ANSWERSall pt medical records: transcribe, coding, release to biling, answer requests for documentation What is utilization management responsible for? - CORRECT ANSWERSmanage cases: services correct, on time What are the three types of utilization review? - CORRECT ANSWERSProspective, Concurrent, Retrospective Where can home health services be offered? - CORRECT ANSWERSHome, Assist Living, neighbors: just not SNF nor Hospital To receive -Care payments, what must a SNF have when receiving a pt from a hosp? - CORRECT ANSWERSA transfer agreement approved by -Care. Can a home health agency employ another agency to provide services? - CORRECT ANSWERSYes, so long as at least one employee of the original agency provides care. What is the Net Collection Rate? - CORRECT ANSWERShow much cash was collected as a % of available to collect? What is the Net Collection Rate benchmark? - CORRECT ANSWERS95% What is the benchmark for denials - CORRECT ANSWERS<2% on first submission Formual for cost to collect - CORRECT ANSWERStotal PFS expenses/gross pt care collections What is the benchmark for cost to collect - CORRECT ANSWERS2.25%

What % of the UB-04 source of data is from pt access? - CORRECT ANSWERS40% What % of the UB-04 source of data is from service depts? - CORRECT ANSWERS11% What % of the UB-04 source of data is from HIM? - CORRECT ANSWERS20% What % of the UB-04 source of data is from billing? - CORRECT ANSWERS20% What % of the UB-04 source of data is not used? - CORRECT ANSWERS9% What % of the CMS 1500 source of data is from pt access? - CORRECT ANSWERS53% What % of the CMS 1500 source of data is from service? - CORRECT ANSWERS14% What % of the CMS 1500 source of data is from HIM - CORRECT ANSWERS7% What % of the CMS 1500 source of data is from billing? - CORRECT ANSWERS26% From whom is the UB-04 directed? - CORRECT ANSWERSinstitutional: hospitals, SNF, hospice From whom is the CMS 1500? - CORRECT ANSWERSnon-institutional: physicians, DME In the FDCA, what is Title I - CORRECT ANSWERSTruth in Lending Act What is the Truth in Lending Act - CORRECT ANSWERS5 points must be triggered (such as interest will be charged), then must disclose APR, total payments, late payment charges, etc. What are the penalties for violating the FDCA? - CORRECT ANSWERScreditors can be sued Who enforces the FDCA for hospitals? - CORRECT ANSWERSFTC

In the FDCA, what is Title III - CORRECT ANSWERSlimits garnishments In the FDCA, what is Title IV - CORRECT ANSWERSFair Credit Reporting Act What is the Fair Credit Reporting Act? - CORRECT ANSWERSprovides consumer rights in reporting loans Are there rules for how a debt collector communicates with debtor? - CORRECT ANSWERSYes, eg no profane language, can't contact before 8 AM Is a newborn a scheduled or unscheduled pt - CORRECT ANSWERSunscheduled What are the three types of pt access incoming to a HCO? - CORRECT ANSWERSscheduled, unscheduled, recurring What is LCD - CORRECT ANSWERSlocal coverage determinants, in absence of NCD, LCD dtermines whether -Care will pay for an item or service What is NCD - CORRECT ANSWERSnational coverage determinants:' nationwide determination of whether Medicare will pay for an item or service What % of pts should be pre-registered of all scheduled pts? - CORRECT ANSWERS98% What is the code for HIPAA transaction set for HC eligibility and benefit responses

• CORRECT ANSWERS270 outgoing 271 response What are some payer data elements needed to process payment? - CORRECT ANSWERSpolicy type, covered persons, mail address, cvr type (HMO), deductible What is an PPO - CORRECT ANSWERSclosest to indemnity plan, only preferred doctors in network get contracted prices What is an EPO - CORRECT ANSWERSexclusive provider - limits services to only EP

What is POS - CORRECT ANSWERSpoint of service - if doc makes referral out, plan will pay, if pt requests out of service, pt pays What is CDHP - CORRECT ANSWERSconsumer directed healthplan, often with a HSA What is the % discount model in MCO - CORRECT ANSWERSa % is discounted What is the DRG model in MCO - CORRECT ANSWERSpymt based on predetermined fixed amount What is the APG model in MCO - CORRECT ANSWERSdivides outpt services into 600 procedural groups, each APG assigned a relative payment weight What is a case rate - CORRECT ANSWERSpt's condition forms basis for payment for all services What is stop loss - CORRECT ANSWERSplan covers 80% of charges to 100%, stop loss is plan covers 50% of charges >$120k What are some managed care requirments? - CORRECT ANSWERSpre- certification/pre-authorization, referral (PCP->specialist), notification - providers notify payer pt is requesting service, days approval, continued stay review, site of service limitations (eg only colonosco as outpt) What are some concerns with EMTALA - CORRECT ANSWERSsign posted on walls, no prior authorization, women in active labor must be assisted thru delivery, on- call MD must respond, no dumping, no transfer (unless cannot provide service), must do mental health screening, must keep pt log What is the referring MD - CORRECT ANSWERSthe one to referred to another MD What is the attending MD - CORRECT ANSWERSOne who wrote order for service What is the consulting MD - CORRECT ANSWERSwho consults with another MD

How long does Medicare Part A cover inpat services? - CORRECT ANSWERS days, then 30 co-insurance, then pt can use 60 days of lifetime reserve HICN - CORRECT ANSWERShealthcare insurance claim # issued by SSN to those elgible for SSN How often does Medicare update co-insurance amounts for Part B? - CORRECT ANSWERSyearly done by OPPS, outpt prospective pymnt system How are payments under -Care A paid? what system? - CORRECT ANSWERSbased on DRGs (more than more ACOs), reasonable cost at CAHs, rehab hosp, psych, ped, lg term care hosp How are payments under -Care B paid? what system? - CORRECT ANSWERSpaid on ambulatory paymt classification (APC), prospective pymt rates What are some unique sources of information that must be provided when submitting a claim to -Caid? - CORRECT ANSWERS-Caid ID # must be on form, newborn weight must be incl Can IHS pts receive care at other clinics? - CORRECT ANSWERSYes, but IHS must be the payer of last resort What must be on the UB-04 or CMS 1500 for BCBS pts? - CORRECT ANSWERSAlpha prefix - specifies specific BCBS What law governs self insured companies - CORRECT ANSWERSERISA - ergo not controlled by state legislation Can -Care be billed after billing a liability payer? - CORRECT ANSWERSyes, after 120 days. Must release liability and -Care will pursue liability payer What are typical claim edits? - CORRECT ANSWERSmedical necessity, invalid demo info, invalid codes, missing NPI #s

Name three aspects to the Hospital Readmit Reduction Act - CORRECT ANSWERSCMS reduces pymt to hosp w/ excessively high readmit for heart, COPD, pneumonia, knee replace; also to MDs who do not report qual data Why is the charge master imptt even in managed care? - CORRECT ANSWERSreimbursemt based on % of charges or stop loss based on total What are the two components of the charge master - CORRECT ANSWERSroom and board (by nursing unit, room type) and ancillary charges - will list UB-04 rev code, CPT/HCPCS code and charge amount What are level 1 CPT codes - CORRECT ANSWERSfive numbers (for procedures) What are level 2 CPT codes - CORRECT ANSWERSfor supplies, ambulance (alpha and 4 digits) What are level 3 CPT codes - CORRECT ANSWERSnot common What are level 1 CPT modifiers - CORRECT ANSWERSeg would be 23 - unusual anesthesia What are level 11 CPT modifiers - CORRECT ANSWERSeg: LT - left side, E4 - lower right eyelid What are level III CPT modifiers - CORRECT ANSWERSXI - FDA approved drug Is there a chain to modifiers? - CORRECT ANSWERSYes, a HCPCS level III has higher precedence than a HCPCS NP level II for example In Pay for Performance, what do hospitals do in the Hosp Qual Initiative? - CORRECT ANSWERShosp must submit data about 10 quality measures In Pay for Performance, what must hospitals do in the Premier Hosp Quality initiative? - CORRECT ANSWERSIf hosp score in top 10%, receive a 2% bonus, if not meet objectives, subject to reductions

In Pay for Performance, what must hospitals do in the capitation type initiative? - CORRECT ANSWERSfor chronically ill, must guarantee CMS a savings of at least 5% over similar population What is Pay for Performance? - CORRECT ANSWERSPay-for-performance" is an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care. Pay-for-performance has become popular among policy makers and private and public payers, including Medicare and Medicaid. Formula for Net Days in Pt A/R - CORRECT ANSWERSNet Pt A/R

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Net Revenue/365 (or time period) What does Net Days in Pt A/R tell us? - CORRECT ANSWERSindication of efficiency of collections, revenue posting, and financial ops of A/R Does Net Days in Pt A/R get aged from date of service, date bill sent, or? - CORRECT ANSWERSDate of service What is goal for aging A/R >90 days - CORRECT ANSWERS15-18% What is goal for aging A/R >1 yr - CORRECT ANSWERS<1% What is goal for time for charge posting - CORRECT ANSWERSw/in 1-3 days of service What is goal for credit balance - CORRECT ANSWERS<1% of billed A/R What is goal for charity and bad debt - CORRECT ANSWERS5-8% of billed A/R What should be taken into account when estimating net revenue (for future) - CORRECT ANSWERShistorical adjustments, new payer contracts, charity care, bad debt What are reserves? - CORRECT ANSWERShow much is not yet collected

What is important about reserves - CORRECT ANSWERSneeds to be as accurate as possible - if caught off guard, could impact available funds What % of reserves are self pay bills >120 days from 1st bill - CORRECT ANSWERS100% What % of reserves are self pay bills 90-120 days from 1st bill - CORRECT ANSWERS50% What % of reserves are self pay bills 60-90 days from 1st bill - CORRECT ANSWERS25% What % of reserves are medicare bills >365 days past discharge - CORRECT ANSWERS20% What % of reserves are medicare bills 180-365 days past discharge - CORRECT ANSWERS10% Are gross charges or contractural amounts posted to a pt's account? - CORRECT ANSWERSIf know contractural amount can post, otherwise post gross charge to pt's account until insurance pays What are instances when -care is a 2ndry payer? - CORRECT ANSWERSDisability (pt <65, has LGHP), ESRD (in 30 day coordination period), working aged, accident (when no liability exists) What is the correct coding initiative? - CORRECT ANSWERSthe purpose of the CCI is to ensure that the most comprehensive groups of codes are billed, rather than the component parts. developed by CMS What are some ways to avoid problems with cash postings? - CORRECT ANSWERSlarge write-offs such as bad debt should be done by managers. What does CMS require when there is a credit balance? - CORRECT ANSWERSreporting to CMS

What does HFMA recommend a HCO do with a small credit to a pt payer? - CORRECT ANSWERSabsorb if pt does not claim after a certain period of time What is a bank lock box? - CORRECT ANSWERScontracting with a bank to receive, deposit, and electronically report payments from pts and payers What were the four goals of HIPAA passed in 1996? - CORRECT ANSWERSportability - the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs; Reduces health care fraud and abuse; Mandates industry-wide standards for health care information on electronic billing and other processes; and Requires the protection and confidential handling of protected health information What is APC? - CORRECT ANSWERSAmbulatory payment classification: United States government's method of paying for facility outpatient services for Medicare. analogous to the Medicare prospective payment system for hospital inpatients (DRG). APCs are an outpatient prospective payment system applicable only to hospitals. What is case rate? - CORRECT ANSWERSfixed price for specified procedure. Gives provider opportunity to manage costs before capitation. What is a silent PPO - CORRECT ANSWERSinsurance companies that offer providers less payment, invalid discounts (they try to look like a contracted PPO) What is electronic remittance advice 835 data set? - CORRECT ANSWERSused to send hc claim payments and advice - four levels from receipt (then paper trail) to level 4 - all electronic and links bank. -Care uses level 4. Can a Medicare beneficiary request an appeal? - CORRECT ANSWERSyes, must be an amount >$130, judicial review if over $ Can a provider request a -Care appeal? - CORRECT ANSWERSyes, must be >$1000; and on Part A, only on medical necess

If a beneficiary knew services would not be provided, is he liable for payment? - CORRECT ANSWERSYes If neither provider nor beneficiary knew services wouldn't be covered, are they liable? - CORRECT ANSWERSNo, -Care must cover. But must have been reasonable to have not known. If provider should have known services wouldn't be covered and didn't give ABN, are they liable? - CORRECT ANSWERSYes What criteria should be used to evaluate a collection agency? - CORRECT ANSWERSreputation, pt relations, agency fees (they should give an estimated recovery amount), 'no recovery, no fee' What is a rentention account (in regards collection agency)? - CORRECT ANSWERSHolding trust account where recovered monies are kept until transferred to the provider What is Chpt 7 bankruptcy? - CORRECT ANSWERSstraight bankruptcy What is Chpt 11 bankruptcy? - CORRECT ANSWERSdebtor reorg - bankruptor has continuing management of business, debtor creates plan to reorg, creditors must approve, may also involve reduction in debt amounts What is Chpt 13 bankruptcy? - CORRECT ANSWERSdebt rehab - no liquidation, reorg holdings, creditors look to future earnings (eg garnishment) What is exempt in bankruptcy? - CORRECT ANSWERSproperty (like house, personal items), alimony, tools of trade What is exempted from discharge in bankruptcy? - CORRECT ANSWERSeducation loans, gvt fines, unpaid alimony/child care, debts arisen from lying FAP (financial assistance program) and its charity agreements? - CORRECT ANSWERSnon-profits will have limitations on charges to uninsured

how should a HCO determine poverty guidelines? - CORRECT ANSWERSCan use the federal poverty guidelines, income does not include capital gain, injury comp, sale of property - and is state defined What is catastrophic charity - CORRECT ANSWERSin the event of catastrophic injury or illness what is an open insurance balance? - CORRECT ANSWERSAfter 60 days, pt must pay or fight with insurance co. to pay (unless prohibitions in contract) what is subrogation? - CORRECT ANSWERShealth plan bills liability insurance Will -Care pay for worker's comp - CORRECT ANSWERSNo Will -Care pay for auto liability? - CORRECT ANSWERSYes, after auto is exhausted What percent of claims and type are 80% of AR? - CORRECT ANSWERS15-20% of high fee What's an example of a claim rejection for technical reasons? - CORRECT ANSWERSdemographic errors, no pre-authorization, exceeded frequency (only 1 PAP/yr) What's an example of a claim rejection for clinical reason? - CORRECT ANSWERSmissing doc to support, HCPCS incorrect, not medically necessary What does a recovery audit contractor do? - CORRECT ANSWERSReview -Care claims to save gvt $ and prevent abuse What is unique about a rural health clinic and how it bills -Care part B - CORRECT ANSWERSCan collapse CPT codes to 520, but HFMA recommends still use CPT for medical necessity Are all -Care services in a RHC defined as rural health? - CORRECT ANSWERSNo, such as SNF How are -Caid claims paid in a RHC? - CORRECT ANSWERSstate by state rules

Will -Care pay for a VA hospice? - CORRECT ANSWERSNo, VA must pay Will - Care pay for hospice? - CORRECT ANSWERSOnly if pt is entitled to -Care part A Can hospice be denied under -Care? - CORRECT ANSWERSyes, if worker's comp related or >210 days of hospice How is hospice payment worker compensation related? - CORRECT ANSWERSCould be cancer caused by exposure, worker's comp must cover, but - Care would then cover respite care, eg Will -Care cover hospice in a SNF? - CORRECT ANSWERSOnly hospice symptom managemnt, not room and board Will -Care cover SNF? - CORRECT ANSWERSonly if discharge not transfer What is mandatory if -Care will cover SNF? - CORRECT ANSWERSmust be to cover condition had at inpt, must have 3+ days inpt (can be at 1+ hosp, if consec), must need daily, skilled nursg service, MD must sign Is there co-insurance at a SNF for -Care? - CORRECT ANSWERSYes, from 21st- 100th day How are SNFs paid under -Care? - CORRECT ANSWERSper diem based on case mix According to the ACA, when must claims be submitted by? - CORRECT ANSWERSw/in 1 year, starts on: institution: through date, MD: from date Hospice type payments are? - CORRECT ANSWERSA - routine (paid ~ rate each day), B- continuous (/24 to get hrly rate), C-inpt respite (5 days for family respite), D-inpt general - a, C, D - one rate applies each day, B - determined on # of hrs continuous care provided that day

Are all ambulance bills paid directly to an ambulance company? - CORRECT ANSWERSNo, if ambulance use is required for transfer w/in hosp, then billed under Part A (eg, obese pt who cannot fit in MRI) Is there only one way an ambulance bill is billed? - CORRECT ANSWERSNo, can be one rate (incl all), or one rate for services, separate for mileage, opposite of last, base rate, separate charges for both How is medical necessity determined in ambulance? - CORRECT ANSWERSbased on services provided, not type of ambulance used What is the FCA - CORRECT ANSWERSFalse Claims Act of 2009, fraud enforcement and recovery act, encourage whistleblowers When is -Care a MSP? - CORRECT ANSWERSgroup health plan, only if > employees, accident (some specifics on liability), disability (Unless >65), ESRD in 30 coordination period What is the 2 midnight rule - CORRECT ANSWERS2 midnights or less can be outpt What is the CCI - CORRECT ANSWERScorrect coding initiative - modifiers to help indicate a special circumstance (eg performed by > 1 MD) What are the 9 forms that should be on hand on admission - CORRECT ANSWERSconsent to treatment condition of admission (financial agreement, surgical consent, release of info, assignment of benefits) privacy notice impt msg from -Care (can dispute) ADP Pt bill of rights How should a PFS introduce payment when speaking with a pt? - CORRECT ANSWERS1. greet

2. review HCO PFS policies
3. review insurance
4. review charges and liability

5. how will pt resolve liability? What are some problems if pt access not done correctly? - CORRECT ANSWERS1. billing (lost revenue)
6. clinical - in wrong file
7. case review - where insurance must be notified w/in 24 hrs
8. legal What is the FDCA? - CORRECT ANSWERSFair Debt Collection Act Hosp benchmark days A/R - CORRECT ANSWERS40-